Over 2 decades ago, ICSI (intracytoplasmic sperm injection) revolutionized the treatment of male infertility. The ICSI procedure involves injection of a single sperm into each egg at the time of IVF (in vitro fertlization). Before the development of ICSI, couples with sperm issues, what we call "male factor," had very low fertilization and pregnancy rates, even when undergoing IVF. Now a days, because of the use of ICSI, poor sperm quality is a very unusual reason for an IVF cycle to be unsuccessful or to blame for poor fertilization. Over concerns about potentially poor fertilization, many fertility centers have chosen to use ICSI routinely to ensure optimal fertilization even when the male partner's sperm is perfectly normal. At Princeton IVF, our philosophy has always been to allow fertilization to happen "naturally" in the dish when there is no history of sperm issues or poor fertilization. While ICSI had been shown to be quite safe, we feel that a more natural selection process makes more sense and research in the past has suggested that ICSI is only beneficial in male factor patients. A recent large-scale study recently published in the Journal of the American Medical Association has borne this out. ICSI when used in IVF cycles used in couples without sperm issues had lower fertilization and lower implantation rates than non ICSI cycles.
One of the chief concerns couples have is the about the safety of the procedures that fertility specialists use to help them achieve pregnancy, such as IVF (In vitro fertilization). Most of us in the field know that serious complications to the mother-to-be can occur but are quite rare. A recent study with the lead author from Emory University looked through nationwide database of IVF clinics across the country over the past 12 years, and confirmed that while IVF does entail risks for women, those risks are quire small.
Could a cure for real cure for infertility be on the horizon? Today many causes for infertility can currently be successfully treated such fertility issues caused by damage to fallopian tubes, ovulation disorders, endometriosis and low sperm counts or motility. These treatments currently available to us include fertility drugs, insemination, surgery and IVF. However, there are still issues in assisting women have very few or no eggs left or men who produce no sperm at all. This is a particular problem for women since women produce all they eggs they will in a lifetime while still in their mother's womb, and by their mid 40s have hardly any normal eggs left. These couples can be successfully treated only with the use of donor eggs or sperm. While these donor procedures are often quite effective, the children who result from these pregnancies do not carry the DNA of one or both of the parents. This is a problem since most couples who seek out the help of a Reproductive Medicine specialist want their own genetic children. With our current state of reproductive science this may not be possible.
One potential way around this would be using stem cells in the lab using cloning technologies. A group of scientists at the Weizmann Institute in Rehovot, Israel and Cambridge in the UK have brought us a little closer to this cure, figuring out how to more efficiently get these stem cells to grow into cells that will eventually develop into eggs and sperm. Their findings were recently published in the journal Nature.
The researchers have yet to take the next step; producing eggs and sperm from these stem cells. While it may become technically feasible, besides the technical issues, there are ethical concerns, perhaps even greater than when IVF when first introduced to overcome before this proceeds. IVF was enormous breakthrough when it was developed, but it is still merely a replication of natural conception, albeit in a laboratory dish. If this next step is even possible, it could bring reproduction to entirely new level. These technologies may make it possible to have genetic children without ovaries, without testes and without age limits, shattering our concepts about parenthood, even more so than it is today. It is not clear if society is ready for this yet.
There are plenty of reasons to quit smoking. The health effects of smoking are well known and well documented, not just on your fertility, but a whole number of health issues including heart disease and cancer. Now, there's yet another reason to quit smoking if you are pregnant or trying to get pregnant. Cigarettes may actually affect a woman's male offspring's sperm quality. As reported in Human Reproduction, the male offspring of pregnant mice exposed to high levels of cigarette smoke had sperm with lower counts, lower motility and more abnormally shaped sperm (low morphology), and these male mice took longer longer to impregnate female mice who in turn gave birth to fewer mouse pups. So, what does this all mean? While we don't yet know if this is true in humans (or even 100 % sure it is true in animals), exposure to tobacco smoke could not only harm your fertility (among other things) but also could harm your unborn son's chances of fathering children. This is another good reason to quit.
In recent years, Vitamin D has become the all the rage in medical research. It seems everybody these days is deficient in Vitamin D and a whole range of medical conditions from cancer to osteoporosis to reproductive issues have been potentially linked to insufficient Vitamin D. A recent study, which was in agreement several other previous studies, showed that women doing IVF with higher Vitamin D levels actually had significantly higher pregnancy rates than those who did not. While it is not clear at this time whether Vitamin D deficiency actually causes infertility or even whether supplementation will help couples conceive, it does suggest that maintaining healthy Vitamin D levels may contribute to good reproductive health.
This sounds kind of odd. Why would fertility specialists use a drug intended to treat breast cancer patients to help couples conceive? To those in the field, the concept is nothing new. Clomiphene (Clomid) is a close relative of Tamoxifen, a drug used for years to prevent the recurrence of breast cancer. These drugs which block the action of the female hormone estrogen, cause hormone fluctuations that stimulate eggs to grow. Over the past decade, doctors have begun to use another breast cancer drug called Femara or Letrozole to treat couples in with infertility. Like tamoxifen, letrozole is used to prevent recurrence in breast cancer patients, and like clomiphene, it can also be used to stimulate ovulation (release of an egg). Until now, clomid has been the gold standard to help make women ovulate since it is relatively inexpensive and safe. Recently, however, a large study was published suggesting that letrazole may actually be more effective than clomiphene and result in fewer multiple births. Over time, it is likely that letrazole may replace clomiphene as a first line fertility drug.
This is one of the most common questions patients ask their fertility doctors and/ or their OBGYNs. Fortunately the short answer is no and this is backed up by large research studies. While their purpose may be to prevent pregnancy, the contraceptive effect of the pill wears off rather quickly. In some women the return to normal cycles and fertility can take a number of months, but usually there is not much of a delay. In other women, such as those with ovulation disorders such as PCOS, coming off the pill may actually increase the chances for conception. If your cycles have not regulated themselves 6 months after stopping the pill or they are becoming less regular over time after then and you're trying to get pregnant, it's probably not the pill, and it's time to discuss this with your GYN or fertility specialist.
A recent study suggests that men who keeps their cellphones in their pants pockets, may have lower sperm motility. Researchers at the University of Exeter in the UK, found that men who kept cell phones in their pockets had lower sperm motility than those who did not, about an 8% reduction. Is this an issue? It remains to be seen whether this decrease really affects a couple's chances for pregnancy and truly causes infertility.
Apparently according to the NFL, it is. One of the players on the Indianapolis Colts was suspended after taking clomiphene, a fertility pill commonly used by Fertility Specialists, OBGYNs and Urologists to help women (and sometime men) coping with infertility. Even though he was using it to help his wife get pregnant, successfully I might add, the NFL considers Clomid a "performance enhancing drug." Most patients who have taken clomiphene, and put up with some its side effects would likely take issue with that assessment.
Being that is National Infertility Awareness Month, this week seemed like an appropriate time to share this story. I recently attended a lecture given by one of pioneers in our field and one my personal mentors, Dr. Eli Adashi. The story he shared with the audience moved me and reminded us of our patients' suffering and why we do what we do. In the history books, when one looks at the breakthroughs in medical infertility treatment, the birth of the first IVF baby does and will stand out as one of the great milestones. The protagonists in the story that everyone knows are, Drs. Steptoe and Edwards, the brilliant gynecologist and scientist team, and of course, baby Louise Brown herself. But the popular narrative leaves out perhaps the most important character in this drama, Lesley Brown, the patient herself. Lesley was a reserved woman who never wanted attention but her delivery was one of the most famous events of the 20th century. She put up with repetitive surgeries and painful medical procedures knowing there was little chance they would work. When she did IVF with Drs. Steptoe and Edwards, she was basically (and knowingly) a human guinea pig. Nobody had any idea as to whether it could work, whether it was safe and if it did whether her child would turn out normal. On top of that she had to put up with moral outrage (and occasionally harassment) of those who opposed the very idea behind IVF. Without her bravery and perseverance, millions of couples would remain childless and millions of babies would never have had a chance at life. Lesley Brown passed away quietly in 2012 but the legacy she left has brought both hope and joy to millions.
One of the most common questions patients ask us when they are about to start fertility drugs, is are they are safe? This question comes up whether they are going to start pills (Clomid, Femara) or injectable fertility drugs (Follistim, Gonal-F, Bravelle, Menopur). Unfortunately, the answers are not always so clear cut as we would like. One of the major concerns women have is about cancer, and the cancer which more women seem to fear than any other is breast cancer. In the past there have been questions about whether fertility drugs increase the risk of breast cancer. A recent study may help to reassure anxious couples. The researchers followed fertility patients from multiple institutions and showed that women treated with fertility drugs, both oral and injectables had the same rates of breast cancer as those who were not. The only exception was women with who took clomid for over year, who did have a slightly higher rate of breast cancer, another good reason to be proactive and see a fertility specialist early on.
Most fertility specialists, obgyns and midwives (and probably even your mother-in-law), know that stress can cause infertility. We see this in practice all the time, and numerous studies have shown that stress reduction techniques can help couples with infertility. Still, we do not quite understand the connection even though we know it exists. A recently published study from Ohio State looked at women trying to conceive and the levels of an enzyme called alpha amylase in their saliva. Alpha amylase is a considered a marker for stress, and the researchers found that women with higher levels had lower monthly pregnancy rates. Is this the missing link? Probably not, but it may be a first step in finding out how the mind affects fertility.
There has been a lot of chatter about effects of BPA in the news, an additive in plastics bottles and their effects on reproduction. The NIH decided to look into plastics additives effects on female and male fertility, and they found something interesting. Men who were exposed to pthalates, additives used to softer plastics such as vinyl took longer for their partners to conceive than those who did not; 20% longer. Surprisingly, BPA exposure in either partner and phthalate exposure in women did not affect fertility. While this does not prove that these chemicals cause infertility in men, it is another piece in the unsolved puzzle about how that environment may be affecting our reproductive health.
The Wall Street Journal recently published an article on one of the hot topics in Reproductive Medicine, Minimal stimulation IVF, also known as "Mini-IVF." This is IVF with very low doses of fertility drugs. It certainly sounds appealing, fewer drugs, fewer doctor visits, fewer side effects and less cost in order to have a baby. But, like most things in life, there is always a downside. Mini-IVF has significantly lower pregnancy rates than regular IVF. Does it work for some couples? Absolutely. Is the lower cost and hassle worth the lower chances for pregnancy? At this time, the jury is still out.
A study recently presented from a fertility center in Korea showed that women who got a good night sleep (7-8 hours) had the best outcomes from IVF treatment when compared to women who got less sleep or even more sleep. Does this mean that sleeping increases your chances for pregnancy? Probably not, but it does confirm what we already know, that a healthy balanced lifestyle and reducing your stress will improve your odds of getting pregnant.