IVF Children are Taller and Have Better Cholesterol Profiles

A number of studies have been performed to determine whether children conceived as a result of IVF have any greater health risks than children conceived in other ways. Some studies indicate that IVF children may be at greater risk for complications during pregnancy and birth defects. Other studies argue that IVF children may be smaller at birth than other children.

A recent study conducted with New Zealand school-aged children compared 50 children conceived as a result of IVF to 60 who were conceived naturally. The children were aged 7 to 9 at the time of the study.

The authors of this study found that 15% of the IVF group was smaller at birth than expected for their gestational age. However...


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IVF children taller

Assisted zonae hatching - AZH - does not increase IVF Success in women with endometriosis

Assisted hatching or AZH is a procedure occasionally used in IVF treatment cycles. There has been great controversy regarding whether AZH increases the chances for an IVF pregnancy. Numerous studies have been conducted over the years. Some studies have suggested that there is a higher chance for pregnancy using AZH while others showed no improvement whatsoever.



The zonae is a hard protein shell that surrounds the embryo. During IVF cycles, the zonae can be seen under the microscope. Before an embryo can implant into the uterine lining, the embryo must break out of the zonae. This is known as hatching. It has been hypothesized that some embryos may have a more difficult time implanting because they cannot break out of the zonae. During IVF, the process of hatching can be assisted by either thinning the zonae or making a small gap.



Recently, a study was performed to determine whether women with endometriosis who underwent treatment with IVF would have a better chance to conceive with AZH than women who did not have AZH.



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IVF in Endometriosis Study

Stress does not reduce the success of IVF

During IVF treatment, patients frequently ask about the relationship between psychological stress and IVF success. They often express concern that their own stress might have a negative influence on the outcome of IVF. Furthermore, support groups have advanced the notion that stress reduction can result in greater IVF success. Groups offering stress reduction services have been actively promoting themselves by citing the results of small scale studies pointing to the benefit of their own services towards improving the success of IVF (at a price of course).



A recent study of 166 infertile women looked at whether stress affected the success of IVF. All of the women in this study were treated using a standard IVF treatment regimen. The women answered extensive questionnaires concerning psychological factors. The first questionnaire was filled in one month before the onset of IVF treatment and the second questionnaire was completed one hour before the egg retrieval.



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Stress and IVF success

PCOS Treatment with Zocor

Zocor-simvastatin is a medication typically used to treat high cholesterol. Recent evidence suggests that Zocor may be a useful treatment for PCOS – polycystic ovary syndrome.

PCOS Study

A recent study presented at the annual meeting of the Society for Gynecologic Investigation is the first to look at the effects of these medications in women with PCOS. Women with PCOS are often found to have high cholesterol and triglycerides.

The PCOS patients in the study were first placed on birth control pills. This was necessary because Zocor and related medications known collectively as statins, are contraindicated in pregnancy. One half of the PCOS patients also received Zocor.

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PCOS and Epilepsy Treatment

Women with epilepsy who are treated with a medication called valproate (Depakote) have a higher incidence of PCOS symtpoms. There is some evidence to suggest that the higher the dose of Depakote used, the greater the chance for developing PCOS. Stopping valproate therefore may improve signs and symptoms of PCOS.

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Egg Donation May Complicate Pregnancies

Egg donation uses the technology of in vitro fertilization - IVF to obtain eggs from one woman, the egg donor, fertilize them in the laboratory and then place the embryos into another woman, the recipient. Egg donation is most commonly used when the recipient is older and thus less likely to get pregnant using her own eggs.

Egg Donation, Complications and Age

Egg donation pregnancies have lower rates of complications such as miscarriage and Down's Syndrome since the egg donor is younger and therefore produces embryos with a lower rate of chromosomal abnormalities and thus lower rates of these problems. Some complications of pregnancy do not change with egg donation. These are problems that are based on the age of the recipient. As women age, they have a higher incidence of complications such as gestational diabetes, pregnancy induced hypertension, intrauterine growth restriction. Older women also deliver by cesarean section more commonly. The increased risks have been thought to occur equally whether or not a woman used egg donation to acheive the pregnancy.

Egg Donation Study

A recent study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society has suggested for the first time that women who conceive by egg donation may be at higher risk for pregnancy induced hypertension (PIH).

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Medical Treatment of Varicocele

Last updated / published 4/15/2005

Varicocele and infertility

Varicocele is a finding in men where enlarged or dilated veins occur in the blood vessels of the scrotum. Normally the scrotal veins have valves that regulate the blood flow. However, in some cases, the valves are absent or defective and the blood does not circulate out of the testicles efficiently. This results in swelling of the veins above and behind the testicles. 85% of varicoceles develop in the left testicle.

It is estimated that varicoceles are present in about 20% of the normal male population and up to 40% of an infertile population. It is uncertain how varicoceles may cause infertility. Some evidence points to the increased temperature of the blood raising the temperature of the testes, which then damages the sperm. Heat can damage or destroy sperm. The increased temperature may also impede production of new, healthy sperm. Another theory is that in men with varicocele, the testicular fluid which carries sperm has an increased concentration of chemicals which can damage sperm. The chemicals are called reactive oxygen species or ROS.

Previously, varicoceles have been treated using various types of surgical procedures.

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Smoking reduces IVF Pregnancy Rates

In a study about to be published in the journal Human Reproduction, infertile women who smoke were found to have lower pregnancy rates and higher miscarriage rates during treatment with in vitro fertilization - IVF.

Smoking reduced IVF pregnancy rates

Danish researchers looked at 8,457 women aged 20 to 40 who had had in vitro fertilization treatment. The patients were divided into four groups, depending on the cause of each couple's fertility problems; male fertility disorder, fallopian tube problems, other clinical explanations - such as polycystic ovaries or endometriosis, or unexplained fertility problems.

Overall, the live birth rate for smokers was 28% lower than non-smokers. Among women with unexplained infertility, the live birth rate was a third lower for smokers, at 13% compared to 20% for non-smokers. This is the same effects as would be seen for women who were ten years older. In other words, a 35 year old woman who smokes would have the pregnancy rate a 45 year old.

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Folic acid does not increase risk for twins

A recent study has disproved the notion that the use of folic acid supplementation increases the risk for twinnning.

Folic Acid prevents birth defects

For some time now, I have been recommending that women who are attempting to become pregnant should take 1000 micrograms of folic acid daily to reduce the risk of having a baby with birth defects. The birth defects are known as neural tube defects and include such problems as spina bifida and anencephaly. Recent data have shown that since these recommendations have gone into effect that the rate of neural tube defects has dropped significantly.

Folic acid, also called folate is a B vitamin found in foods such as spinach and other leafy greens, beans and orange juice. Despite the addition of folic acid to many breakfast cereals, breads and other grains, many women have a difficult time getting the required amound on a daily basis. Thus, prenatal vitamins containing folic acid have been recommended. In the United States, fortifiaction of foods has been required since 1998.

Folic acid and twinning

Some studies have suggested that the rate of twinning has risen since the introduction of fortification. The largest effect was reported in a Swedish study that reported a 45% increase in multiple gestation if a woman use folic acid before pregnancy. However, several studies since 1999 have attributed the increase risk to the greater use of fertility treatments and not from the use of folic acid itself.

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Blood test to predict tubal damage

A recent study published in the journal Fertility and Sterilityindicates that a combination of inexpensive blood tests can predict the presence or absence of tubal damafe from chlamydia infection with fairly good accuracy.

Chlamydia Background information

Chlamydia is a common sexually transmitted infection (STI) caused by the bacterium, Chlamydia trachomatis. Chlamydia infection is extremely common. Chlamydia is the most common sexually transmitted infection in the United States. The Center for Disease Control estimated that 2.8 million Americans are infected with chlamydia each year.

Chlamydia can be transmitted during vaginal, anal, or oral sex. Chlamydia can also be passed from an infected mother to her baby during childbirth. Any sexually active person can be infected with chlamydia. The greater the number of sex partners, the greater the risk of infection.

About 75% of infected women and about 50% of infected men have no symptoms of chlaymida infection. If symptoms do occur, they usually appear within 1 to 3 weeks after exposure. Women who do have symptoms might have an abnormal vaginal discharge or a burning sensation when urinating. If the infection spreads from the cervix to the fallopian tubes some women still have no signs or symptoms; others have lower abdominal pain, low back pain, nausea, fever, pain during intercourse, or bleeding between menstrual periods.

Chlamydia can cause infertility

In women, untreated infection can spread into the fallopian tubes and cause the tubes to become blocked at the very ends (distal tubal obstruction). They can also develop scar tissue around the fallopian tubes that makes it more difficult for the tube to "pick up" the egg at the time of ovulation. The problems can lead to infertility and an increased risk for ectopic (tubal) pregnancy.

Distal tubal obstruction can be detected by performing a hysterosalpingogram. Pelvic adhesions, however, can only be detected by undergoing a surgical procedure to look inside of the abdominal cavity. This is usuaully done using a technique called laparoscopy where a fiber optic telescope is inserted through the belly button under general anesthesia. Since laparoscopy is a much more invasive procedure, it is desirable to avoid it whenever possible.

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New FDA regulations will hurt egg and embryo donation

On May 25, 2005, new FDA guidelines for the donation of human cells, tissues, and cellular and tissue-based products (HCT/Ps), will go into effect. Reproductive tissue such as sperm, eggs and embryos will be affected by these testing guidelines.

Sperm which are frozen and quarantined for several months already will not be adverseley affected. However, eggs, which are currently donated "fresh" and embryos that are designated for cryopreservation will be significantly affected.

7-Day Testing Requirement

The new FDA guidelines require donor testing for a number of communicable diseases such as HIV (AIDS) and hepatitis seven days prior to (oocyte) egg retrieval . This 7-day window poses a large problem. Most women who are taking fertility medications for in vitro fertilization - IVF cycles need 9 to 10 days before the hCG trigger injection. The (oocyte) egg retrieval follows two days later. The same time course applies to egg donors.

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Americans support preimplantation genetic diagnosis - PGD

These are the results of what is the largest public opinion survey ever conducted of American attitudes toward preimplantation genetic diagnosis -PGD. The study conducted by the Genetic and Public Ploicy Center shows that more than 67% of Americans approve of preimplantation genetic diagnosis - PGD of embryos during in vitro fertilization - IVF procedures to select those embryos free of a fatal disease-causing gene mutation's.

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2/18/2005 Infertility increases risk of neonatal death

A study just published in the British Medical Journal indicates that couples who take longer to conceive, are at greater risk for having babies that die. This is a very important study.

The study looked at Danish women who were enrolled in a large cohort study. The authors studied 27,329 births over a three year period. Only first born births were counted. In that group there were 66 babies who died within the first 28 days. This is known as the neonatal death rate. (The neonatal period is from birth to 28 days).

The mothers had been interviewed during their pregnancies and asked about pregnancy planning and other factors. Women who reported having planned or partly planned their pregnancy were asked how long it had taken them to conceive. If the answer was six months or longer, they were further asked whether they had
received infertility treatment.

They were then separated into 5 groups based on how long it took them to conceive:

Two months or less;

3-12 months;

More than 12 months but with no infertility treatment;

More than12 months and also had fertility treatment

Those women who had unplanned pregnancies (weren't trying)

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Study: Blastocyst transfer for repeated IVF failures

An ongoing debate in the treatment of infertility is how to manage patients who have failed to conceive after multiple In vitro Fertilization - IVF failures.
A recent study out of Spain, published in the medical journal Fertility and Sterility attempted to determine whether using blastocyst transfer may work better for these patients.

Some Definitions:

Cleavage stage embryo: An embryo which has begun to divide. Cleavage stage transfers are typically performed on the third day after egg retrieval. This is known as a Day 3 transfer

Blastocyst stage embryo: An embryo which has divided into hundreds of cells. The cells have separated into those that represent the fetus (inner cell mass) and those cells which will go on to produce other tissues like placenta (trophoblast).

Part of the problem with cleavage stage embryos is that it is more difficult to determine which ones have the greatest likelihood for implantation. Even if they look healthy under a microscope, they may not develop well after the third day. To compensate for this shortcoming, in vitro Fertilization - IVF programs will increase the number of embryos they place in the uterus. This will occasionally work but it also increases the chances for a multiple pregnancy.

By waiting for 5 or six days, the in vitro Fertilization - IVF laboratory staff can better pick those embryos which are likely to produce a pregnancy. Typically, less embryos are required and this will also reduce the multiple pregnancy rate.

In this recent study, the researchers identified 148 women who had failed to conceive after at least three in vitro Fertilization - IVF failures. The patients underwent another In vitro Fertilization - IVF attempt but this time planning to use blastocyst transfer. They compared the pregnancy rate for patients who had > blastocysts develop by Day 5 to those in which > blastocysts developed only by day 6.

91% of the patients had at least one blastocyst to transfer and 73% had at least two. For those patients who had Day 5 > blastocysts, the pregnancy rate was 38%. For those who had a day 6 transfer, the rate was only 11%

What does this study show? Well, you could conclude the doing a > blastocyst transfer is a reasonable treatment option even for women with repeated in vitro fertilization - IVF failures. We cannot say that doing a blastocysttransfer would have worked better than simply performing another cleavage stage transfer because there was no cleavage stage control group. A major shortcoming of this study.

We can also state that at least in patients with recurrent in vitro fertilization - IVF failure, that a Day 5 transfer seems to work better than a day 6 transfer.

As far as studies go, this one is pretty weak.

Single embryo transfer in IVF- in vitro fertilization- may be equal to transfer of 2 embryos

The chance for pregnancy in in vitro fertilization - IVF is affected by numerous factors. One important modifiable factor is the number of embryos transferred into the uterus. The data tell us that placing two embryos into the uterus will produce more pregnancies than placing one. Unfortunately, it also increases the risk of multiple pregnancy.

Multiple pregnancy, even twin pregnancy, is associated with greater risks than a singleton pregnancy. In fact, every complication that occurs in pregnancy occurs more often in twins. This includes, premature birth, gestational diabetes, hypertensive disorders of pregnancy (pre-eclampsia), birth defects and even death of the baby. The greater the number of babies in a multiple pregnancy, the greater the risk.

Unfortunately, many in vitro fertilization - IVF programs still transfer high numbers of embryos in an attempt to boost or maintain their pregnancy rates. This may make the program look better but it puts both mother and baby in greater jeapordy.

It has been questioned, over the years, whether you can get just as many women pregnant if you put one embryo in over two different attempts compared to putting both in at once.

Recently, researcher from Sweden put that question to the test. They looked at a specific group of women undergoing in vitro fertilization - IVF. These women are generally considered to be good prognosis patients.

All under 35 years of age

On their 1st or 2nd in vitro fertilization - IVF attempt

Had at least two good quality embryos for transfer into the uterus

They divided these women into two groups at random. One group received transfer of two embryos. The other group had transfer of a single embryo with cryopreservation (freezing) of the remaining embryos. If not pregnant, this secoond group were brought back for transfer of a single frozen embryo.

The results were looked at in two ways. The pregnancy rate for each attempt or the per cycle pregnancy rate and the cumulative pregnancy rate over two cycles.

In the double-embryo-transfer group, 142 (42.9%) of 331 women had pregnancy resulting in at least one live birth compared with a cumulative live birth rate of 29.6% after the first and 38.8% after the second transfer for the single-embryo group. It should also be pointed out that 38 women did not receive a second transfer because they did not have a viable embryo after thawing.

However, multiple births occurred in a whopping 33.1% of women in the double-embryo-transfer group and in only 0.80% of women in the single-embryo-transfer group (basically one twin pregnancy).

The difference in live birth rate between the groups was about 4% on this study. Doing some statistical analysis we can say that any reduction in the rate of live births with the transfer of single embryos is unlikely to be greater than 11.6 percentage points.

What can we conculde from all this? Well in a well selected group of good prognosis patients, transferring one embryo at a time is just about as successful as putting two embryos in at once but with a fraction of the risk for multiple pregnancies.

The costs to the patient will initially be higher because of the extra expense of embryo cryopreservation, storage, thawing and preparation of the uterus for the second transfer. However, the financial and social costs down the road will be considerably lower due to the avoidance of multiple pregnancy.

At our program, we are well known because we do very well but transfer very few embryos. We have done single embfyo transfers but for the most part patients have been resistant to them. This is in part due to the fact that patients talk on the internet and in support groups and say "My doctor recommended transferring four embryos" Instead of running as fast as they can away from that program, they create the illusion that you have to transfer many embryos to get pregnant.

Another problem results from failed cycles. Patients have a tendency to demand larger and larger numbers of embryos be transferred after failed attempts even though there is no data that this will improve their chances for becoming pregnant.

We cannot continue like this for much longer. Some countries already have passed laws limiting the number of embryos that can be transferred. I don't believe we are too far from that happening here.

Indiana legislature rules in favor of lesbian couples using donor insemination

In a landmark decision, the Indiana Court of Appeals has ruled that lesbian partners who agree to conceive a child through artificial insemination are both the legal parents of any children born to them.

In a unanimous ruling, the court said that "no (legitimate) reason exists to provide the children born to lesbian parents through the use of reproductive technology with less security and protection than that given to children born to heterosexual parents through artificial insemination."

This case arose when the two partners split up and one wanted visitation rights for the child. The lower court initially ruled that one partner had no parental rights because she was not a biological parent.

Now, I'm no lawyer but, it seems to me that this ruling is important not just for gay couples but for all my Indiana patients who use donor egg, donor sperm or donor embryos. If the lower court could negate the parental rights of a partner in a gay relationship, the same would apply for those in a heterosexual relationship who use donated gametes.

In my opinion, the Indiana court made the right decision and one which will benefit all of my patients who live there.

Study: In vitro fertilization - IVF - babies are at higher risk for birth defects

A story published a few days ago in The Australian reports that researchers at the Telethon Institute for Child Health Research in Perth, Australia analysed 25 studies from around the world and concluded that in vitro fertilization (IVF) babies consistently showed a 25 to 40 per cent greater risk of abnormalities.

The actual study itself has not been published yet. The authors are quoted however as stating that their study could not determine whehter the increased risk seen was due to in vitro fertilization (IVF) or due to the higher risk population being studied. Several studies have indicated that infertile couples may not be representative of the general population and that underlying factors may predispose them to higher risk of pregnancy complications and/or birth defects.

Interestingly, another study by Kathy Hudson, PhD., of John Hopkins University, reviewed 169 studies on children conceived through in vitro fertilization (IVF). (See Jnauary 6 2005 BLOG entry). She concluded that in vitro fertilization (IVF) babies do not have higher rates of cancer, malformations, psychological or developmental delays.

So which study is to be believed? This is the current difficulty in counseling couples about the possible risks of in vitro fertilization (IVF). At this point there is no clear and conclusive data that in vitro fertilization (IVF) itself poses any special risks for birth defects.

Lets assume for the moment that I am wrong and the new Australian data is correct. The overall risk of birth defects in the general population is about 3%. If the risk is increased by in vitro fertilization (IVF) by 30-40% then the OVERALL risk amongst all in vitro fertilization (IVF) babies is between 4-5%. Stated another way, even if the risk is increased, the chances for baby without defects is over 95%!!. This means that in vitro fertilization (IVF) is still a failry safe procedure.

I am not really ready to concede that the Australian study conslusions are correct, however. In order to settle the issue, we will need a very large study of in vitro fertilization (IVF) patients compared to infertility patients of the same age and same diagnoses who conceived without in vitro fertilization (IVF). This would be a very difficult study to do. In some cases, it would be impossible. For example a woman without fallopian tubes could not conceive without in vitro fertilization (IVF) so you could never have a valid comparison.

Bottom line? Everything we do in this world has some risk associated with it. In vitro fertilization (IVF) is no different. The questions is whether the potential benefits outweigh those risks. This is not something that can be determined by a study. every couple is going to have to make those decisions for themselves.

Rh sensitization prevented with IVF and PGD

Background:
Rh sensitization is a complication of pregnancy where a woman can make antibodies against her own baby causing that baby to become sick even while still in the uterus. This occurs when a woman with an Rh negative blood type (A Negative, B negative, AB negative or O negative) conceives a child with a father who has an Rh positive blood type. If the baby turns out to be Rh positive like the father, then the mother's body makes antibodies against the baby's red blood cells. The red blood cells can be destroyed making the baby anemic. In a fetus this can cause a serious condition called hydrops fetalis which can be so severe that the baby dies.

Because the immune system has a "memory" each time a woman is exposed to an Rh positive baby her response gets bigger and more aggressive.

This problem isn't as common as it used to be. The reason is due to the use of a medication called Rhogam. Rh negative mothers who are given the Rhogam injection during and after a pregnancy with an Rh positive baby will be prevented from making the antiboides so that subsequent pregnancies won't be affected.
However, cases of Rh sensitization still occur.

Could Leptin be the next fertility medication?

Leptin is a hormone produced in adipose tissue (fat cells). It has been the subject of much study in recent years. Leptin was first discovered in 1994. It is primrily thought of as an appetite and weight regulation hormone. However, leptin also functions to signal the brain and other organs about dangerous states of very low energy availability. Leptin is secreted into the bloodstream in proportion to the amount of energy stored in fat. The leptin is detected by receptors in the brain where it signals how much energy is available. It thereby regulates several key physiological functions that depend on adequate energy balance, including reproduction, metabolism, and bone formation.

We have known for some time that women who have very low body fat and/or those who exercise vigorously, can stop ovulating. Once they stop ovulating, they no longer produce essential hormones like estrogen and their periods can also stop or become infrequent. This condition is called hypothalamic amenorrhea.

Traditionally, in order to acheive pregnancy in these women, we used one of several techniques. First, we might ask the woman to decrease or stop her exercise or try to gain weight. This is usually successful in getting ovulation to return. However, some women are reluctant to try this approach. for them, we would use fertility medications to induce ovulation. This is effective but requires monitoring and has a risk for multiple pregnancy.

Researchers in boston recently studied 14 female athletes who had stopped menstruating on average five-and-a-half years before the start of the study. They had about 40-percent less body fat than the average woman. Eight of the women received leptin, while the others served as controls. After just three months of treatment, women receiving twice-daily leptin supplements resumed menstrual periods, and their ovaries began to function normally. The hormone also significantly improved bone density bone markers in the blood. No change was observed in the control group.

This is pretty exciting stuff. If these results can be confirmed in larger studies and if a pharmaceutical compnay is wlling to put forth the financial risk to do the additional dosing and safety studies then Leptin could become a vialbe treatment option for this group of patients.

Could Leptin be used to treat other ovulation problems like polycystic ovary syndrome - PCOS? This is less certain. Many studies have been conducted trying to determine whether leptin levels are correlated with polycystic ovary syndrome - PCOS but with inconsistent results. Theoretically, however, polycystic ovary syndrome - PCOS patients may have too much Leptin and need a medication which blocks or reduces its effects.

Three dimensional structure of FSH is detailed - could lead to new drug forms

Whenever you see a publication in the journal Nature, expect something big and important. This is no exception. Wayne A. Hendrickson and his colleague Qing Fan of the Howard Hughes Medical Institute (HHMI) have created detailed images of the reproductive hormone FSH - follicle stimulating hormone and its receptor.

FSH is the hormone which is created in the pituitary and when secreted into the bloodstream serves to stimulate the ovaries or testicles. Like all hormones, FSH "connects" with a receptor on a cell. This "connection" causes changes in the cell that accomplishes some function. Until now, researchers did not understand key details about how FSH interacts with its receptor, largely because the complex had never been crystallized and examined at the molecular level. These researchers set out to produce crystals of the complex to use in determining its structure using a method called x-ray crystallography. With this technique, x-rays are directed through crystals of a protein to be analyzed. The patterns that result are then analyzed using computers to deduce the structure of the molecule under study.

So why should you care about this? Well the key to understanding how hormones work is understanding where and how they act on their receptors. Once this is understood, scientists can devise derivatives.

FSH is available as a fertility medication under the trade name Gonal-F or Follistim. It is administered as a subcutaneous injection on a daily basis.

With greater understanding, you might be able to create a variant of the hormone that acts for a longer period time. What if it were possible to give FSH only once a month and still get the same effect? How great would that be? Another possibility is the creaton of orally active FSH medications. Currently this is impossible because FSH which is a protein gets broken down in the stomache.

Of course, none of this will happen overnight but it is a major breakthrough that will yield benefits for years to come.

67 year old woman delivers twins using In vitro fertilization -IVF and egg donation

Over the weekend, the wire services released a story of a 67 year old Romanian woman who has become the oldest woman in history to deliver a baby. The previous record holder was a 62 year old Italian woman.

Obviously, this woman used donated eggs and possibly also donated sperm though the story wasn't clear on that point. Evidently, she has been trying conceive for nine years which means she was "only" 58 years old when she started trying.

Importantly, she conceived a twin pregnancy but was delivered by cesarean section when one of the twins died in utero.

We know that it is possible to get older women pregnant using egg donation at the same success rate as younger women. We also know that the risk of older women carrying a pregnancy are increased. Specificially, the risk for gestational diabetes, preeclampsia, intrauterine growth restriction and even intrauterine fetal death are all higher. Essentially 100% of these older women deliver by cesarean section.

What we do not know is whether there is an age beyond which

Women stop getting pregnant, even with donor eggs

The risks of carrying a pregnancy approach an unacceptably high level

This case brings that point up since she lost one of the twins. It is impossible to say on the basis of one case that this was due to her age. Younger women can lose a baby also.

Even if we do beleive that her age increased the risk of fetal death, what then should we do about it? The simple answer is to restrict the age that women can attempt pregnancy at. However, this is a very slippery slope. If we restrict a woman's right to have children based on risk then what do we do about younger women who may be at greater risk because of other problems? Who becomes the judge in deciding who is allowed to have children and who is not?

This is a question that only society at large can answer and it won't be an easy one

Do In vitro fertilization IVF success rates decline with age? Duhh!

Yesterday, the CDC released a statement along with the results of the 2002 in vitro fertilization (IVF) statisitcs for U.S. in vitro fertilization (IVF) programs.

The statement indicated that in vitro fertilization (IVF) success rates decline with increasing age of the female. Well no kidding. The fact that fertility declines with female age has been known for a long time. In particular, it has been known that in vitro fertilization (IVF) success rates decline with age. In fact, every year the CDC has published the clinic success rates the same decrease has been found. This is not news!!

ICSI - Intracytoplasmic sperm injection- does not increase miscarriage risk

A study out of Italy published in the December issue of Fertility and Sterility compared the rate of pregnancy loss - miscarriage - bewtween patients who underwent standard in vitro fertilization - IVF and those who had intracytoplasmic sperm injection - ICSI .

The study looked at the number of fetuses identified on ultrasound in the second trimester compared to the number identified in the early first trimester.

The conclusion was that intracytoplasmic sperm injection - ICSI does not increase the risk that a pregnancy will miscarry.

I think this adds to the growing body of evidence that intracytoplasmic sperm injection - ICSI is as safe as in vitro fertilization - IVF . However, the design of the study does not allow us to determine whether very early miscarriages (those that might occur before a pregnancy can be seen on ultrasound) occur at the same rate. These are referred to as chemical pregnancies and are identified by a positive blood or urine pregnancy test.

Pregnancy after menopause? Not a big deal.

A report from a British newspaper and picked up by Reuter's indicated that a woman rendered infertile by chemotherpay has delivered a baby without any treatment.

Why this story made the news is anybody's guess but it is certainly not that newsworthy. It has long been known that premature ovarian failure (premature menopause) can be induced by cancer treatments such as chemotherapy and radiation. It is also known that of all the possible causes of premature menopause, ovarian failure caused by chemotherapy and radiation have the highest rate of remission. In other words, it is the most reversable.

Studies indicate that women with premature menopause may ovulate and conceive spontaneously in 3-4% of cases. If the menopause was a result of chemotherapy, the rate may be as high as 10-20%.

Which brings me back to my first point. Why is this is a news story? Probably the medical center where she delivered had a good publicity department. The fact that a Belgian women recently delivered a baby after cancer treatment but with transplantation of a portion of her ovary may also have had something to do with it. Non-medically inclined editors may have thought that this was a similar story which, from the Reuter's report, does not appear to be.

Health risks for in vitro fertilization - IVF children?

A study conducted by Kathy Hudson, PhD., who is the director of the Genetics and Public Policy Center at John Hopkins University, reviewed the available medical literature (169 studies) on children conceived through in vitro fertilization (IVF).

The results are generally reassuring. In vitro fertilization (IVF) babies do not have higher rates of cancer, malformations, psychological or developmental delays.

Singleton in vitro fertilization (IVF) babies ARE at increased risk for premature birth, low birth rate and death in the first few weeks of life.

Twin in vitro fertilization (IVF) babies are NOT at any higher risk for these problems than naturally conceived twins. I should mention that twins are at higher risk for these complications compared to singletons and twins are more likely to occur as a result of multiple embryo transfer but in vitro fertilization (IVF) itself does not appear to increase the risk.

There were two rare genetic disorders, Beckwith-Wiedemann syndrome and Angelman's syndrome that the study made a special comment about. In the case of these two problems, the study found evidence that was "suggestive but not sufficient" to indicate that in vitro fertilization (IVF) may increase the risks of these problems.

The problem is that these syndromes are both very rare to start with. That makes it very difficult to determine then whether in vitro fertilization (IVF) has any adverse effect. Further study is needed in a much larger study to determine whehter there is a risk.

There has been alot of information in the media about the possible risks to the babies born through in vitro fertilization (IVF). This study, which is the largest study of its kind, I think is very reassuring.

There has been some noise in the field about establishing an in vitro fertilization (IVF) registry for children born through in vitro fertilization (IVF) I think it is probably a good idea and may be the only way to answer some of the questions we have about in vitro fertilization (IVF). Opponents say that it violates the privacy of the children in the registry and places a "stigma" on them. I can't argue that but still feel that benefits outweigh the disadvantages.

Device to improve sperm selection?

A story in New Scientist Magazine stated a machine being developed at the University of Newcastle in New South Wales is intended to be able to select sperm with less DNA damage.

The premise is that sperm with normal maturation and therefore less DNA damage is negatively charged. The "sperm sorter" consists of two chambers separated by a filter. After the sperm is injected into the first chamber a voltage is applied across the filter to move sperm to the second chamber.

In one test of the machine,using semen from medical students, 20 percent of sperm made it into the second chamber. This "select sperm" had only half as much DNA damage as the sperm in the first chamber.

Without having actually seen the data, I am very suspicious about this. My big concern is how they were determining whether sperem had DNA damage. Recently there has been alot of interest in sperm DNA damage testing. The most popular of these tests, the Sperm Chromatin Structure Analysis (SCSA) initially had some very enouraging studies suggesting that it could identify men less able to produce a pregnancy.

However, at the fall 2004 meeting of the American Society for Reproductive Medicine (ASRM), there were three studies from three separate groups which failed to find any benefit to the test.

It leaves considerable question as to whether identification of sperm with more or less DNA damage makes any difference. Some will argue that it is only logical that choosing sperm with less DNA damage would work better. This is not necessarily so. Cells such as eggs contain mechanisms to repeair DNA damage. Maybe the differences we find are clinically unimportant.

If anyone has a complete copy of the New Scientist article, please email me.

Bedrest after in vitro fertilization (IVF) not necessary

I hear it all the time. My patients correspond with in vitro fertilization (IVF) patients at another program. "Their doctor says they have to go on bed rest after the embryo transfer or it won't work." I have always thought this was baloney. Now more proof that it is baloney.
A recent study of 378 women who were undergoing in vitro fertilization (IVF) were randomly assigned to rest for either 1 or 24 hours following an in vitro fertilization (IVF) embryo transfer. The 1-hour rest group had a rate of 21.5 percent, whereas the 24-hour rest group had a rate of 18.2 percent. Actually, the implantation rate per embryo in the 1-hour rest group was 14.4 percent, which was higher than the 9 percent rate seen in the 24-hour rest group.
Previous studies have all reached the same conclusion. Resting after an in vitro fertilization (IVF) embryo transfer does nothing to improve the pregnancy rate. This makes good sense since women who achieve pregnancy spontaneously do not rest so why would it be necessary after in in vitro fertilization (IVF).
Also, since implantation does not occur until day 7 or 8, a day or two of rest after a day 3 embryo transfer would seem to be ridiculous. Now I couldn't argue if someone was recommending five days of rest, that study has never been done but programs that stick by this do not recommend rest for that long.
Bottom line? Rest if you want to but if you don't it won't hurt your chances.

Alternatives to glucophage for treating insulin resistance

For women with polycystic ovary syndrome - PCOS, insulin resistance is a common finding. In addition, many of these women do not respond to clomiphene citrate (Clomid resistance). For these reasons, many women are now treated with a diabetes medication known as glucophage (metformin) which works, in part, to reduce insulin resistance and improves the chances for ovulating spontaneously or with Clomid. However, many women will have side effects from glucophage such as bloating, cramping, diarrhea, flatulence and nausea. The most serious complication of glucophage is lactic acidosis which is a rare but potentially life threatening condition.

Acarbose is another medication used to treat diabetes. Acarbose is an alpha-Glycosidase inhibitor. It works by reducing the absorption of monosaccharides (simple sugars) through intestines and minimize the increase in blood sugar and insulin seen after meals. Serious side-effects of acarbose are rare and
although it shares many of the gastrointestinal side effects as glucophage, lactic acidosis is not a problem with this drug.

In a recent study, researchers looked at 30 women with polycystic ovary syndrome - PCOS who did not previously respond to clomid. The women were divided into two groups. One group received acarbose and clomid. The other group received glucophage and clomid.

By the end of three months, the women taking acarbose lost more weight than the glucophage group. Both groups showed a similar improvement in the number of women who ovulated. There were 15 women in each in group and they were studies for three months so there was a possibility of 45 ovulatory cycles (15 x 3). The acarbose group had 20 ovulations and the glucophage group had 24 ovulations. The incidence of side effects were the same in both groups and there were no serios adverse effects in either group.

In summary, it seems that acarbose could provide a reasonable alternative to glucophage for treating insulin resistance in polycystic ovary syndrome - PCOS patients, though the expected benefits are minimal. This was a small study so there isn't nearly as much data showing a positive effect as exists for glucophage at the moment. Acarbose did not have a better ovulation rate than glucophage so the main benefit comes down to a lower risk of lactic acidosis which is a very rare complication anyway.

I would think of acarbose as a second line drug for the time being. If first line drugs like glucophage or Actos or Avandia were not tolerated or ineffective than trying something like acarbose might be reasonable.