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Why are You Afraid of Infertility Treatment (and generally should not)

Why are You Afraid of Infertility Treatment (and generally should not)

Why are You Afraid of Infertility Treatment (and generally should not)

When have been trying to conceive for a while, women and men often are reluctant to seek help from a fertility specialist. What if they told me you cannot conceive? what if they find a major problem with my fertility? what if I need extensive treatment? All are viable questions. One deviation at that point is to consult with a specialist in your immediate circle but in another discipline: gynecologist or internist. This deprives you from valuable resources and tend to underestimate any issues you may have. This is a very common reaction in general use of supplements instead of medicine, go to a holistic specialist instead of a physician..

Why are you afraid of Fertility Consultation

When you consult with a reproductive endocrinologist you may anxious about a discovery of one or more fertility issues, that may require treatment. Fertility problems are very private, maybe more than any other medical problems. They are certainly more private,  though less risky, than heart disease or intestinal problems. You are also worried about the treatment of such factors and the required time and financial resources. One evidence of evidence of such fear is reluctance to seek consultation for years sometimes.

Why are you afraid of fertility treatment

Once you start a consultation with a fertility specialist and treatment is recommended, couples are worried about the treatment process: complications and results.

Possible Complications of Fertility Treatment

All the complications of fertility can be classified into proven complications and unproven complications

Proven Complications

i. Multiple Pregnancy

Multiple pregnancy

Multiple pregnancy

Twins and higher order multiple pregnancy is an established complication of fertility treatment. It is directly related to the type of treatment (IUI or IVF), age and the number of embryos (IVF) transferred or follicles observed (IUI). The general incidence of twins is 1% after natural conception, 30% after IUI or two or more embryo transfer and 1% after single embryo transfer. The general incidence of triplets or higher is less than 0.1% after natural conception and 3% following fertility treatment.

ii. Ovarian Hyperstimulation Syndrome

Also an established complication of ovarian stimulation. It is more common in younger patients with large number of antral follicles seen in the ovary and high AMH levels. Women with PCOS are particularly at risk. The incidence of sever forms is 0.5 to 1%. In its severe forms it may lead to accumulation of fluid in the abdomen, blood clotting and may require hospital admission.

iii. Complications from egg retrieval

Egg retrieval is associated with very low level of comlications <1/1000, including bleeding, infection and anesthetic complication.

iv. Pregnancy Complications

Like any pregnancy there is a risk for miscarriage (15%) and ectopic pregnancy (3%) (e.g pregnancy in the fallopian tubes).

Unproven Complications

Cancer

There is no conclusive evidence that ovarian stimulation or any fertility treatment, in itself,  increases the risk of cancer (any type). It is true that women who delay conceiving are at an increased risk for some types of cancer e.g breast cancer, ovarian cancer…There is however no proof that there is an increased risk of cancer due to treatment. For example, the risk for breast cancer in women living in the US is 1 in 8. This risk is slightly increased for women who deliver their first child after age 30. If a woman decided to undergo fertility treatment, her risk for breast cancer is not increased say to 1 in 6 because of that above her baseline risk

Congenital abnormalities

There is also no conclusive evidence that congenital abnormalities in babies conceived after fertility treatment is significantly increased after fertility treatment, for the vast majority of couples. In any population in the world, the incidence of birth defects after natural conception is 3-4% (not zero). This is the baseline risk. If a couple undergo fertility treatment, there no proof that that incidence is increased, say to 5%, compared to couples that declined fertility treatment. Many women seeking fertility treatment are older and are at increased risk for chromosomal abnormalities. Also infertility itself appear to be a risk for factor for slight increase in birth defects. But there is no evidence that medical procedures themselves increases the risk for congenital abnormalities. There are some special situations e.g severe male factor that even associated with further increase in risk of abnormalites, so a couple specific risk should be discussed with your reproductive endocrinologist. Note also that becoming pregnant at a younger age (with or without  fertility treatment) reduces your risk for chromosomal abnormalities.

Results

You are certainly worried about the result of fertility treatment. That may make some women fearful of proceeding with treatment. Do confront this heads on. Ask your reproductive endocrinologist to give you a customized chance for pregnancy and delivery. Generally, fertility treatment is ultimately very successful. Over 60% of women seeking treatment ultimately deliver a baby or more after fertility intervention. There are many factors that indicate high chance for success, prior to starting treatment: age, ovarian reserve markers, the order of the cycle (first and second cycles are more successful)..

Long Term Effects

Outcomes of babies and young adults conceived after ovarian stimulation and IVF are definitely a long term concern. The first baby conceived at delivered following IVF was in 1978. Since then, approximately 1% of the world population are born after IVF. The scientific community have long term follow up data on babies born after fresh and frozen embryo transfer. There is even data on the third generation of babies (children of women who were conceived after IVF).

Egg freezing recently gained ground into as a procedure that broadens reproductive options for women. There are no long term data, nor a large number of babies (millions) conceived after egg thawing.

Why you should not be afraid of fertility consultation and fertility treatment

Fertility Consultation

The majority of women undergoing a fertility consultation turns out to have no specific fertility factors and simply regular intercourse is advised. A fertility consultation is crucial in identifying risk factors (e.g genetic, multiple pregnancy) and to estimate odds for a healthy baby without or with treatment. Here is an example. A Caucasian couple are seeking fertility treatment. No fertility factors found, female partner is young. The only abnormality found is that they are both carrier for cystic fibrosis gene mutation (risk of transmission to baby is 25%). Same example apply to an African American couple in the case of sickle cell anemia. Would you want to know this? Another example, you are young but on fertility testing it was found that both of your fallopian tubes are blocked  and you may need help conceiving. Is this an important information for you to know? Knowledge is very important, even if you decide not act upon.

Fertility Treatment Complications

Multiple pregnancy: is definitely the most dreaded complication of fertility treatment. There are many steps in evaluation and treatment that can minimize the risk of multiple pregnancy to a rate close to natural conception. Avoiding ovarian stimulation and IUI in favour of IVF with single embryo transfer appears to be the most important treatment decision that can minimize multiple pregnancy. IUI appears more conservative but actually that is not true. IVF with a single embryo transfer is more conservative due to lower risk for multiple pregnancy. Acceptability of fetal reduction is also another issue that should be discussed before starting treatment. The indiscriminate use of clomid appears to contribute the largest magnitude of risk for multiple pregnancy due to its widespread use without monitoring.

Ovarian Hyperstimulation Syndrome: is largely preventable complication through judicious use of fertility medication and avoiding the use of hCG as a trigger shot in favor of using lupron. An astute reproductive endocrinologist is able to keep this complication to a bear minimum.

Fertility Treatment Results

From one aspect the success rate of fertility treatment (per treatment cycle) is a factor of female medical factors and quality of fertility treatment she receives, if needed. On the other hand, the majority of courageous women who persevere, do get pregnant with fertility treatment. Those who are very unlikely to conceive are identified early on during evaluation and are should counseled accordingly. Women who do get pregnant do not write about it in lay media. Because the chance for conception is personal, you should seek to know your own chance for conceiving fertility treatment success, paying no attention to what your peers say or what you read. They cannot in any way reflect your own odds for success.

Long term effects of fertility treatment

Data on long term outcomes of young adult conceived with fertility treatment are reassuring of normal development and no significant abnormalities. In relation to egg freezing, there are reports of about a 1000 babies followed for short interval. They appear to show no increase in abnormalities. There are no long term follow up studies of babies conceived from thawed eggs.

The anxiousness about fertility treatment is natural, considering its intimate relationship to our life. Input from lay media and peer anecdotal stories is skewed and not readily applicable to anyone else. Irrespective of the decisions you make, knowing the facts about fertility treatment, personalized to your own personal medical reality is probably empowering and can prevent harm even if you decide not to pursue fertility treatment.

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Ten Reasons why You Should not Use Clomid for Fertility Treatment

Ten Reasons why You Should not Use Clomid for Fertility Treatment

Ten Reasons why You Should not Use Clomid for Fertility Treatment,

Not the Way your Using it Anyway

Ten Reasons why You Should not Use Clomid for Fertility Treatment, Not the Way your Using it Anyway. Clomiphene citrate (clomid) was the first medication introduced for fertility treatment (1960s). It works through masking of estrogen receptors in the brain. The brain, blind to estrogen in the blood, starts pouring FSH, the protein that drives development of dormant follicles in the ovary.

When one considers a fertility treatment: not only the pregnancy and delivery rates per cycle is considered, but also the time to conceive (TTC) and the complication rate especially multiple pregnancy. Clomid is a very attractive medicine to women and gynecologists, alike. It is an oral medication, easy to use for both general gynecologists and women seeking fertility treatment. It is also cheep. It is successful in inducing ovulation in 90% women that do not regularly ovulate e.g. polycystic ovary syndrome. Response to clomid is modest in most cases (1-2 follicles).

In spite of all these advantages, there are many other disadvantages. It, most likely, will not improve the odds of conception in regularly ovulating women. Its indiscriminate use, in The US and worldwide (without ultrasound monitoring of ovarian response), probably makes clomid the drug responsible for multiple pregnancies over all other forms of fertility treatment. Although clomid is successful in inducing ovulation in 80-90% of well selected patients, only 20% become pregnant. This discrepancy happens because of undesirable effects of clomid on the lining of the uterus (thin) and cervical mucus (thick). In my opinion though, many clomid cycles fail due to its in women that are not destined to benefit from it. Those are older and regularly ovulating women with unexplained infertility as opposed to suitable candidates: younger non-ovulating women. Clomid offers little help to women with unexplained infertility (ovulating) because in these women, the majority do not conceive because of chromosomal abnormalities in the eggs. Clomid commonly does not induce superovulation (many follicles) to partially compensate for abnormalities in the eggs.

Do Not Use Clomid Unless

1. Preconception labs are normal. Many patients are prescribed clomid without a complete fertility workup, including genetic screening. If you and your partner are carriers of cystic fibrosis or sickle cell anemia gene abnormalities, for example,you are at risk of transmitting these diseases to your future children (1:4). Genetic screening should be performed BEFORE starting fertility treatment. It does not help you to detect these abnormalities after pregnancy ensues. Decline clomid or any other fertility treatment without proper preconception history and lab tests.

2. Evidence of patent tubes. After ovulation induction, using clomid, the eggs has to be picked up by the fallopian tubes. Sperm also has to enter the fallopian tube to allow fertilization. Completely blocked fallopian tube may prevent the egg and sperm to meet. Partially blocked fallopian tube may allow fertilization but the the embryo may become stuck in the tube leading to ectopic pregnancy.

3. Near normal sperm analysis. A sperm concentration of < 15 million per mL and movement < 50% may reduce the odds for fertilization and reduce the chance of pregnancy after clomid treatment.

4. If you ovulate regularly. Together with normal sperm analysis and open tubes, that indicates you have unexplained infertility. The most likely cause for not conceiving is chromosomal abnormalities in the eggs. We cannot fix chromosomal abnormalities if the egg but we can induce the ovaries to produce more eggs. More mature eggs means more chance of producing a normal egg. Clomid induces the ovary to produce 1-2 eggs in most cycles, thus does not address effectively egg abnormalities. On the other hand, if you are young and do not regularly ovulate, clomid is able to induce ovulation and potentially solve your problem.

5. Without monitoring. Some women are more sensitive to the effects of clomid. They respond by producing a large number of follicles. The safest approach here is to cancel the cycle and restart another treatment with a lower dose. Although the risk of multiple pregnancy with clomid is about 10%, women that respond with producing a large number of follicles are at a much higher risk. Careful monitoring of response, using vaginal ultrasound, is required in all clomid cycles.

6. Use the lowest dose that leads to ovulation (start with one tablet per day). Do not increase the dose if ovulation took place at a lower dose. Most patients get pregnant at adoses of 50 to 150 mg (1-3 tablets) per day. Increasing the dose does not increase the chance for pregnancy and increases the side effects of clomid e.g thin endometrium, chick cervical mucus..

7. Do not use clomid more than 3 months (6 months life time max). The majority of women get pregnant in the first three months of treatment. If you are younger and ovulate on clomid and would like to try few more months, then 6 months is the maximum amount of time you should use clomid in your life time.

8. Clomid less likely to lead to pregnancy  delivery in women >38y. In women 38 or older with unexplained infertility, there is good evidence that clomid-IUI is inferior to IVF. The vast majority of women in that age group that start on clomid end up switching to IVF to achieve pregnancy.

9. Expertise with optimizing clomid cycles: clomid cycles should be supervised by a physician with expertise in clomid dosing, use of repeat courses, use of adjuvant treatments as estradiol and IUI. This enables maximizing the benefits of fertility treatment and tailoring treatment to individual woman.

10. Use letrozole before using clomid. Accumulating evidence from many studies, including randomized clinical trials, indicates that letrozole is superior to clomid in terms of achieving pregnancy. Applying the same principals above, letrozole should be considered as the initial treatment for anovulatory infertility.

On tailoring Fertility Treatment to Specific Patient’s Needs

In too many times, the use of clomid for fertility treatment is a stark example of tailoring patients to treatments familiar to general gynecologists, rather than individualizing fertility treatment to women biology and fertility needs, citing ease of use, perceived safety and familiarity. Cheep treatments that appear safe can quickly become aggressive and unsafe if they lead to low pregnancy rate and high multiple pregnancy. The time lost treating older patients with clomid for a prolonged periods can be detrimental to their ovarian reserve and can minimize the chance for eventually achieving pregnancy and delivery.

On men and clomid

There is no proof that men benefits from the use of clomid and similar treatment to improve sperm parameters. Specifically, there is no evidence that female partners of men that were prescribed clomid conceive at higher rates. With very few exceptions, clomid should not be used to treat male factor infertility.

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IUI or IVF for Unexplained Infertility

IUI or IVF for Unexplained Infertility

Choosing IUI or IVF for unexplained infertility can be confusing. If you have been trying to conceive for several years and initial fertility tests does not reveal any abnormalities (open fallopian tubes, normal sperm and regular ovulation), you will be diagnosed with unexplained or idiopathic infertility.

Possible treatments include ovarian stimulation-IUI or IVF

What should you consider before deciding between IUI and IVF?

IVF In Vitro Fertilization

IVF In Vitro Fertilization

 

Intrauterine Insemination (IUI)

Intrauterine Insemination (IUI)

  1. Pregnancy rate: IVF is associated with higher pregnancy rate than IUI, approximately 3 times. In women less than 35 pregnancy rate is approximately 50% with 2 embryo transfer and 35% with one embryo transfer versus 10-15% per one cycle of IUI.
  2. Multiple pregnancies: When ovulation is stimulated using injection medications (FSH) the chance for twins is about 30% and higher orders multiple pregnancies 1-3%. Multiple pregnancies is associated with increased risk of preterm delivery with possible long term effects on the newborns. Compared to IVF with single embryo transfer, the chance for twins is 1% and higher order multiples is very low. Actually IVF with single embryo transfer is the more conservative approach in women at risk for multiple pregnancies with IUI.
  3. Cost: IVF is more costly due to the requirement of lab procedures to fertilize the eggs and culture the embryos. If multiple pregnancies at it complications are factored in IVF with single embryo transfer appears to the cheaper approach.

Sound evaluation by a reproductive endocrinologist can give you the advice and guide you through the decision.

Women with high ovarian reserve as PCOS are better served in general by avoiding injection medication + IUI and proceed to IVF if oral medication e.g clomid do not succeed. Women with reduced ovarian reserve generally will have a high odds for getting pregnant with IVF than IUI.

 

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