Tuesday, November 29, 2005

IVF and acupuncture double blind study to begin

You may know acupuncture as an ancient Chinese medical procedure used to treat all sorts of conditions. Combining it with IVF is a relatively new idea. Some couples have reported success with acupuncture treatments and IVF combined, after a number of failed IVF cycles without acupunture. To date, however, there have been no so-called double-blind studies of IVF with and without acupuncture.

The University of Maryland Medical Center has announced plans for a double-blind study of IVF combined with acupuncture. The study is funded by the National Institute for Health and is currently recruiting patients to participate. They hope to identify if acupuncture results in increased blood flow to the uterus, a rise in hormone levels, or reduced stress that might account for the apparent increase in IVF success rate.

A couple of issues came to mind when we read this news. One is how they might implement a double-blind test. It seems that it might be quite difficult to have a placebo control group. How might they make the placebo group believe they had a real needle insertion when there was none? Or perhaps they insert needles but not at the correct point in the body? The details of how they plan to do this would be interesting.

Another issue concerns the basic differences upon which Chinese and western medicine are founded. The study is going to look for changes in physical systems as understood by western medicine, while acupuncture is based upon a completely different model of the body and energy flows. So if the study does not find changes in uterine blood flow or hormone levels do they conclude that acupunture has no effect? That would seem to be a flawed conclusion. If the study group is statistically significant and the number of live births is compared then that might lead to useful conclusions.

Saturday, November 26, 2005

The marketing of IVF

The St. Louis Business Journal's online publication called St. Louis Bizwomen had a recent article titled " Infertility specialists boost marketing" in which the trend of fertility clinics applying new business approaches was discussed. While the focus of the article was the marketing of fertility treatment, the story had a number of interesting statistics.

Some of the statistics of interest included the following:
  • More than 6 million women in the U.S., or 10% of reproductive-age women, have fertility issues.
  • ART (assisted reproduction technology) procedures grew 43 percent in the U.S. from 1997 to 2002.
  • Average cost per ART cycle is $10,000 plus thousands of dollars more for diagnostic exams, genetic screenings and other expenses.
  • More than 100,000 ART procedures are performed each year in the U.S.
  • Infertility treatment is a $1 billion per year industry in he U.S.
  • Kato Ladies' Clinic in Tokyo, Japan is the world's largest IVF center and administers 14,000 cycles per year.
  • 1 percent of the babies born in the U.S. each year are the result of IVF while in Europe the number is 5 percent, the difference being attributed to readily available insurance coverage in much of Europe.
The article also says that only about 20 percent of the demand for ART is met in the U.S. because so many couples who want it cannot afford it. Some centers are exploring innovative methods to make treatment more affordable such as long term financing and success guarantees.

The issue of insurance coverage for ART has clinics divided, some saying it will give access to more people while others say it will encourage lower quality treatment. The insurance providers are definitely against mandatory coverage requirements, and cite concerns such as the costs associated with complications such as delivery of triplets which can cost $250,000 U.S.

Monday, November 21, 2005

Potential side effects of IVF treatment

Side effects of clomiphene citrate and gonadotrophins are rare and of short duration. Although concerns have been expressed over prolonged use of clomiphene, short-term, closely monitored treatment is considered safe. However, there are two important risks from ovulation induction - ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. When the likelihood of either is detected via ultrasound doctors typically stop the treatment cycle and do not proceed to the hCG injection.

The two potential side effects are:

  • Ovarian hyperstimulation syndrome (OHSS): A rare condition which occurs when too many follicles grow and cause abdominal distension, discomfort, nausea and sometimes difficulty breathing. In extreme cases hospitalization is necessary. OHSS is potentially serious but can be avoided by careful monitoring.

  • Multiple pregnancy: Studies show that multiple pregnancies are associated with an increased risk of miscarriage and premature delivery.

Thursday, November 17, 2005

Prominent hospital sets upper age limit for IVF

The Sydney Morning Herald reports that a prominent IVF center in Australia has decided to set an upper age limit for women seeking IVF treatment at their facility. The Westmead Hospital reviewed their cases and found that for women 43 and older there were only two live births for 250 women treated at their center. With a success rate of less than 1% for this age group they have made the ethical choice to limit IVF treatment to women under 43.

Elsewhere in Sydney the success rate for women 42 to 44 is reported to be five to ten percent per cycle. Westmead said that 50% of their patients are smokers, so perhaps this is contributing to a lower than average success rate.

Westmead is a nonprofit clinic which may be one reason why they have chosen to limit treatment instead of pushing it even for low probability cases. Older couples should remain realistic about their chances of success with IVF treatment. Remember that if you are in the 5% to 10% probability of success range that means each IVF cycle has only a 5% to 10% chance of success. It is not like you can do 10 cycles and guarantee success - each cycle is independent.

Post-implantation steps

Following embryo implantation your physician will normally recommend the following:

1. Relax and take things easy for two to three days, but no need to stay in bed.

2. Avoid intercourse for at least one week.

3. Avoid lifting heavy objects and strenuous activities, and also avoid stressful work until pregnancy has been confirmed or menstruation occurs.

Wednesday, November 16, 2005

Sample calendar for donated egg cycle

If the choice is made to use donor eggs the IVF cycle gets even a bit more complicated since two women are involved. To understand the steps as the donor and recipient are undergoing the cycle it really helps to have it laid out on a calendar.

Advanced Fertility Center of Chicago has a sample egg donation calendar that is worth studying if you are considering this route.

Monday, November 14, 2005

PGD improves IVF success rate, raises controversy

The online newspaper The Australian carried a story on November 10, 2005 about the successes and controversies of preimplantation genetic diagnosis (PGD).

The story of a couple who had repeated failures during IVF treatment explains how they learned through PGD that the embryos that were being implanted were defective and would not survive beyond a few days. Only after they elected for PGD did they establish a pregnancy and have a successful birth.

While PGD is normally opted for in cases where there is a family history of genetic disease or other potential factor that may implicate the viability of the embryos, the story also discusses the possibility of the extension of PGD to select desirable characteristics in babies, or the identification of potential genetic latent disease indicators. This is where the controversy begins to arise, as it is seen by some to be open to intrepretation and abuse. And an interesting case mentions a Tasmanian couple who used PGD to select embryos that would produce a baby who could be a bone marrow donor for their first child.

The cost of PGD is substantial, $1,700 Australian according to the article, and not any cheaper in some of the overseas IVF clinics. So it isn't taken lightly by most couples. Still, the potential for designer babies is there and the controversy will probably continue.

Saturday, November 12, 2005

Pregnancy testing

Approximately 14 days after embryo transfer a blood test for pregnancy is done. In the happy event that the pregnancy test is positive the couple will normally be asked to retunr two weeks later for the first ultrasound scan. This is to check that the pregnancy is normal and to see if there is more than one fetus in the uterus. In the event of normal pregnancy, hormone injections will be administered until 10 to 12 weeks from teh start of the treatment cycle.

In the event of a negative pregnancy test result patients are normally advised to contact their physician in order to discuss the outcome and what their next step should be. Future options may be discussed and a plane made if the couple wish to continue treatment. Patients are usually advised to wait two to three months before initiating another treatment cycle.

Wednesday, November 09, 2005

Hormone injections after embryo transfer

After embryo transfer it may be recommended that some patients have hormone treatment to encourage uterine receptivity and implantation. Treatment is either

  • hCG by injection

  • progesterone either by oral, injection, or vaginal administration

The type and dose depend on the level of hormone in the blood and the the of drug regimen that has been previously followed.

Tuesday, November 08, 2005

IVF calendar calculator

A handy little tool for calculating the dates of your IVF cycle is available. This is the first release and calculates a nominal cycle but does include the option for blastocyst transfer. Future releases are planned to include additional options.

Get the IVF calendar calculator here.

Monday, November 07, 2005

Embryo transfer

The embryo transfer is done using one of two methods:

  • Tubal transfer: If at least one fallopian tube is present the embryos can be transferred laparoscopically directly into the fallopian tube.

  • Cervical transfer: If the woman has both tubes blocked the embryos will be drawn into a fine catheter which will be gently inserted through the cervix then the embryos are placed into the uterine cavity.

Friday, November 04, 2005

Preimplantation genetic diagnosis by FISH technique

In couples with advanced maternal age, carriers of genetic disease, carriers of X-linked disease, or repeated abortion, selecting only normal embryos for transfer is essential. Embryos at the six to eight cells stage on day three after egg collection can be processed for embryo biopsy by making a small hole in the zona and one to two embryo cells can be taken out for genetic diagnosis. The biopsied embryos are kept in culture for further development.

The extracted embryo cells are fixed on microscope slides and diagnosis is performed by using specific probes (chromosone pieces) and specialized instruments. At present, chromosones 13, 18, 21, X and Y can be detected. The results can be obtained within one day so that normal embryos can be transferred that day or the following to ensure their further development.