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Archive for September, 2011

Bet I Can Make You Guys Cry

By Tracey Minella

September 30th, 2011 at 6:25 pm

It’s the last day of the blogging month, so this one’s for the boys. However, it’s a great read for the ladies, too.

I am going to share a link to a moving story about a man and his love for a little girl. It’s about a love so strong that it literally became this man’s life force.

Here’s a teaser: Church-going Vietnam vet and his wife end up taking in the baby girl of a young stranger who showed up in church one day, completely overwhelmed by trying to parent this baby. It was supposed to be for one night. The man falls in love with the baby and they want to adopt her. But the man is dying. Soon. He wants to adopt her so she can have his survivor benefits after he dies. Can this small town make this all happen before the man dies?

Before you click on the llink to the story, you must promise to come back and weigh in on whether you cried. Also there will be a question at the end of this post.

Here’s the link to the story: http://www.msnbc.msn.com/id/44597789/ns/health-health_care/#.ToP3uOxiYfU

Cue the Jeopardy music while we wait for you to read and return…

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Was this a beautiful story of love and community?

Or does anyone have any concerns about any of the following issues:

The birth father’s consent

A man on death’s door adopting a baby

Pushing an adoption for survivor benefits

What would you guys have done in this man’s shoes?

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Do I Need Clomid to Get Pregnant?

By Tracey Minella and David Kreiner MD

September 29th, 2011 at 12:00 am

It’s not working. It’s not working.

Why isn’t it freakin’ working?!

Feel like a slave to the calendar and temperature chart? Spending a king’s ransom on those damn ovulation kits? Constant sex causing you to walk like you just got off a horse?

Is a voice telling you that you may need something more in order to get pregnant…but you’re scared to face that possibility?

Well, clomid is that first step for many women.

Dr. David Kreiner of East Coast Fertility answers all your questions about Clomid therapy:

It has become commonplace for women who have been frustrated with repeated unsuccessful attempts to conceive naturally on their own to see their gynecologist who often times will try clomid therapy on them. Clomid, the traditional brand name for clomiphene citrate, is a competitive inhibitor of estrogen. It stimulates the pituitary gland to produce follicle stimulating hormone (FSH) which in turn will stimulate the ovaries to mature follicle(s) containing eggs. Estrogen normally has a negative effect on the pituitary: Clomid blocks estrogen and leads to pituitary FSH production and ovarian stimulation.

Infertility patients — those under 35 having one year and of unprotected intercourse without a resulting pregnancy and those over 35 having six months without pregnancy — have a two to five percent pregnancy rate each month trying on their own without treatment. Clomid therapy increases a couple’s fertility by increasing the number of eggs matured in a cycle and by producing a healthier egg and follicle. The pregnancy rate with clomid therapy alone is approximately ten percent per cycle and 12 -15 percent when combined with intrauterine insemination (IUI). Women who are unable to ovulate on their own experience a 20 percent pregnancy rate per cycle with clomid, the equivalent to that of a fertile couple trying on their own.

Clomid and Your Cervical Mucus

Women who are likely to conceive with clomid usually do so in the first three months of therapy, with very few conceiving after six months. As clomid has an anti-estrogen effect, the cervical mucus and endometrial lining may be adversely affected.

Cervical mucus is normally produced just prior to ovulation and may be noticed as a stringy egg white like discharge unique to the middle of a woman’s cycle just prior to and during ovulation. It provides the perfect environment for the sperm to swim through to gain access to a woman’s reproductive tract and find her egg. Unfortunately, clomid may thin out her cervical mucus, preventing the sperm’s entrance into her womb. IUI overcomes this issue through bypassing the cervical barrier and depositing the sperm directly into the uterus.

However, when the uterine lining or endometrium is affected by the anti-estrogic properties of clomid, an egg may be fertilized but implantation is unsuccessful due to the lack of secretory gland development in the uterus. The lining does not thicken as it normally would during the cycle. Attempts to overcome this problem with estrogen therapy are rarely successful.

Side Effects

Many women who take clomid experience no side effects. Others have complained of headache, mood changes, spots in front of their eyes, blurry vision, hot flashes and occasional cyst development (which normally resolves on its own). Most of these effects last no longer than the five or seven days that you take the clomid and have no permanent side effect. The incidence of twins is eight to ten percent with a one percent risk of triplet development.

Limit Your Clomid Cycles

Yet another deterrent to clomid use was a study performed years ago that suggested that women who used clomid for more than twelve cycles developed an increased incidence of ovarian tumors. It is therefore recommended by the American Society of Reproductive Medicine as well as the manufacturer of clomiphene that clomid be used for no more than six months after which it is recommended by both groups that patients proceed with treatment including gonadotropins (injectable hormones containing FSH and LH) to stimulate the ovaries in combination with intrauterine insemination or in vitro fertilization.

Success rates

For patients who fail to ovulate, clomid is successful in achieving a pregnancy in nearly 70 percent of cases. All other patients average close to a 50 percent pregnancy rate if they attempt six cycles with clomid, especially when they combine it with IUI. After six months, the success is less than five percent per month.

In vitro fertilization (IVF) is a successful alternative therapy when other pelvic factors such as tubal disease, tubal ligation, adhesions or scar tissue and endometriosis exist or there is a deficient number, volume or motility of sperm. Success rates with IVF are age, exam and history dependent. The average pregnancy rate with a single fresh IVF cycle is greater than 50 percent. For women under 35, the pregnancy rate for women after a single stimulation and retrieval is greater than 70 percent with a greater than 60 percent live birth rate at East Coast Fertility.

Young patients sometimes choose a minimal stimulation IVF or MicroIVF as an alternative to clomid/IUI cycles as a more successful and cost effective option as many of these patients experience a 40 percent pregnancy rate per retrieval at a cost today of about $3,900.

Today, with all these options available to patients, a woman desiring to build her family will usually succeed in becoming a mom.

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Should Your Fertility Doc Discuss Financial Options?

By David Kreiner MD

September 27th, 2011 at 9:15 pm


One of the most distressing things I face in practice is when I get negative feedback from a referring physician.  Fortunately, it happens rarely but recently I was shocked about the complaint.  Apparently, his patient was offended that I discussed the finances involved with her treatment.  Her Ob Gyn agreed with her that it was inappropriate for me to discuss the cost of her options.  He told me, “I like you and think East Coast Fertility is an excellent program but I never talk about money directly to patients!  It’s not – I don’t know…seemly!”   “Money issues are discussed with the business office, the doctor only discusses the medicine”.

Perhaps it’s unfortunate that fertility doctors have to be so concerned about their patient’s pocket books unlike other fields of medicine that are usually covered by some measure of insurance.  But in the case of infertility with only a handful of states having some kind of mandated coverage – not everybody in the United States - mandate or no mandate for infertility -even has health insurance!  Many fertility patients are in some form or another “cash pay” patients.  One of the most popular places that patients visit when they go to any fertility clinic’s website is the finance page.  This is simply a fact of life.

For this reason I have developed many programs that will create access to fertility care for as many people as possible.  But here is the catch! One program does not fit all. These are simply not over sized tee shirts – each of these programs represent a certain course of  medical care – and each individual and couple needs the assistance of a caring doctor to help them choose the right program that will fit their own particular medical history. 

In addition to the NY State DOH Grant Program and our own East Coast Fertility Grant Program, we have the Micro-IVF Program, The Money Back Guarantee Program,  and The Single Embryo Transfer Program

The most effective treatment and the most efficient is always a full stimulation IVF. However, if someone has insurance coverage for IUI and meds but not IVF then they may prefer to do IUI. If they do not have coverage for IUI either then it may be more cost effective to do the Micro-IVF Program or minimal stimulation IVF at 2-3 x the success of IUI with less risk than gonadotropin IUI and less cost per pregnancy. Yet at a price of $3900 it may be more attractive than a full stimulated IVF.

There is also The Single Embryo Transfer Program where we reward patients transferring one embryo at a time by making their cryo, embryo storage and unlimited frozen embryo transfers for free. 

Others prefer the insurance of The Money Back Guarantee Program where patients are offered six IVF retrievals and frozen embryo transfers for a fixed fee that is refunded if they do not result in a live birth.   In order to inform patients about our success and programs that make IVF more available to them we offer free consultations.

And now we have the brand new ECF Miracle Plan. We are always working to offer the most competitive and comprehensive financial plans possible to assist in your family building efforts. Plus we offer contests through this blog, our website, and in the office and recently awarded one lucky patient a free Micro-IVF cycle. Check out the video where we surprised the winner with an in-person visit announcing her as the winner. http://vimeo.com/28993272.

In today’s world of fertility care – a good doctor will help a patient find not only the right treatment but how to access that care.  In order to do that – a doctor may have to do what some may think is unseemly – and that is to talk about money.

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Infertility and Family Traditions

By Tracey Minella

September 26th, 2011 at 6:20 pm

With the holiday season approaching, and the fall festivals in full swing, the thought of family traditions comes to mind.

While you’re waiting to start or expand your family, have you imagined how your baby will fit in to your family’s traditions? Have you thought of any new traditions you’d like to begin when you have children?

For over twenty years, I’ve been entering fairs in the fall. I compete in baking and canning (yes, me and the little blue-haired eighty year-old ladies). I’ve won hundreds of ribbons in New York, Connecticut, and even Nevada.

For years while I was TTC, I imagined having a daughter who would grow up baking beside me, learning to make jams and pickles, and eventually be old enough to enter the fairs, too.

It took some time, and a few IVFs, but my dream came true.

I’ve been blessed to make my tradition of entering fairs into my family tradition. We added apple picking to the fun as well. Both my daughter and son enter the junior divisions of the fairs and love winning ribbons.

Sometimes it can seem like those dreams will never come true, but you need to believe.  In the meantime, it can help to write down your ideas on traditions you’d like to start with your family.

We buy ornaments from each vacation, even if it’s a mini “day-cation” and date them. We make a family photo ornament each year, too. We have Chinese food with the whole extended family every New Years Day and make zillions of honey struffoli every Christmas together. We pick berries and make jam. And the list goes on…

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What traditions do you do now? What traditions would you like to start when you start or expand your family?

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IVF (and Life) Do-Overs

By David Kreiner, MD

September 23rd, 2011 at 8:45 pm

I was at a college graduation party for Rebeka, one of the first IVF babies I ever helped create. Her parents and grandparents beamed with pride, bragging about Rebeka’s achievements and plans while passing the hot wings and beers. I shared in this proud moment, feeling as if I bore some responsibility, since were it not for IVF, the party itself would never have happened.

Among the guests was a family friend, Conrad, who talked about the old neighborhood. He grew up in Kew Gardens and I was from Queens Village and Floral Park. Conrad asked me if I remembered playing handball and what would happen when the ball hit a crack on the floor and took an awkward bounce away from its original path, preventing a player from returning the ball cleanly. “It was called a Hindu and you got to do the point over.” Yes, I remembered “Hindus” and “do overs” and thought to myself that it would be an ingenious concept if we could extend the “do over” beyond the game to life in general.

Who hasn’t come across some crack in their path that causes an unexpected detour? My patients grow up expecting that they, like everyone else, can create their own family when they reach a stage in their lives, perhaps married and financially and emotionally secure. When a woman does not get pregnant as expected, it’s as if she hits that crack in her path — just like the handball — and her life gets thrown off track. If only she could get that “do over” and set her life back on its rightful path.

We also see these “Hindus” in our IVF cycles especially when a patient develops an LH surge and her ovulation is accelerated so that her eggs and ovulation are affected prior to retrieval.

Perhaps we need to consider the “do over” rule. IVF is a great way to give a couple a second chance to replay their errant family building when a “crack” in their fertility prevents successful procreation.

Fortunately, Rebeka’s parents got a “do over” and now, 22 years later, are celebrating their baby’s college graduation.

Life can throw a lot of cracks in our path that will detour us along our way. We should help each other by offering “do overs” whenever we have the opportunity.

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Donor Eggs or Their Own: Are Older Celebrities Lying?

By David Kreiner, MD

September 22nd, 2011 at 3:25 pm

The Fertility news is constantly highlighted in sensational headlines, such as “49 year old woman conceives with own egg through IVF”. In the past, readers have been entertained with “Octomom”, “a woman pregnant with a supposed dozen”, “Jon and Kate plus eight” and “a 62 year old mother through IVF” not to mention the numerous over 45 and sometimes over 50 year old celebrities having babies supposedly with their own eggs.

Reading these “news” stories one may get the impression that Fertility is a thriving business bearing little resemblance to the medical specialty of reproductive endocrinology requiring seven years of post medical school training.

The medical pioneers Drs. Steptoe and Edwards in the UK and Drs. Howard and Georgeanna Jones Jr. in the US envisioned a world in which couples inflicted with the curse of an inability to procreate, would, with the benefit of this technology that they developed, give these couples the ability to build their own families.

They were excited that as the technology improved and became more efficient and the cryopreservation of embryos became routinely available that risky multiple pregnancies could be eliminated. They believed that insurance companies would pay for an IVF benefit that had a high success rate and could deliver healthy singleton pregnancies with far greater confidence than any alternative treatment especially intrauterine inseminations (IUI).

They were unhappy that in the early years when IVF was inefficient, many embryos needed to be transferred in order to give a patient a reasonable chance for success. This resulted in multiple pregnancies, many of which delivered prematurely requiring expensive neonatal intensive care and unfortunately many did not end well. Today, we have control over this with IVF by transferring one embryo at a time but not with IUI.

They also did not believe that women should be subjected to the medications, blood work and retrieval process without a fair chance for a successful outcome.

The idea of subjecting a 49 year old woman to IVF for what may be a 1% chance of conception with a greater than 50% chance of miscarriage is not medically reasonable. Women of this age have a 70 to 80% chance for conception through egg donation.

This is how the 50 something celebrities are getting pregnant.

They are not using their own eggs. Misleading the public with news stories that feature these older pregnant celebrities gives patients the misconception that they too can create their families at the same age using their own eggs.

We have recently performed IVF on two perimenopausal patients with FSH levels over 50 at age 45 after days of counseling regarding the extreme low odds of pregnancy and a live birth. In both cases, they felt they needed to give it one shot before moving on to egg donation.

They had one follicle each and both resulted in pregnancies with a gestational sac seen on ultrasound. One has since miscarried and will now move on to egg donation where her odds of having a live baby jump from less than 5% to 60% per attempt. The other remains pregnant and is miraculously the exception to the rule.

IVF is a medical procedure that is part of a proud tradition of reproductive endocrinology. It is a medical treatment that can cure one of the cruelest maladies known to man, the inability to have a child.

This problem is featured in the bible with several references including from the woman’s perspective with Hanna weeping for a baby of her own. The Old Testament proclaims the commandment to procreate. This is part of the human condition.

Does it not make sense then that insurance companies provide the financial coverage to allow IVF, a treatment that can be controlled by transferring one embryo at a time to result in a singleton pregnancy? Regulations to prevent costly dangerous multiple pregnancies and the performance of IVF in patients with unreasonably low odds of success need to be instituted.

Financial programs that make it no more expensive to patients to transfer one embryo at a time such as our Single Embryo Transfer program at East Coast Fertility need to be the news highlight of the day not the 49 year old who conceived on her sixth try.

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Do YOU think any of the older celebrity moms… who claim or imply that their children are not conceived through donor egg programs… are being untruthful?

Do you think their right to privacy is more important than the disservice such lies do to the public’s misconception about how old women can be and still conceive with their own eggs?

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Infertility Treatment and Dental Issues

By Tracey Minella

September 16th, 2011 at 9:13 am

In keeping with the theme of reorganizing and getting life back in order now that September is here, it’s time to get your dental health in order.

It’s so easy to get distracted when TTC.

All things that don’t involve needles and pee sticks get put on the back burner.

But keeping your dental health in check is a “must-do” item on your list. And I don’t mean bleaching the pearly whites into a unnatural blinding state.

Before conceiving it’s good to get a cleaning and take care of any nagging issues, like cavities and loose fillings. Don’t keep ignoring that occasional twinge that’s trying to tell you a root canal is in your future.

The last thing you want to do, after working so hard to conceive, is find our while your pregnant that some major dental work is in order. And it can’t wait until after the baby.

Whether its considered safe or not, would you want to expose your body…with a baby developing inside…to the raditation of dental xrays? Hey they don’t slap that heavy lead blanket and run from the room for nothing!

What about injectable novacaine? Wanna breathe in nitrous oxide gas…or anything other than oxygen? And how about heavy duty anesthesia for the big jobs? Yeah, I didn’t think so.

And while I’m worrying you, there’s something else to consider. Old fillings.

If you’ve got a mouth full of silver, and some of those fillings are breaking up, take care of that right away. And be sure that the dentist you go to for that job specializes in removing them safely.

Why?

Because the debate has begun on whether the mercury in that metal filling can leach out and harm you or your baby.  Its one of the many avenues being explored as a possible connection to autism and other neurological disorders. And like anything in medicine, it will be decades before we get to the truth.

So err on the side of caution and have them removed and replaced with the mercury free stuff they use today. You don’t want to have to do it while pregnant or breastfeeding.

In fact, if you can afford to…though you probably can’t since your funds may be marked for infertility treatment… have them all replaced.

Call the dentist today. That way, when you conceive, you will be flashing a happy healthy smile for those nine months…and for the rest of your life.

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Do you keep up with your scheduled dental visits or has TTC gotten in the way? Do you worry about old fillings?

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Time for Your Fertility Workup!

By Tracey Minella and David Kreiner MD

September 13th, 2011 at 6:41 pm


Well, summer’s over and we’re all settling into the new routine.

Second only to January’s New Year’s resolutions, September has always been a time to reorganize life and  reassess goals.

That means fall cleaning. Garage sales. Preparing for winter. Maybe that pre-holiday diet or renewed gym membership?

Well, fall is also a good time to get your “fertility business” in order. What have you been putting off?

Have you been delaying seeing a reproductive endocrinologist, despite TTC for quite awhile? Or have you had an exam, but put off the follow-up testing?

Dr. Kreiner of East Coast Fertility discusses the fertility workup:

I have received an enormous amount of email from patients over the years asking for information about how they should get started with their infertility workup.  Apparently, they are women, men and couples who have experienced difficulty conceiving and now want some direction about how they should proceed.  Building a family was something they had imagined their entire lives to be a natural progression–from student to career, getting married then having a family–and they’re frustrated that their difficulty conceiving has affected their lives.  For many—some of whom have never experienced a health problem– it prevents them from appreciating or even doing anything else.

See an RE for a Fertility Workup

My response to these emails has been to tell the patients to seek assistance from a reproductive endocrinologist, whose specialty and experience is in helping infertility patients conceive.  A reproductive endocrinologist, who has two to three years of additional specialty fellowship training in infertility after completing an OB/GYN residency.

The RE will conduct a history and physical examination during your initial consultation.  This exam typically includes a pelvic ultrasound of a woman’s ovaries and uterus.  He/she can tell if there are any uterine abnormalities that may affect implantation or pregnancy as well as assess ovarian activity and rule out cases of moderate or severe endometriosis.

Pelvic Inflammatory Disease

If he elicits a history of previous abdominal or pelvic surgery, a physician may suspect that scarring may have developed that typically interferes with fallopian tube transport of the egg to the sperm and the conceptus to the uterus.  An infection that develops after a pregnancy may lead to pelvic adhesions affecting the tubes as well as scarring within the uterine cavity itself which can prevent implantation.  Pelvic inflammatory disease, PID, can lead to tubal disease and may be associated with other sexually transmitted diseases including HPV, Herpes and especially Chlamydia.

Semen Analysis

The semen analysis is the simplest test to perform and will reveal a male factor in 50% of cases.  A post coital test performed midcycle around the time of ovulation when the cervical mucus should be optimal can detect a male factor or cervical factor when few motile sperm are detected within hours of intercourse.

Hysterosalpingogram

A hysterosalpingogram, HSG, is a radiograph x-ray of the uterus and fallopian tubes after radio opaque contrast is injected vaginally through the cervix directly into the uterus.  It can detect uterine abnormalities that can affect implantation and pregnancy as well as tubal patency.  Unfortunately, this exam may be painful and in some patients with PID can result in serious infection.  Some physicians will administer antibiotics prophylactically for this reason.

Hydrosonogram

A hydrosonogram is an ultrasound of the uterine cavity performed after injecting water vaginally through the cervix directly into the uterus.  It can also detect uterine abnormalities and shares some of the risks seen with HSG but to a lesser extent and usually with less associated discomfort.

Hysteroscopy

A hysteroscopy is a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus.  The physician can visually inspect the cavity to detect uterine abnormalities.  The risks of pain and infection are also seen with hysteroscopy.

Blood Tests

Blood tests may be run to identify if a patient is ovulating with adequate progesterone stimulation of the uterine lining.  Day 3 E2, FSH and LH levels can give information regarding ovarian activity and ovulatory dysfunction.  AntiMullerian Hormone (AMH) levels correlate with ovarian reserve.   That is the number of eggs remaining in the ovaries.  Hormones that can affect fertility such as thyroid and prolactin are also assessed to ensure that extraneous endocrine problems are not the cause of the infertility.

Laparoscopy

Laparoscopy is a surgical procedure in which a telescope is placed abdominally through the navel thereby allowing a physician to inspect the pelvic organs.  He/she can identify endometriosis, cysts, adhesions, infection, fibroids etc. that may be causing the infertility.  Unfortunately, only about 25% of cases in women who have a laparoscopy performed will conceive because of treatment performed at the time of the laparoscopy.

Workup Results and Treatment

Treatment can be directed at the cause such as surgery to correct adhesions or remove endometriosis, uterine polyps or fibroids.  Treatment can also be independent of the cause but improve fertility nonetheless.   Ovulation induction increases the number of eggs and therefore the likelihood that an egg will fertilize.  Gonadotropin injections stimulate many more eggs to develop in a cycle than clomid fertility pills.  IVF with minimal or full stimulation is the most successful treatment for any cause of infertility.  The decision as to what treatment to undertake will depend on numerous factors including your age, duration of infertility, cause of infertility, cost of treatment and success of treatment as well as your insurance coverage for the treatment and your motivation to conceive and willingness to accept the risks associated with the treatment.   Today, there is a highly successful treatment available for nearly all women.

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So, what test are you putting off and why?

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Can Fertility Medications Cause Ovarian Cancer?

By Tracey Minella, David Kreiner, MD

September 8th, 2011 at 12:00 am

September is National Ovarian Cancer Awareness Month.

Admit it. If you’ve done IVF or stimulated IUI cycles, or even Clomid, the thought has crossed your mind. Will fertility drugs cause ovarian cancer later? Am I doing all this to become a mother, but I won’t be around to see my baby grow up? And the more cycles you do, the more you start to worry.

It’s natural to worry.

I worry… even though I know better. But to help keep my fears in check, I am vigilant with my annual exams and I get an annual ovarian sonogram as well. By spacing the regular annual and the sonogram 6 months apart, I am examined every 6 months and figure that I’m boosting my odds of catching any problems that may arise early. [Fertile folks think I’m nuts going twice a year, but as we infertiles know, stirrups twice a year is a welcome change from stirrups every… damn... day.] If you are freaked out about cancer, you can follow my neurotic lead.

Fortunately, Dr. Kreiner of East Coast Fertility can put the fears of rational ladies like you to rest. Read on for some peace of mind:

I am often asked whether the medications we use in our fertility treatments can cause ovarian cancer. In the past, conflicting stories have been published mainly in the newspapers and non medical magazines. Recently, a scientific forum, Medscape Medical News, reviewed research on this topic and the good news is summarized below.

On February 10, 2009 — It was concluded in the largest study of the subject to date that Fertility drugs do not increase the risk for ovarian cancer. There was no convincing association with ovarian cancer for any of the 4 different types of drugs used to treat infertile women — gonadotrophins (Bravelle, Menopur, Gonal F, Follistim), clomiphene citrate (Clomid, Serophene), human chorionic gonadotrophin (HCG,Novadrel, Ovidrel) and gonadotropin releasing hormone agonist/antagonist (Lupron, Ganirelix, Cetrotide).

Instead, the data suggest that factors related to the diagnosis of infertility (for example, genetic or biological factors) — and not the use of fertility drugs — increase the overall risk for ovarian cancer.

However, they also point out that there is a major limitation to this study — many of the participants have not yet reached the age at which the incidence of ovarian cancer peaks (early 60s).

The study, headed by Allen Jensen, PhD, assistant professor of cancer epidemiology at the Danish Cancer Society’s Institute of Cancer Epidemiology, in Copenhagen, Denmark, is reported online February 5 in BMJ(British Medical Journal).

These data are reassuring but cannot absolutely rule out a very small increase in ovarian cancer or one that occurs much later in life.

Main Limitation Is Age of Participants
A link between fertility drugs and increased risk for ovarian cancer was suggested by several studies in the early 1990s, and this has created concern for patients undergoing infertility treatment. However, many of the studies over the past 8 to 10 years have been very small and none were able to reject or confirm the hypothesis.

This study was the largest because it included 156 women with ovarian cancer, more than 3 times as many as any previous cohort.

The main limitation of the study, however, is the age of the participants. These were young women; they were first evaluated for infertility at a median age of 30 years. Despite a long follow-up, the median age of these women at the end of the follow-up period was 47 years. This is below the usual age at which women are diagnosed with ovarian cancer, which reaches a peak incidence in women in their early 60s. So there is a possibility that there could still be a spate of ovarian cancers diagnosed as these women age, which could alter the conclusions.

This is a question that nobody can answer yet, we should say that the data so far are reassuring with this observation period, and with this age of the cohort, we cannot see any association with an increase in the risk of ovarian cancer.

The researchers intend to revisit the data at regular points in the future to check on the progress of the study cohort with “passive surveillance.” The Danish system of personal identification numbers and nationwide health and cancer registries will allow them to track any new diagnosis of ovarian cancer.

Cannot Exclude Small Possibility
The Danish study investigated the records of 54,362 women with infertility problems, and compared 156 women who developed invasive epithelial ovarian cancer with 1241 controls.
However, although this study was much larger than previous investigations, it still could not exclude the possibility of a small increase in the risk for ovarian cancer in users of fertility drugs, The rate ratio for use of any fertility drug was 1.03, but the upper bound of the 95% confidence interval was 1.47.

Larger numbers of women will need to be studied to answer this question, and these will come with further follow-up of the cohort as they enter the age range where ovarian cancer is most common. Some women who take fertility drugs will inevitably develop ovarian cancer by chance alone, but current evidence suggests that women who use these drugs do not have an increased risk.

Clinical Context
Infertility has previously been associated with an increased risk for ovarian cancer. In an epidemiologic study of 3837 women treated for infertility, Rossing and colleagues demonstrated that infertility increased the risk for malignant ovarian tumors by a factor of 2.5 vs. the overall community prevalence of ovarian cancer. This study, which was published in the September 22, 1994, issue of the New England Journal of Medicine, also suggested that the use of clomiphene in particular could increase the risk for ovarian cancer, particularly in women who had used the medication for more than 1 year.

The current study uses a large cohort of women to examine the effects of different fertility medications on the risk for ovarian cancer.

Study Highlights
• Thestudy cohort consisted of women referred to Danish hospitals or infertility clinics between 1963 and 1998. A total of 54,362 women had data available for analysis.
• Cases of ovarian cancer were documented with use of 2 national registries: 176 women were diagnosed with epithelial ovarian cancer during a median follow-up of 16 years, and 156 women had data for analysis.
• The main outcome of the study was the relationship between fertility drugs and the risk for ovarian cancer. The 156 women with ovarian cancer were compared vs 1241 women from the infertile cohort who did not have ovarian cancer.
• The median year for entry into the infertility clinics was 1989, and the median age at the first evaluation for infertility was 30 years.
• The median time from entry into the cohort until the diagnosis of ovarian cancer was 14.5 years.
• Overall, the use of fertility drugs did not significantly affect the incidence of ovarian cancer. Fertility drugs were used by 49% and 50% of women with and without ovarian cancer, respectively.
• Clomiphene was the most widely used fertility drug, followed closely by human chorionic gonadotropins. Other gonadotropins and gonadotropin-releasing hormones were used less frequently.
• Nulliparity (No births) conferred an especially high risk for ovarian cancer in these women with infertility. The risk for ovarian cancer decreased with a higher number of births.
• The use of oral contraceptives and the cause of infertility did not significantly affect the risk for ovarian cancer.
• After adjustment for parity (Births), none of the individual fertility drugs were associated with a significant effect on the risk for ovarian cancer. The number of cycles used or the number of years since first use did not affect this conclusion.
• Similarly, combination treatment with multiple fertility drugs did not appear to increase the risk for ovarian cancer.
• Serous tumors were the most common histological type of ovarian cancer. Clomiphene use was associated with a higher risk for serous tumor vs. no use of fertility drugs but only in women who used clomiphene at least 15 years before the diagnosis of ovarian cancer.
• Previous research has found that infertility is associated with an increased risk for ovarian cancer, particularly in women who used clomiphene for more than 12 months.
• The current study suggests that fertility drugs do not significantly increase the risk for ovarian cancer.

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Do you worry about getting ovarian cancer from fertility drugs? Do you trust the results of studies like the ones referred to above?

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Avoiding IVF Disasters

By Tracey Minella and David Kreiner MD

September 7th, 2011 at 3:22 pm

With all the natural disasters happening lately…hurricanes and earthquakes and floods… and with the worst weather season ahead of us, you might be feeling a bit uneasy. It’s bad enough that infertility forces us to relinquish control of our baby-making, but not knowing if the next storm is going to further disrupt our lives adds more edge to life’s daily worries.

Although we can’t avoid most natural disasters, Dr. Kreiner explains how he and his ECF team have managed to avoid IVF disasters for over 25 years:

Practicing medicine for the past 30 years, I have developed an enormous respect for those things that happen to people that are beyond our control.  Sometimes, the issue of preventability is a gray one and defies definitive blame assignment.  Yet, when the dust settles there remain victims who are harmed for whom we are all sympathetic.  It is for this reason that we are compelled to do everything within our power to ensure that tragic errors do not occur.

Elsewhere in society there are potentially devastating outcomes to human error and, like in medicine, it may be difficult to unravel how much fault is from natural calamity and how much we could have avoided with more rigorous human controls.

Last March, the world was exposed to perhaps the worst of Mother Nature’s natural disasters: a severe earthquake with multiple aftershocks, followed by a massive Tsunami.  Aside from the horrendous devastation that took place in Japan, ongoing danger persists from damage to several nuclear power plants.  

These unintentional, uncontrollable catastrophes occur naturally and are arguably nobody’s fault.  And although some claim that nuclear power is dangerous because of the history of accidents like at Chernobyl and Three Mile Island, nuclear power plants continue to be constructed throughout the world because many perceive that the benefits of this alternate source of energy outweigh the risks.  We are assured by those responsible that these plants are safe even in the face of the worst disasters… until we learn they are not.

 It is our human condition to speculate how to prevent these complications from occurring.  In IVF, perhaps the greatest potential disaster we face is the mixing up of embryos.

 In February, 2009, a case of a mix-up of frozen embryos in a Michigan IVF program occurred to a couple who already had a set of twins as a result of a successful IVF.  Their embryos were mistakenly transferred into the wrong woman, who then carried the pregnancy and after delivery handed the baby back to his biological parents. Reports of the mix-up have triggered calls from some to make IVF illegal.  This sounds like the recent calls to decommission nuclear power plants and stop production of new facilities.

Mixing up gametes and embryos is tragic and society must do everything humanly possible to prevent it… except disallow the practice of IVF. As with other societal advances, accidents are rare but have unfortunately happened in the field of IVF. But, weighed against the benefit of all the babies who otherwise would never have been born, we should strive to improve the safety of IVF, not eliminate it.

Many of the greatest advances have had tragic results, unintended accidents that could sometimes been avoided. Sometimes, like the post-earthquake nuclear disasters in Japan, they are spawned by natural causes.  But other times, there is an element of human error often preventable with the institution of carefully designed safeguards with a system of checks and balances.

Significant risk, including that of injury or death, is part of nearly everything we do in life today. The construction industry has always been plagued with accidental deaths. Not a bridge or a great high rise has been completed without misfortune. Do we stop construction? No, we ensure that all possible regulations that could protect those involved are in place and followed as strictly as possible to prevent further accidents.

Cardiac bypass surgery and other surgeries save lives and relieve suffering but, occasionally, patients intended to benefit are hurt or even killed accidentally. Rules and regulations are instituted to avoid problems such as performing the wrong operation on the wrong patient, using the wrong medication, operating on the wrong limb. Yet situations do occur rarely, usually because of a human slip. Rules are broken and mistakes result. When they do, hospitals review the procedures and protocols to better insure a sufficient system is in place to catch future errors before they effect patient care.

Just as we have safeguards in the operating room, we have them in place for identifying gametes and embryos with checks and balances that should prevent a mix-up such as the one in Michigan.

In our operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date. As soon as the ovaries are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is double-checked with the patient’s record which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.

Every attempt is made to confirm the identity of the gametes and embryos repeatedly throughout the IVF process from retrieval through transfer. A similar system of double checks of patient and embryo identity exists for frozen embryo transfers as well.

In over 25 years of practicing IVF, my program has not mixed up gametes or embryos.

There are approximately 3 million babies born through IVF and only a few rare mix ups reported. Perhaps we don’t hear …or know…about every mix up. I’d estimate that less than 1/100,000 pregnancies from IVF have occurred with some mix up in the embryo or gamete. When it occurs, it is tragic and requires the attention of our field and a refocus on those checks and balances we have in place to prevent such mishaps.

When it comes to institutions whose impact on society is of such great magnitude, it is essential that governing regulatory agencies ensure that all possible checks and balances are in place to ensure the greatest degree of safety.  All involved must work hard to maintain the highest standards and then we can only pray that we have done everything possible so that such disasters never have such devastating consequences.

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Do you feel that your embryos are safe? Is there any other safeguarding procedure(s) you think should be implemented?

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