Lower doses of IVF drugs?

There have been a number of articles about "mild" or "soft" IVF in the last few months, all suggesting that the higher doses of fertility drugs often used in the UK and USA during fertility treatment are potentially hazardous as they can lead to hyperstimulation. One recent piece described OHSS, or ovarian hyperstimulation syndrome, as a "little-known" side effect of treatment making it sound as if the condition had only just been discovered.   While it may well be little known to the journalist in question, it is hardly little known to anyone who knows much about infertility and treatment.

What's quite interesting about these articles is that they're all entirely one-sided, only quoting experts who happen to be great advocates of mild IVF and making it sound as if anyone who doesn't do this cannot possibly have their patients' best interests at heart.  Such articles would make far more credible reading if they also allowed space for those who don't use mild IVF to explain why.

While it's true that OHSS can be a very dangerous condition, it is also true that some women are at greater risk than others and that careful monitoring during treatment can reduce the chances of the condition developing.  Generally success rates are lower with mild IVF, which is why fertility specialists choose to stimulate the ovaries to produce more eggs in order to increase the chances of success.  Perhaps in the future we will be able to get excellent outcomes with far lower doses of drugs, but in the meantime it may be more prudent to continue to tailor the dose to the individual to increase the chances of success and reduce the risks.

Responses to article on fertility education for schools

I knew when I set out to write a piece for the Guardian about including infertility into the school sex education curriculum that it was a contentious issue, but hadn't anticipated how angry the idea would make some people.

None of the people I interviewed were suggesting any hugely radical changes, just mooting the thought that including some teaching about fertility awareness at school might be helpful.  It became apparent during my research that sex education isn't always as good as it could be, and that young people are often left confused about reproduction and fertility.  Even any worries about sending potentially confusing messages by teaching about infertility were allayed when it became apparent that including this as part of a coherent well-planned sex education programme would probably help to reduce teenage pregnancies, rather than encouraging young people to take risks.

So why did the suggestion make some people so cross?  I've always been fascinated as to why any mention of infertility sends a small percentage of the population - often those with quite a few naturally-conceived children of their own - into some kind of mental tail spin.  Not only did many people start raging at the very thought of mentioning infertility to young people, there were also the by-now-all-too-familiar rants about infertility itself.  What on earth induced one person to say that we should be "grateful" for infertility in the light of our rising world population?  Imagine changing that a little and suggesting we should be "grateful" for heart disease or cancer in the light of population growth...

One of the tweets I received after the piece summed it up for me, saying that the comments alone showed that infertility should be included into the sex education curriculum to encourage more understanding if nothing else -  and with that, I would most certainly agree...

Being unhappy doesn't affect IVF outcomes...

I was hugely heartened by the recent research, published in the journal Fertility and Sterility (awful title but it's an academic journal!),  which showed that feeling anxious or depressed when going through fertility treatment didn't affect the outcome.  I've always maintained that it's unhelpful to tell people who are embarking on fertility treatment that they should be cheerful and positive when they are living with  the huge emotional ups and downs of infertility - it just seems completely unrealistic.  I know I felt stressed, anxious and worried when I was having IVF.  I was not happy, I was not positive, I was unable to "visualise success" or any of the other things that we are often told will increase our chances of a successful outcome - and yet my treatment worked.

We need to be realistic, to accept that infertility is stressful, that it often makes you unhappy and miserable.  There's a growing industry surrounding conventional fertility treatments of complementary therapists and coaches who make a lot of money telling us how they feel we can improve our chances of success. Some of this can be very helpful, but it is perhaps inevitable that when those who have no personal experience take an objective view of infertility and treatment there are sometimes fundamental misunderstandings which can lead to this kind of advice that's often way off the mark. It's just like the friends who tell you that you'd probably get pregnant if you stopped thinking about it...

I've seen too many people who've blamed themselves for their unsuccessful treatment, somehow feeling that they've failed when it doesn't work, and that it must be something they've done or haven't done, that it might have worked if they'd been able to be more upbeat and positive.  Now there's research to show that this simply isn't the case - infertility and unsuccessful treatment makes you depressed - depression doesn't lead to infertility and unsuccessful treatment.

Fresh or frozen?

An interesting new piece of research has looked at the effectiveness of freezing all the embryos created during an IVF cycle and then replacing them in a later cycle where no stimulation has been used.  It seems there are concerns that when you stimulate the ovaries, this may have an impact on how well the lining of the womb receives embryos. Not only this, but replacing frozen embryos in a later cycle also reduces the risk of hyperstimulation (OHSS).

The suggestion is that freezing embryos and transferring them later could actually increase pregnancy rates and also make IVF far safer for women by cutting the risk of hyperstimuation - although most women who get OHSS have fairly mild symptoms, it can be extremely dangerous.  Now, researchers from Spain have reviewed all the relevant studies in this area and analysed the results, coming to the conclusion that the chance of a pregnancy is as much as 30% higher if all the embryos are frozen for a later transfer rather than transferring them right away.

As is often the case with these rather interesting news stories, those responsible for the study have said that more research is needed to confirm their findings before making any changes to routine treatments for patients - but it will be reassuring for anyone who is having frozen embryos transferred. We often assume that this reduces the chances of success, but the evidence seems to suggest it could be quite the opposite.

Improving your chances of IVF success

Anyone going through fertility treatment wants to try to maximise their chances of success, and a number of new reports out today suggest that there are some lifestyle factors that can make a real difference.

The first report looked at caffeine consumption, and found that women who drink five or more cups of coffee a day reduce their chances of getting pregnant after IVF by a shocking 50%. Up until now there have been conflicting results from investigations into caffeine consumption, but this new study was a large one, following up nearly 4,000 women who'd had IVF or ICSI. Interestingly, for women who drank coffee but consumed fewer than five cups, the coffee didn't have any effect.  So, there's no need to cut out your wake-up coffee altogether, but just make sure you limit your consumption.

The second study looked at consumption of saturated fats, and found that women who had a higher than average intake didn't have as many mature eggs ready for collection in IVF treatment. This was a far smaller study, but showed that different types of fat had different effects.  The doctors who carried out the research said it was too early to make any firm recommendations to patients, but as it's not good to eat lots of saturated fats anyway, this may perhaps emphasise that healthy eating when you're trying to conceive may make a difference.

The final study looked at smoking, and found that it affected the environment in the Fallopian tube and uterus, which may explain why women who smoke are more likely to have ectopic pregnancies.  The vast majority of women who get as far as fertility treatment have already given up smoking because it reduces the chance of success and increases the risk of miscarriage - but this new research provides yet more evidence of the way smoking can damage your fertility.

All of these research projects are interesting, but perhaps not entirely surprising as they sum up what we may well have suspected already - that moderation, common sense and a healthy diet can make a difference when it comes to IVF success.

We're still trailing behind when it comes to IVF

Anyone who has any personal experience of IVF will know that our funding situation in the UK is patchy at best, but the report released from ESHRE this week showing quite how badly we're trailing behind our European neighbours was still something of a shock. We came third from the bottom in a European table for funding fertility treatment, with only Russia and Ireland behind us. Belgium and Denmark both fund around three times as much treatment per million inhabitants as we do.  Even Slovenia funds twice as much.

I've just been on Radio Humberside discussing the situation, and the presenter seemed not to have considered that infertility might be a medical condition. It always strikes me as odd that if it's your fallopian tubes or your ovaries that don't work, a medical problem becomes  a "lifestyle choice".  Where do we draw the line with "lifestyle choices" and medical treatment? Infertility is not going to kill anyone, people often say. No, it probably isn't, but surely the NHS wasn't set up only to treat people who would drop dead if they weren't helped right away?  Even funding three full cycles of IVF for all those who needed it would be a tiny drop in NHS budgets - and cutting all IVF funding entirely wouldn't begin to solve our financial problems (indeed it could make them far worse, if more and more fertility patients started going overseas and coming back pregnant with triplets).

I think this debate is about something much more than infertility - although our attitudes to families and children in the UK probably provide an interesting tangential discussion. It seems to me that deciding that some medical conditions are unworthy of treatment is the tip of a very large iceberg which rests on our decisions about what the NHS is for. What other treatments might constitute "lifestyle choices"? Hip and knee replacements perhaps? Might people decide that they aren't entirely essential?  Perhaps being able to walk long distances without any pain is a "lifestyle choice" - you don't have to walk far, you can take painkillers.

Cutting IVF funding is easy - some people even think it's a good thing.  People with fertility problems are often so distressed that they haven't told their closest friends and family about what's happening to them.  They aren't going to be outside the local PCT waving banners and shouting.  Just because something is easy, that doesn't make it right - and being oblivious to the longer term consequences of short-term financial decisions seems to be all too common at the moment.