Infertility treatment updates
Does Ovarian Stimulation for ART Hasten Menopause?
Over the past 30 years, large numbers of women have received gonadotropins for ovarian stimulation in order to obtain oocytes for assisted reproduction technologies (ART). Evidence so far indicates that concern about the possible long-term risk of ovarian cancer does not appear warranted, but another potential side effect of ovarian stimulation might be premature menopause, resulting from accelerated follicular atresia. Now that the first wave of patient who underwent ART has reached menopausal age, Elder et al from the Bourn Hall Clinic, United Kingdom, investigated this question by contacting many of these women.
The data indicated that gonadotropin administration for the treatment of infertility had no lasting impact on ovarian aging and either the timing or the symptoms of menopause. This study thus provides reassuring evidence that ovarian stimulation does not hasten menopause and consequently does not compromise reproductive potential. The findings are insistent with animal data showing that the timing of follicle depletion is independent of gonadotropin stimulation.
Elder K, Mathews T, Kutner E, et al. Impact of gonadotropin stimulation for assisted reproductive technology on ovarian ageing and menopause. Reprod Biomed Online 2008;16:611-616.
Body Weight and Risk of Miscarriage After IVF/ICSI and FET
Obesity and low body mass have been shown to increase the risk of miscarriage in spontaneous pregnancies, but the data are conflicting regarding the risk after conception through in vitro fertilization / intracytoplasmic sperm injection (IVF/ICSI). Veleva et al from the University of Oulu, Finland, studied the effect of body mass index (BMI) on the miscarriage rate after IVF/ICSI with frozen-thawed embryo transfer (FET), a practice becoming more common because of wider use of elective single-embryo transfer.
The authors concluded that both obese and underweight women have an increased risk of miscarriage. However, the rate is even higher for women who received FET after hormonal ovarian stimulation.
Veleva Z, Tiitinen A, Vilska S, et al. High and low BMI increase the risk of miscarriage after IVF/ICSI and FET. Hum Reprod 2008;23:878-884.
Outcomes for Cancer Patients with Use of Cryopreserved Semen
The success rates for in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) using cryopreserved semen are almost as high as those using fresh semen; however, only a few studies have involved cancer patients, and most oncologists are not sufficiently aware of the technical progress made in this area. To help spread the information, van Casteren et al from Erasmus Medical Center, the Netherlands, undertook a retrospective study of a large cohort of cancer patients followed for an average of 7 years (range, 2-24 years). They assessed the use rate and outcome of assisted reproduction with cryopreserved semen.
With approximately half of the couples surveyed achieving live births using cryopreserved semen and ART, the authors concluded that this is a reliable method for preserving fertility of men who have undergone gonadotoxic treatment for cancer. Neither the length of semen storage time more the quality of the semen prior to treatment need rule out banking sperm and using it. The authors have been actively informing oncologists about the increased success rates and recommend discussing semen cryopreservation with male cancer patients.
Van Casteren NJ, van Santvrink EJP, van Inzen W, et al. Use rate and assisted reproduction Technologies outcome of cryopreserved semen from 629 cancer patients. Fertil Steril 2008;doi:10.1016/ j.fertnstert.2007/10.055.
A Combined Approach for Endometriosis and Infertility
While laparoscopic surgery is considered the “gold standard” for the treatment of endometriosis, it does not always increase conception rates of women who have been rendered infertile by the condition. Coccia et al from the University of Florence, Italy, assessed whether using in vitro fertilization and embryo transfer (IVF-ET) after laparoscopic surgery would increase the pregnancy rate for women with endometriosis-associated infertility.
For patients with endometriosis-associated infertility, laparoscopic surgery followed by IVF-ET was more effective than the surgery should be the first line of treatment and patients should be advised to begin trying to conceive soon afterward. If pregnancy does not occur spontaneously within 9-12 months, patients should be advised to undergo IVF-ET.
Coccia ME, Rizzello F, Cammilli F, et al. Endometriosis and infertility surgery ant ART: an integrated approach for successful Management. Eur | Obstet Gynecol Reprod Biol 2008;138:54-59.
Preserving Oocytes of Young Cancer Patients
Cure rates for cancer in children and adolescents now approach 75%. However, these results are obtained through intensive use of chemotherapy and radiation, which can negatively impact future fertility. While cryopreservation of sperm from pre- and postadolescent males has proven successful, cryopreservation from pre- and postadolescent females has been much less successful and requires ovulation induction and ovarian stimulation, an impractical option for young patients. Ovarian cryopreservation has shown only limited success; in part because of the inability of germinal vesicle stage oocytes to survive the procedure. The treatment also requires a significant delay in the onset of chemotherapy. Revel et al from Hadassah Hebrew University Medical Center, Israel, proposed an alternative treatment involving oocyte aspiration from antral follicles of the ovarian cortex, followed by in vitro maturation (IVM) and oocyte cryopreservation.
Perhaps the most surprising result of this study was the discovery of oocytes in the 4 premenarchal patients. Because none of the patients has yet to under fertility treatment using the cryopreserved oocytes, the ultimate success of this procedure is still unknown. However, the study findings suggest that young cancer patients may still have a realistic chance of pregnancy.
Revel A, Revel-Vilk S, Aizenman E, et al. At what age can human oocytes be obtained? Fertil Steril 2009;92:458-463.
Pregnancy Rates and FTET
Oocyte donation to treat infertile women has been successful for nearly 2 decades. While fresh embryo transfer has shown higher implantation and pregnancy rates than frozen-thawed embryo transfer (ETET), a need exists to understand the factors that influence successful pregnancy rates after FTET and adapt in vitro fertilization strategies accordingly. Dessolle et al from Hopital Tenon, France, conducted a retrospective study to determine the factors that influenced successful pregnancy after oocyte donation and FTET.
The study indicated that pregnancy rates after FTET are lower than rates noted in studies using fresh embryos in oocyte donation programs, and that FTET may be more successful in women with ovarian failure than in women with persistent ovarian function. Weight loss and optimizing endometrial priming could also increase the potential for success of FTET.
Desolle L, Darai E, Cornet D, et al. Determinants of pregnancy rate in the donor oocyte model: a multivariate analysis of 450 frozen-thawed embryo transfers. Hum Reprod 2009;doi:10.1093/humrep/dep303.
The Affect of Physical Activity on Women’s Fertility
While regular physical activity is beneficial to maintain general health, female athletes reportedly have a higher prevalence of reproductive dysfunction than the general population. The association between physical activity and fertility in healthy women remains unclear. Gudmundsdottir et al from the Norwegian University of Science and Technology analyzed a large-scale population-based health survey and its follow-up to evaluate this association.
The study suggests that physical activity up to a certain level may positively affect fertility, but physical activity beyond that threshold may negatively affect fertility. While weight loss associated with exercise can lead to a significant improvement in fertility, adjustment of BMI in this study did not significantly change the increased risk of infertility for women with the highest intensity or frequency of physical activity.
Gudmundsdottir SL, Flanders WD, Augestad LB, Physical activity and fertility in women: the North-Trondelag Health Study. Hum Reprod 2009;doi:10.1093/humrep/dep337.
Impact of Smoking on Intrauterine Insemination
Cigarette smoking has a significant negative effect on the outcome of in vitro fertilization (VF) treatment. Smokers require higher mean gonadotropin doses for ovarian stimulation and have lower peak estradiol (E2) levels, fewer oocytes retrieved, lower fertilization and implantation rates, lower pregnancy and live-birth rates, and require nearly twice as many IVF cycles to conceive. This study examined the impact of smoking on controlled ovarian hyperstimulation (COH) combined with intrauterine insemination (IUI).
Previous studies of IVF treatment have shown that smokers required an increased amount of gonadotropin during COH. However, the end result – clinical pregnancy – in this study differed from the findings of IVF studies. The effect of smoking on the more vigorous stimulation required for IVF may be moderated during COH for IUI, which requires less vigorous stimulation. After undergoing COH for IUI, smokers achieved a pregnancy rate similar to nonsmokers, although they required more gonadotropin to reach this result.
Farhi J, Orvieto R. Influence of smoking on outcome of COH and IUI in subfertile couples. J Assist Reprod Genet 2009;26:421-424. |
