Winter 2011
Uterine transplantation?? Believe it or not, this has now been successfully performed in animals, according to a recent article in Reproduction Review. And humans may not be too far away! The surgical techniques are now being perfected, and immunosuppressive regimens are being defined that will not cause significant ovarian damage
Summer/Fall 2010
Egg freezing in newly diagnosed cancer patients.
A recent article in Fertility and Sterility featured an “outside the box” way to stimulate patients and perform
egg retrieval. Typically, newly diagnosed cancer patients want to begin treatment asap, to minimize the chance of cancer
spread. Unfortunately, most ovarian stimulation protocols require waiting for down-regulation with GnRH agonists or waiting
until the next menses to begin the stimulation drugs. The authors of this German study decided to begin the stimulation no
matter when the patients presented, even though they often had just ovulated or had relatively high hormone levels. The found
that the stimulations went well, requiring just slightly more medication and time, and perhaps resulted in a couple of less
eggs. However, the avoidance of delay for these patients was well worth these changes. We plan to begin such a protocol the
Southeastern Fertility Center in the near future.
Natural Cycle IVF:
A group from Italy recently published their experience of 500 consecutive natural IVF cycles. In “naturaly cycle”
IVF, medications are not used to stimulate the ovaries, therefore usually only one egg develops. As a consequence, it is often
not possible to perform a successful retrieval, or to obtain an embryo for transfer. Still, patients younger than 35 showed a
pregnancy rate of about 30% per transfer, patients 36-40 had a 20% pregnancy rate per transfer, and those older than 40 just
10%. Therefore, the authors felt that this approach was justified in younger women who were poor responders. While we
don’t typically use a natural cycle approach at the SEFC , we do allow poor responders to complete their cycles if we
can obtain at least a few well-developed follicles, and we have seen similar success rates even in this difficult group.
Spring 2010
Vitamin D and PCOS:
While the general medical literature continues to show the high rate of Vitamin D deficiency in the U.S., and the diseases it is associated with, the reproductive literature has also noted some connections. In particular, women with PCOS (polycystic ovarian syndrome) have a higher incidence of 'hypovitaminosis D' than other infertile women. Although it is not clear if this contributes substantially to the PCOS process, we strongly recommend Vitamin D supplementation in this setting. The easiest and cheapest way to do this is with prescription strength Vitamin D2, 50,000 units weekly for 3 or 4 weeks.
Diagnosis Endometriosis:
2 recent articles in Human Reproduction have proposed a new way to diagnose endometriosis. Performing an endometrial biopsy can be used if the specimen is stained with special techniques which allow the identification of nerve fibers. The specificity and sensitivity of these tests are high when used in the appropriate setting/patient population. While it is still too early to recommend this test, it could turn out to be the best way for identifying this disease without performing a laparoscopy. Stay tuned...
Robotic surgery:
More and more operations are being reported using the surgical Robot. The advantages of this type of operation include smaller incision sites, more rapid healing, and improved dexterity and visualization when compared to laparoscopic procedures. While there definitely seems to be a place for this technology, my fear is that it will be overused and 'sold' to consumers. The robot has several distinct disadvantages as well, including a significant learning curve for the surgeon, substantially longer operating times, and much higher costs. We as a profession will have to monitor our use of this tecnology, especially as we continue down the road to rationing of health care under the
newly passed U.S. law.
Summer / Fall 2009
The CDC has just released the 2006 national ART surveillance system (NASS) data, in compliance with the Fertility Clinic Success Rate and Certification Act of 1992. There were a total of 138,198 ART cycles. These cycles resulted in the birth of 54,656 babies.
48% of the babies were born as a part of multiple deliveries (twins, triplets, etc.). The states with the highest number of ART procedures were California, New York, Illinois, New Jersey and Massachusetts (all states with mandated insurance coverage of infertility).
Got DOR?
A recent article in Fertility and Sterility reviewed studies on how to help “poor responder’ patients in Assisted Reproduction. These are, in general, patients who have Diminished Ovarian Reserve (low egg supply). This meta-analysis showed that only the addition of Growth Hormone, and embryo transfer on day 2 (as opposed to day 3 or 5) could be shown to improve pregnancy rates in these groups. This is interesting in that GH has largely been felt to be non-helpful in IVF stimulation.
Hepatitis C and Reproduction.
Another article in F & S looked at effects on semen parameters in men treated for Hepatitis C. Hep C is a serious and increasingly prevalent disease in the U.S. The disease can often be eradicated by a combination of drugs – Interferon and Ribavirin. There has been much uncertainty about what effects these drugs have on both male and female fertility. This study showed that there is significant and long term damage to sperm DNA after administration of these drugs. The effects of such damage on fertility is uncertain, but given the low cost and wide availability of sperm freezing, I think that men should consider this option prior to undergoing such therapy for Hepatitis C.
Winter / Spring 2009
Obesity effects on fertility quantified:
In a recent article in Human Reproduction, a European group studied a large group of couples wanting to conceive. They found that for every unit of Body Mass Index (BMI)
greater than 30, there is a 4-5% lower chance of pregnancy each month. For reference, a BMI of 20 – 25 is “normal”, 26 – 30 is “overweight”
and 31 and above is “obese”. To find your BMI, click on this link :
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/00binaries/bmi-checkbook.pdf . To
put this in more practical terms, a 247 pound woman who is 5' 6” tall has a BMI of 40. Therefore, her chances of becoming pregnant each month is only half that of
a 130 pound woman of the same height! As Tennessee has the second highest rate of obesity in the nation, we are particularly concerned about this problem, and agree with
other health professionals that obesity has truly reached epidemic proportions in America.
Have you stopped your Metformin?
Last year, a study presented at the national meeting of the ASRM showed research data which indicated that metformin (Glucophage, Fortamet, and others) was helpful as an
adjunct in helping women with PCOS conceive. Unforntunately, many doctors stopped using metformin in their patients after this study was published. We disagreed
with the conclusions of this study, because we felt that the it had been conducted poorly. While we do believe that metformin is not needed to treat ALL women with
PCOS, it can be quite helpful as an adjunct in several types of patients. This was recently confirmed in another study from Human Reproduction out of the
Netherlands. They found that Metformin did in fact help certain groups of patients, especially older and more obese patients who had extra fat centrally.
Furthermore, we have found that many of these patients belong to another group whom benefit from metformin use – those with high testosterone levels and insulin
resistance. Finally, the use of metformin is also helpful in women whom have “failed” Clomid. We find many 'clomid failures' will respond to clomid
once they are on an adequate does of metformin. SO, if you have been taken off your metformin and aren't doing as well, talk to your physicians about getting back on
this valuable medication!
Summer 2008
A very nice study recently appeared in the European journal Human Reproduction. It showed that, in subfertile couples, every unit of BMI over 30
resulted in a drop of 4-5% in monthly fertility. This is important for several reasons. Obesity is an epidemic in the U.S. and many developed countries around the world. It is no doubt contributing to the growing rate of infertility in our population. Needless to say, this is a self-induced state of infertility which can be overcome by healthy eating and exercise.
To put this in simple terms, a 5 foot, 4 inch female who weights 235 pounds has a BMI of 40. This is 10 units above a BMI of 30, which is the lower limit of
what is considered obese. Multiply this number (10) by 4-5% and you will see that this individual has a 40-50% lower chance of getting pregnant over any time period than a normal weight woman. Conversely, by losing enough weight to reduce her BMI to 30, she can effectively double her chances of becoming pregnant! Want to know what your BMI is?? Just copy and pace the URL below into your web browser and find out. There, you will also find tips on how to achieve a normal body weight.
http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.htm
You can also find more about Healthy Eating and Exercise by clicking here.
Spring 2007
Why Bother? – Another recent article in Fertility and Sterility has added to the literature that ultrasound tracking of follicles with injection
of hCG to cause ovulation does NOT improve the pregnancy rates in ovulation / superovulation cycles with clomiphene citrate (Clomid). We often see patients who have transferred from another practice where this is done routinely, and they expect similar measures. While there is probably no harm in this practice (only one study has shown a lower pregnancy rate), the additional cost and time involved are clearly not justified by the results. On the other hand, for patients who cannot detect the LH surge using ovulation prediction tests, this is the only method available to ensure proper timing of insemination or intercourse.
No longer the ‘Lone Ranger’ – For many years, Clomid was the only orally active agent for treating infertile anovulatory patients.
Unfortunately, it is still the only medicine used by many physicians dealing with PCOS and other conditions which inhibit ovulation in women. I say “unfortunately”, because there is a high percentage of patients who will not ovulate or conceive with Clomid, yet they will do so with other drugs such as metformin, Tamoxifen, or Femara. The recent literature is awash with reports on these agents. These medications can also be given in combinations so that it is relatively rare now that women cannot be made to ovulate with oral meds. This is important, because injectable medications are not only expensive, but also result in a higher rate of twins, triplets, and beyond. Talk with your physician to see if one of these medications may be right for you, or call for an appointment to discuss this.
New testing for ovarian reserve – A number of reports have been published lately documenting the effectiveness of a new test to determine ovarian reserve,
or egg supply. Previously, checking serum FSH levels, with or without a ‘Clomid challenge test’, was our only option for determining the egg supply, health of those eggs, and the potential response to ovulation induction and IVF. Now, AMH, or Anti-Mullerian Hormone appears to be showing promise as an alternative to FSH testing. The advantage to AMH is that it is constant throughout the menstrual cycle, and so does not require testing on specific days, which is often a significant inconvenience to patients.
