Tuesday, August 12, 2008

An ethical dilemma? Infertility and drug addiction

(I sometimes tell this (true) story when talking to medical students or public groups about the ethics of reproductive technology. MPS)

"A couple presented to my office requesting care for infertility and recurrent miscarriages. Within a few visits, it was clear to me and the office staff what the problem was - they were both drug addicts. Their particular addiction was known to increase the risks of infertility and miscarriage, and was associated with a variety of other pregnancy complications. They were in their early 30's and successful in their professions and daily lives. We offered help and strongly recommended that they stop their drug use, but they just wouldn't (or couldn't) do it. How should one proceed in a case such as this?"

Audiences are uniformly unsympathetic towards this couple - no one wants to offer them fertility treatment. Often someone will comment that the situation is appropriate, as drug addicts shouldn't be reproducing anyway. I ask if it matters which drug they are taking, and the answer is "no". Then I reveal that the drug being abused is nicotine - the patients are heavy smokers. At this point some members of the audience become very quiet, as they have packs of cigarettes in their pockets. The rest of the audience usually become less vigorous in their condemnations. No one tries to dispute the harmful effects of smoking on reproduction, but it seems that this addiction is much more socially acceptable than the cocaine or heroine use the audience had in mind.

What ultimately happened with the patients? I finally told them not to come back until they stopped smoking. They never returned.

Friday, April 25, 2008

More fertility questions

Q: "Is there anything else to test a husband for if his count is excellent and they're "strong swimmers"?"

A: Basically, no. You would think that evaluation of male fertility would be very straightforward, since the male gametes are readily available for examination, but this is not so. Just because a sperm has a normal shape and is moving doesn't mean it can fertilize an egg. Many tests have been developed to try to answer this question, and while some advanced sperm tests show a correlation with fertilization capacity in research studies, none of them wind up being clinically useful. Here are some male fertility tests that, in my opinion, fall into this category: hamster egg sperm penetration assay, hemizona assay, strict morphology testing, DNA fragmentation studies. I have seen men who have failed these tests but whose sperm could fertilize a human egg without difficulty. I don't think the tests are worth the expense, and they are seldom covered by insurance.

It turns out that a simple semen analysis is about as good as anything for predicting male fertility. If there are more than 20 million motile sperm in a man's ejaculate, he is probably fertile. If there are less than 10 million, he probably isn't.

Q: "I underwent IVF with ICSI at age 35 after trying for my first pregnancy for 2 years. My husband had a slightly abnormal SA that may be from his previous exposure to chemotherapy (you can comment on that if you'd like). They wanted me to have PGD since I was 35. No thanks, I said. Especially since they were charging $4000 out of pocket.... I knew my chances for an abnormality based on our history and I also trusted nature to take care of any abnormalities they could have picked up with PGD, accepting the consequences if nature didnt....

I got pregnant the first attempt and have a wonderful son after a very traumatic pregnancy (threatened miscarriage, chronic abruption, fetal abnormalities). The genetic testing on my son is all completely normal, however, he does have a syndrome, there is just no test for it....

Are there any abnormalities or genetic syndromes related to IVF with ICSI, or with chemo exposure to the dad?"

A: Whether fertility treatment causes birth defects has been debated for many years. People are still arguing about whether clomiphene causes birth defects, even though the drug has been on the market for more than 30 years. The development of in vitro fertilization has renewed interest in this matter. Several studies have shown that children conceived with IVF have a higher incidence of birth defects, but the defect found is not consistent among all the studies. More recently, it was suggested that IVF caused certain "imprinting" disorders by altering methylation of DNA due to culture of the embryos outside of the body. However, a larger study failed to confirm this.

Why all the conflicting results? I think a lot of it has to do with the nature of the IVF patients, and how a control population is chosen for study. Infertile women are different from the general population of pregnant women: they are older, of different ethnicity and socio-economic status, and their infertility problem is often associated with other problems that may affect pregnancy outcome (for example, the association betweeen polycystic ovary syndrome and diabetes). In my opinion, there is no convincing evidence showing that IVF (or clomiphene, or any other fertility treatment) causes birth defects.

There are two exceptions to this. (1) IVF for male factor infertility is more likely to yield a child (if male) that will be infertile himself. (2) The incidence of cystic fibrosis is higher in children of men with congenital absence of the vas deferens who conceive by IVF. In both of these cases, it isn't the fertility procedure that causes the defect, but rather the underlying problem.

Wednesday, January 30, 2008

SEX! and other FAQs

A former patient with a particularly wry sense of humor has observed that this blog is a bit dry. I can’t help it – when patients see me in the office, I try to inject a little humor into the visit in order to put them at ease (you must admit that some aspects of infertility treatment can be funny), but it’s hard to be light-hearted when putting things down on paper (or rather, on a screen) for everyone to see.

There is something to be said for a sense of humor. It’s a coping mechanism of sorts, kind of like prayer or meditation. It worked for my patient, anyway, and we enjoy her periodic visits to show off her baby. JT, this blog is dedicated to you.

Q: How often should I have sex if I’m trying to get pregnant?

MPS: It’s the number-one question of infertile patients, and I’m amazed at how much misinformation there is about it. First of all, NO ONE HAS EVER SHOWN THAT HAVING TOO MUCH SEX WILL DECREASE YOUR CHANCES OF CONCEIVING, assuming that we are dealing with intercourse that ends with ejaculation into the vagina. Yes, I know semen quality declines with frequent ejaculation, but hey, those sperm are going where they need to go. In more than 20 years of practice, I have never seen a couple who presented with infertility due to having too much sex – I challenge you to find such a case. If you want to do it every day, be my guest. However, anything more than about three times a week is for recreational purposes only. Sperm survive in the female genital tract about 2 or 3 days near the time of ovulation, so more than every other day will not improve your chance of pregnancy. Now, if you look around in the medical literature, you can find papers that show increased pregnancy rates with more frequent intercourse, up to five times a week, but those investigators didn’t account for the fact that younger couples are more likely to have sex, and are more likely to get pregnant as well. When you control for age, maximal fertility tops out at about three times a week. I tell patients that if you having 28-day cycles you should have sex at least three times a week between days 10 and 20. I think that doing it every other day is bit too regimented, but some people find that schedule helps them stay focused.

Often, infertile couples are burned out on sex by the time they see me. They work hard, they are tired when they get home, and they’re sick of doing it like bunnies month after month. I think if you want to pick the ONE DAY to have sex the entire month, use an ovulation prediction kit, and have sex the night the kit turns positive. You can achieve success almost as good as with the three-times-a-week regimen if you do it that way. (See below for more info about ovulation predictor kits.)

Q: Someone told me I should elevate my hips on a pillow after sex. Will this help me get pregnant?

MPS: If pillows were required for reproduction, our species would have long since died out. I am not aware of any study showing improved pregnancy rates with post-coital hip elevation. Here’s what I recommend: after sex, lie there for five minutes or so, then get up and go to the bathroom to empty your bladder (this is good hygiene for preventing bladder infections). Yes, fluid is going to leak out, but that’s ok.

Q: What kind of ovulation prediction kit should I use?

MPS: Several years ago, Consumer Reports did a study on ovulation prediction kits. I was impressed at how much difference in quality there was among the brands out there. The winner in that evaluation was a product called Clearblue Easy (it used to be called Clearplan Easy), and a newer version called Clearblue Easy Digital is even better – that’s the one I recommend. (By the way, I have no financial interest in this product.) We use these kits to time artificial inseminations and post-coital tests, and they work quite well.

Most ovulation predictor kits detect a surge of luteinizing hormone (LH) in the urine. This is the hormonal trigger that tells the ovary to release the egg. However, there are some other products out there that claim to predict ovulation by detecting changes in saliva, vaginal discharge, or sweat. One product even claims a 65% improvement over urine LH kits, but in my opinion, no one has ever shown these products to be as good as a quality LH kit, and I don’t recommend them.