It seems like there is a story almost every day about threats to our health from products we use almost every day. Today's threat is to reproduction. The Los Angeles Times reported, "In a study published today, a decreased likelihood of pregnancy is linked to flame-retardant chemicals in foam furniture, electronics, fabrics and more. Californians may have higher exposures compared with residents of other states.  Their study joins several other papers published in the last two years suggesting that the chemicals, polybrominated diphenyl ethers, or PBDEs, affect human health.

PBDEs have been used as flame retardants for four decades and are found in foam furniture, electronics, fabrics, carpets and plastics. The chemicals are being phased out nationwide, and certain PBDEs have been banned for use in California. But they are still found in products made before 2004. Californians may have higher exposures compared with residents of other states because of the state's strict flammability laws, according to the study authors, from UC Berkeley."

I have been impressed with the increasing numbers of men I am seeing with motility and morphology issues with no apparent reason and have thought that environmental factors may be partially to blame. This is just another of those potential threats.

There is now more evidence that women who have two copies (are homozygous) of mutations for genes that can cause inappropriate blood clotting (thrombophilia) are not as likely as previously thought to suffer from some pregnancy complications. The Jamuary 2010 issue of the medical journal "Obstetrics & Gynecology" contains two articles and an editorial, "The Truth About Inherited Thrombophilias and Pregnancy" discouraging random testing for thrombophilias, and when found, treatment with anticoagulants.

One study shows that although the prothrombin gene mutation results in an increased risk for the development of certain pregnancy complications in asymptomatic women, another thrombophilia, MTHFR, may actually protect against those complications. Their overall conclusion was that the majority of asymptomatic women who carry an inherited thrombophilia mutation have a successful pregnancy outcome. The other study showed no association between the prothrombin G20210A mutation and pre-eclampsia, premature separation of the placenta or small-for-gestational age babies in a low-risk group of women. These findings raised the question of the need for screening asymptomatic women for this mutation.

Based on these studies and others, Dr. D. Ware Branch wrote an editorial expressing concern that doctors are prescribing heparin and other anticoagulants too frequenlly after testing women who had almost any adverse pregnancy experience. The enthusiasm for using heparin and its derivatives comes from success in heparin treatment of antiphospholipid syndrome in pregnancy. He believes that a primary cause of an adverse pregnancy outcome may be inflammation, not thrombosis which would not be helped by anticoagulants. Using heparin and related drugs can lead to serious complications.

Regarding this question, infertility specialists deal mostly with patients who have experienced recurrent early pregnancy and Dr. Branch points out that two prospective trials show no improvement in live birth rates using low molecular weight heparin in women with antiphoispholipid antibodies and recurrent miscarriage. Years ago there was a great deal of enthusiasm for testing women with recurrent miscarriage and other pregnancy complications for thrombophilias and antiphospholipids and, when found, treating with heparin or one of its derivatives. Now the tide seems to be turning against even testing. Definitive multi-center studies are needed to determine "The Truth."

A question that I occasionally hear is whether inherited tendencies to clot abnormally (thrombophilias) are a cause of infertility or early pregnancy loss. Most people asking this question have gotten this notion from surfing the internet. Our group’s opinion on the subject has been that these conditions are not major factors in either early pregnancy loss or infertility.

A study in the December 2009 online edition of the medical journal “Fertility & Sterility” found no significant difference in the prevalence of three genetic mutations associated with the increased risk of thrombophilia (Factor V Leiden G1691A, prothrombin G20210A, and methylenetetrahydrofolate reductase [MTHFR] C677 T) in 100 infertile women with unexplained infertility when compared with 200 control fertile women without an infertility history.

There can be issues in late pregnancy in women who are homozygous (have two copies of the mutant gene) for some of these conditions and these women may require significant anticoagulation. But prevailing current thinking is that women with infertility or early pregnancy loss do not need significant anticoagulation even if homozygous for these genetic mutations.

This is important because anticoagulation beyond one baby aspirin a day may result in health and potentially even life-threatening complications

I hate when this happens. Fortunately it is fairly unusual, but devastating. We start a retrieval with everything going well but the embryologist does not find any eggs. It's called Empty Follicle Syndrome. The follicles are not really empty but the hCG administered to start the process of releasing the egg has not worked. What do we do? In the cycle in which it happens one strategy is to stop the retrieval, readminister the hCG and repeat the retrieval 35 hours later. According to a study from Harvard published in the December 2009 issue of Fertility and Sterility, this does not result in a viable pregnancy.

The authors conclude, "This represents the largest case series to date regarding repeat administration of hCG in so-called “false” empty follicle syndrome cycles and indicates that patients should be counseled regarding the low likelihood of cycle success after repeat administration of hCG in this setting." At Reproductive Partners we have employed strategies to overcome this problem in future cycles, once we are aware of the problem. 

One myth about unexplained infertility is that it may be caused by a hereditary thrombophilia, a mutation in a gene such as prothrombin, MTHFR or Factor V Leiden, mutations that can predispose an individual to abnormal blood clotting. They have also been postulated as a cause of recurrent early miscarriage. Neither cause-and-effect relatioship has been proven and most authorities do not believe one exists. Now there is additional evidence that these mutations do not cause unexplained infertility. A study reported in the December issue of Fertility & Sterility found no significant difference in the prevalance of these mutations in 100 women with unexplained infertility compared to a fertile control group of 200 women.

There is a saying in medicine, "If you hear hoofbeats, don't think of zebras."  This concept can now be considered a zebra.

One concern that has been raised in the past about fertility drugs has been that they were thought to increase the change of developing ovarian cancer later in life. Now there is another piece of evidence that agrees with most recent studies that there is no link.

A study reported in the British Medical Journal evaluated the effects of fertility drugs in 52,362 women being treated for infertility in Danish fertility clinics and hospitals between 1962 and 1998. They looked at four groups of fertility drugs (gonadotropins like Bravelle, Follistim and Gonal-F), clomiphene citrate (Clomid), human chorionic gonadotropin (hCG) and gonadotropin-releasing hormone). There was no overall increase in ovarian cancer with use of any of the groups analyzed.

Women who carry the BCRA-1 and BCRA-2 genes may be predisposed to both infertility and ovarian cancer, but this increased risk is not based on using fertility drugs.