AFRAID of IVF?

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You’re not alone. Many couples, when faced with the possibility of needing to undergo fertility treatments, much less in vitro fertilization, react with disbelief and fear. Most of what we know about fertility treatments are the unpleasant things we hear in the media, from well-meaning friends, family and even from the most casual of acquaintances. Yet it is possible that many women you know have safely and successfully undergone IVF without serious disruption to their lives and with a minimum of discomfort.

So what is the truth? Is the process of fertility treatment and in vitro fertilization really the house of horrors it is rumored to be? If the idea of having to undergo fertility treatment or in vitro fertilization causes you to have serious concerns, please take a moment to read this. We would like to address some of the most common fears associated with undergoing IVF treatment and demonstrate how, with modern medications and compassionate care, the process can be much less unpleasant than you might imagine.

“Aren’t the injections painful?”

Most women have heard that a series of painful injections of fertility drugs must be undertaken during the IVF process. Some of the hormones used to stimulate multiple egg development are large protein molecules and cannot be given orally. However, the new technologies for the manufacture of these medications have helped us minimize the number of injections needed and the size of the needles used to administer the medication.

One of the common medications used for IVF is a drug called Lupron. Lupron works to temporarily shut off the hormonal signals from the brain to the ovaries and thus prevents the eggs from being ovulated before they are ready to be harvested for the IVF procedure. Lupron is usually self-administered for about 21 days by injection with a small needle under the skin, similar to the way diabetics take daily insulin injections. There is an equally effective alternative to Lupron called Synarel that can be administered by nasal spray, thus avoiding the 21 days of injections. At Pacific Fertility Center, where I practice, our physicians have had over 15 years of experience using Synarel for IVF and have published journal articles demonstrating how effective Synarel is for this purpose. Another common medication now used to prevent an LH surge in an IVF cycle is Antagon or Cetrotide. These new medications are given by injection but, rather than 21 days of Lupron, Antagon and Cetrotide are usually given for 3-4 days.

Many of the older drugs, such as Pergonal, Metrodin and Humegon, used in IVF to stimulate multiple egg development had to be administered by intramuscular injection, deep into the muscle of the buttocks. This technique was used because these older medications were less pure than the medications available today and a larger volume of fluid had to be given with each dose. Thanks to recombinant DNA technology, we now have medications such as Gonal-F and Follistim that are extremely pure, can be dissolved in small amounts of liquid and injected just under the skin (subcutaneous) with a small needle. These medications are usually injected over a period of ten to eleven days plus or minus three days. The newer drugs are as effective as the older drugs, perhaps more so. There is now a pre-filled “pen” injection system much like a ball point pen which holds a cartridge of premixed medication. The only remaining medication that still must be given by intramuscular injection is hCG. HCG is a single injection given 36 hours prior to the egg retrieval procedure.

During the IVF process, it is necessary to supplement the ovary’s production of progesterone to help implantation and early pregnancy. Many clinics still use deep intramuscular injections of progesterone (which must be dissolved in an oil base). Some women are prescribed these injections for as long as 100 days in a row. At Pacific Fertility Center, where I practice, we have been offering progesterone vaginal suppositories or capsules as progesterone supplementation for many years, thus avoiding progesterone injections altogether. We know from our success rates that this treatment is as effective as injections. Unfortunately, for recipients of donor eggs whose own ovaries do not make any progesterone, injection is still considered the only form to adequately provide support.

In addition, the physicians at PFC are advocates of using natural cycles for frozen embryo transfers whenever possible. This protocol can significantly minimize both the amount of medications required and the costs of the procedures for most patients. There is no difference in the success rates of frozen embryo transfer cycles comparing a natural cycle to a programmed cycle, which uses estrogen and progesterone injections routinely.

Using our protocols at PFC, a woman who wishes to minimize the number of injections in her IVF cycle, may need only 10-11 days of subcutaneous injections and one intramuscular injection of hCG. That’s it!

“Are the procedures painful?”

The only procedure that could be considered a minor surgery in the IVF process is the retrieval or harvest of the eggs from the ovary. This is done by introducing a needle attached to a vaginal ultrasound probe through the wall of the vagina and into each ovary.

If you were to undergo this procedure without any anesthetic, it would likely be painful. We are able to take advantage of an array of excellent anesthetic medications that are administered through an intravenous line, are rapid in onset of anesthetic effect, and wear off quickly when the procedure is over. Our patients breathe completely on their own during the approximately 20 minutes of the procedure, but sleep deeply enough to be completely unaware of any discomfort. After the retrieval procedure the patient wakes up relatively quickly and, at most, may feel some minor cramping in the ovaries, which can also be treated with very safe medications.

At PFC, each patient at every egg retrieval procedure is closely monitored by a fully board certified M.D. anesthesiologist. We can safely provide as much anesthetic as may be necessary for complete pain relief during the procedure.

“Will my baby suffer birth defects?”

In 1977 the first baby was conceived through in vitro fertilization. This then radical new method of human conception raised significant concerns about whether babies born from the procedure would be “normal.” When Louise Brown was born in England nine months later, she appeared to be a perfectly normal infant girl. However, scientists and physicians knew that much more data was needed to determine whether the rate of birth defects was higher in children conceived in the in vitro laboratory.

It is important to note that the rate of birth defects in humans in the general population is about 3% of all births for major malformations and 6% if minor defects are included. Fortunately, 20-plus years following Louise Brown’s birth, we now have ample data that children conceived through IVF have no increase in these rates of birth defects, outside of the use of ICSI. Further follow-up on older children indicates that IVF children have done as well or better than their peers in academic achievement (probably a social bias) and have no higher rates of behavioral or psychological difficulties.

“Will the hormones cause long-term health risks?”

The only long-term health risk that has ever been suggested to be associated with the use of medications used for IVF is the possibility of an association between these drugs and the risk of cancer, specifically ovarian cancer.

An important facts to keep in mind is that women who suffer from infertility and have never conceived appear to have a slightly increased risk of ovarian cancer as compared to the general population (about 1.6 times the rate). As these are the women who use fertility medications, the medications themselves have been implicated in the cancer risk. However, these medications have never been proven to be a cause of cancer. Since this initial concern was raised in a 1992 study by Whittemore and colleagues, several studies have addressed the issue more directly. These studies from Australia, England and Denmark all find no association between fertility medications or IVF treatment and a higher risk of ovarian cancer.

An ongoing National Institutes of Health-funded study in California is specifically designed to address the question of whether fertility medications themselves may play a causal role in ovarian, breast or uterine cancer. While the study is still under way and needs another 5-10 years of follow-up to be conclusive, preliminary results suggest no association between fertility medications and risks for invasive cancers. At this time, we can say that there is no direct evidence that fertility drugs play a causal role in increasing a woman’s risk of invasive ovarian, breast or uterine cancer.

“Will the hormones make me a raving maniac?”

A common misconception is the notion that women become emotionally unstable and out of control while taking these hormone injections, both during the stimulation process and beyond. Why does this notion exist?

One potential reason for this misconception is that the injectable medications are perceived to be “stronger” than the other common oral fertility drug, clomiphene. While it is true that injectable hormones are more powerful in terms of recruiting more eggs, the manner in which they work is completely different from clomiphene. Clomiphene is an anti-estrogen and “tricks” the brain into thinking there is no estrogen available. The brain responds by putting out more natural FSH hormone to stimulate the ovary. Because the brain perceives there is no estrogen available, the brain reacts similarly to menopause. The symptoms of temporary hot flashes, mood changes and irritability are a result. Conversely, the injectable medications such as Gonal-f and Follistim contain pure FSH and stimulate the ovaries to make more estrogen. Estrogen is a hormone that has a positive effect on the brain, hence no hot flashes. It is uncommon to see significant mood changes or irritability on these injectable medications.

Undergoing IVF treatment can be stressful and it is possible that some of the hormones accentuate whatever a woman’s prevailing mood is at the time. Couples may often feel conflicting emotions of hopefulness, apprehension and uncertainty. We recognize these feelings are normal human responses to this type of stress. The vast majority of our IVF patients say that the process was not as emotionally difficult as they had anticipated. We strongly recommend that couples seek the information and support they need. PFC provides an on staff marriage and family therapist experienced in fertility issues. RESOLVE is a national organization that is an advocacy and support group for couples coping with infertility and can be an important resource for both emotional support and unbiased facts.
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About the Author

Dr. Herbert is a fertility expert and an innovator in the field.

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