Archive for the ‘Education’ Category

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For unexplained infertility-IUI with drugs or IVF, which is best?

Monday, August 30th, 2010

Conventional treatment for couples experiencing unexplained infertility has usually consisted of three cycles of clomiphene (CC) with IUI, followed by three cycles of gonadotropins (FSH) with IUI and then IVF if those conservative measures did not work.

A study in the August 2010 issue of Fertility & Sterility looks at the time it took to establish a pregnancy that led to a live birth and cost-effectiveness of either conventional treatment with three cycles of clomiphene citrate CC/IUI, three cycles of gonadotropins FSH/IUI, and up to six cycles of IVF or an accelerated treatment that omitted the three cycles of FSH/IUI.

An increased rate of pregnancy was observed in the accelerated arm compared with the conventional arm. Median time to pregnancy was 8 and 11 months in the accelerated and conventional arms, respectively. Per cycle pregnancy rates for CC/IUI, FSH/IUI, and IVF were 7.6%, 9.8%, and 30.7%, respectively. Average charges per delivery were lower in the accelerated arm compared to conventional treatment. The observed incremental difference was a savings of $2,624 per couple for accelerated treatment.

In my experience many couples are bypassing the option of FSH/IUI, not only because of the increased time and expense to success, but also because IVF provides more control over high-order multiple pregnancies as we transfer fewer embryos.

Arthur L. Wisot, M. D.

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What treatment works best for PCOS?

Monday, August 9th, 2010

Polycystic Ovarian Syndrome (PCOS) is a condition that involves a combination of symptoms including irregular or absent cycles and male-type hormone (androgen) symptoms, Many women with PCOS also have difficulty controlling their weight. Treaments recommended for PCOS vary widely ranging from drugs like metformin designed to reduce resistance to the hormone insulin which is thought to be a cause of the condition, to drugs to induce ovulation such as clomiphene to lifestyle changes such as significant weight loss.

But which is most effective?  A study in the July 2010 edition of Fertility and Sterility compared  metformin, clomiphene, metformin and clomiphene and weight loss. The clinical pregnancy rate was 12.2% in clomiphene group, 14.4% in metformin group, 14.8% in clomiphene + metformin group, and 20% in lifestyle modification group. The lifestyle modification group achieved a significant reduction in waist circumference, total androgen, and lipid profile, not only improving their fertility, but general health as well.

The problem is that very few patients are able to lose enough weight to achieve a pregnancy with lifestyle modification alone and most need to also use the drugs. But if they can achieve it, their fertility and general health will benefit substantially.

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Dr. Wisot not quoted in US Weekly

Monday, August 2nd, 2010

RPMG's Dr. Arthur Wisot was interviewed for a story in the August 9th issue of US Weekly, "Baby after Cancer." The story chronicled Christina Applegate's journey from breast cancer through bilateral mastectomy to now being pregnant.

Dr. Wisot was interviewed about the dangers of pregnancy after breast cancer, an aspect of the story they completely ignored in the article. The most important point he made to them was the option now for women to preserve their fertility using egg freezing prior to starting chemotherapy, an aspect of the story they also ignored. According to the story Christina Applegate did not undergo chemotherapy or radiation so she could pregnant, instead choosing to have a bilateral mastectomy which would not affect her fertility.

Egg freezing is now a very realistic option for women choosing to delay having a family as well as women surviving cancer.

Dr. Wisot has been quoted in many media outlets including celebrity magazines such as People Magazine, US Weekly and Life & Style.

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Does IVF increase the chance of identical (monozygotic) twins?

Tuesday, July 20th, 2010

It does, at least according to a study in the July 2010 issue of Fertility & Sterility.

The authors surveyed 4976 clinical pregnancies from one large IVF center and found ninety-eight cases of monozygotic twins (MZTs) were diagnosed after first-trimester ultrasound evaluation (2% incidence). In naturally conceived pregnancies the incidence is about 0.25-0.5%. 

The incidence in women transfering embryos from their own eggs was 1.7% but was 3.3% with donor eggs; however, younger women (<35 years old) using their own eggs displayed a similar rate (3.1%) to women using donor eggs.

Eighty MZTs occurred after fresh day-5 transfer; only 14 followed fresh day-3 transfer (2.6% vs. 1.2%). The MZT incidence in day-3 transfers without assisted hatching was not different from those with hatching (1.3% vs. 1.1%). In addition, MZT incidence did not differ significantly whether or not ICSI was performed (2.4% vs. 2.0%). Four MZTs occurred after frozen-thawed embryo transfer (0.8% incidence).

The good news is that ninety-five percent of all placental arrangements were confirmed as having two amniotic sacs on obstetric ultrasounds, making them safer pregnancies than when both babies are in the same amniotic sac.

The take-home message is that this is a good reason for young women and those using eggs from a young donor to seriously consider elective single embryo transfer (eSET) so if a set of identical twins does occur and the other embryo implants one does not have to deal with a triplet pregnancy.

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Genetic screening for sperm donors

Monday, July 12th, 2010

According to a survey of 26 sperm banks reported in the July 2010 edition of Fertility and Sterility, sperm banks vary considerably in their practices of genetic screening of donors.

Cystic fibrosis carrier screening, chromosome analyses, and hemoglobin evaluations are performed on the majority of sperm donor applicants. Tay-Sachs disease carrier screening is performed on most donors with Jewish heritage but there is significant variation in screening for other disorders .

Since the screening of sperm donors is not usually complete, we recommend that all of our patients do a fairly comprehensive screening of themselves or their partner (if they are using their partner's sperm) for recessive genetic diseases. We use Counsyl screening which screens over 100 recessive diseases using a saliva specimen. Of course there are still some genetic diseases not covered such as the ones that are dominant and others that are not in Counsyl's panel. One still needs to rely on family history and ethnicity to determine if any other testing is needed.

We are fortunate that technology exists to determine if anyone is a carrier of an abnormal gene since we can now employ preimplantation genetic diagnosis (PGD) for single gene defects to detect whether an embryo is affected before transfer, thus reducing the chance of a child with the genetic disease without needing to consider termination of a pregnancy.

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Prognosis is good for infertility patients after miscarriage in a spontaneous pregnancy

Friday, July 9th, 2010

One of the most disappointing scenarios is when a couple who has tried to conceive for a long time miscarries their hard-fought-for pregnancy. A study reported in the July 2010 issue of Fertility & Sterility shows that the prognosis for a subsequent healthy pregnancy is good.

They looked at 5,663 subfertile couples, of which 1,098 (19%) conceived spontaneously. Among these 1,098 couples, 199 (18%) miscarried . They were able to obtain follow-up for 171 couples, of which 95 conceived again within 24 months of follow-up. Of these 95 pregnancies, 86 (91%) were ongoing. The cumulative spontaneous ongoing pregnancy rate after 24 months was 70% . Keep in mind that these were couples who concieved even without treatment.

This is reassuring for subfertile couples who experience a treatment-independent pregnancy resulting in a miscarriage. They have very good prospects of a spontaneous ongoing pregnancy in the near future.

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If (insert name of actress or singer) can have a baby at (insert age over 42), why can’t I?

Wednesday, June 16th, 2010

That's a question I am frequently asked.

In an article in the June 21st issue of the medical journal US Weekly, "Baby After 40." they give examples of current and recent pregnancies as "Hollywood's 'miracle' moms beat the odds."

But can they beat the odds just because they are famous? I think not. For many of them the "miracle" is egg donation but they are not willing to admit it. Just look at our age related live birth success rates  for the last 5 years at above age 40 and contrast those with egg donation in the next column.

When you see a pregnancy above age 42 it could be a miracle that beat the odds, but more likely it's egg donation.

I wish some of these famous people would come clean and admit it's egg donation because they do other women a disservice by giving them unrealistic expectations.

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IVF or IUI for Women Over 40?

Monday, June 7th, 2010

Selection of a treatment method for women over 40 whose main limitiation in conceiving is their age can be difficult. If they are in the "unexplained infertility" group with open tubes, no significant gynecologic problems and a partner with normal sperm parameters the common choices are to try injectable fertility drugs (COH) with artificial insemination (IUI) or in vitro fertilization (IVF). A recent study in Fertility & Sterility compared groups of women aged 38-39 with a group over 40.

The women who were 38–39 years old had an overall live birth rate of 6.1% per cycle, with no live births occurring after the second cycle, and women  over 40 years old had an overall live birth rate of 2.0% per cycle, with all births occurring in the first cycle. These data suggest that the efficacy of COH/IUI cycles significantly decreases with age, but women aged 38–39 years had reasonable success during the first two cycles. However, for women aged over 40 years, no benefit after a single cycle of COH/IUI was observed. Women over 40 years should be considered for in vitro fertilization as the first choice or after one failed COH/IUI cycle.

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How long to abstain before an IUI?

Saturday, May 22nd, 2010

Traditionally a two day period of abstinence has been recommended prior to ovulation or an IUI. A recent study in the March 2010 issue of Fertility & Sterility suggests that shorter period of absintence results in better pregnancy rates. In this study an ejaculatory abstinence period of less than 2 days before IUI produced the highest pregnancy rates per cycle compared with longer intervals of ejaculatory abstinence. This higher conception rate occurred despite a lower total number of motile spermatozoa inseminated.

This may be explained by the observation that shorter periods of abstinence can result is less fragmentation in the DNA of the sperm. This is another demonstration of the fact the quality can be more important than quantity. It's important that those trying to conceive consult their doctors to determine the best period of abstinence in their case.

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Your sperm are what you eat

Tuesday, April 20th, 2010

There's more evidence that a man's diet can not only affect his potency, but the quality of his sperm as well. In a study reported in Science Daily a  little-known omega-3 may have implications for treating male infertility. In a study done in mice that lacked the gene responsible for an enzyme important in making the omega-3, docosahexaenoic acid (DHA), male mice are basically infertile, But, when DHA was introduced into the diet, fertility was completely restored.

This is the first time that the importance of DHA to male fertility has been shown this directly, although some studies have suggested that male fertility patients with low sperm counts and less motile sperm tend to have low levels of this fatty acid.

The message here that may apply to humans is to make sure your intake of Omega-3 fatty acids is adequate. For more information and references see the Lifestyle and Fertility pages on our website.

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