Sweet’s Rules: Four simple rules I use each day to guide me as I diagnose and treat my infertile patients

During National Infertility Awareness Week, I’d like to share my four patient care rules. I made them up rather spontaneously nearly 22 years ago and I still use them each and every day when I am uncertain of what to tell a patient or how we should proceed.

Before the rules are invoked, it is most important to first understand what brings patients to my clinic. By understanding the causes of their infertility, I will better be able to tailor a treatment plan specific to their needs. Some patients feel this is a waste of time and want to proceed immediately to treatment, but I strongly recommend understanding the issues first before proceeding forward.

So, once the evaluation is complete, my Sweet’s Rules are used to guide us forward-

1. Get my patients pregnant as fast as I can
Time can be an enemy and patients are not necessarily patient. We need to complete the evaluation quickly and move forward as most of my patients wanted to be pregnant many yesterdays ago. Some will call this a “duh!” rule, but it is still a good one to keep me moving forward as the patient desires.

2. Achieve success in the most cost-effective manner possible
We always want to choose the least costly conception method. This might even mean sending the patients on a date to try natural means for a tad bit longer. Hopefully, the successful patient potentially saves a bundle by my guiding them away from costly alternatives. Sometimes, adoption is also the best option and I’ll send them down this new road, if it is needed, even if the practice loses a patient. My cardinal rule is to treat the patients like family and tell them what I would tell someone close to me, regardless of the gain or loss to the practice. Practicing this way has always served may patients well.

3. Minimize complications (i.e., no litters)
I took an oath to do no harm and I take that oath very, very seriously. A multiple pregnancy can be a million dollar pregnancy with complications too long to list here. Always pull back, no matter how much pressure from the patient, if I fear a complication is likely.

4. Minimize the use of procedures with minimal chances of success
This may be the most important rule. I do not like being a “Gynechiatrist” (borrowed from the movie “Knocked Up”) by performing procedures that are unlikely to work. While some patients need to try a procedure destined for probable failure, to have closure and the inner knowledge that they gave it a shot, I prefer to move quickly through these treatments and get the patient to understand what will truly bring them to their goal.

I tell patients these rules when I am trying to guide them through their treatment plan. I believe it helps them to understand why I am telling them something, especially when they don’t necessarily want to hear it. Understanding my motivations, I believe, helps them to appreciate that I truly have their best interests at heart. By following these simple four rules, I will always keep my patients’ needs first and foremost.

While I may not be successful with all my patients, I will always try my best, give them the best information I can and provide options that simply make sense. Interestingly, these rules help me keep on the path, as much as they simultaneously guide my patients, as we make decisions and travel the infertility to fertility journey together.

By: Dr. Craig R. Sweet

Medical Director & Founder

Dr. Craig Sweet, April 22nd 2013 | Tags: , , , , , , ,
Posted in Questions & Answers

Give the gift of family through surrogacy

Surrogacy is a wonderful gift choice for many women. At Specialists in Reproductive Medicine and Surgery we are continually looking for women to volunteer as surrogates and assume the responsibility of the pregnancy and delivery. What are the types of surrogates? Do you get paid or reimbursed for surrogacy? What does the process involve? Learn more at http://www.dreamababy.com/surrogacy-become.htm or call 239-275-8118.

admin, January 20th 2013 | Tags: , , , , ,
Posted in Uncategorized

How Old Should a Woman Be to Donate Her Eggs: An ethical debate

admin, July 11th 2012 | Tags: , , , , , , ,
Posted in Egg Donation, Embryo Adoption, Medical Ethics, Questions & Answers, Reproductive Politics, Research, Uncategorized

Free Contraceptive Insurance Coverage: A Good Idea?

The National Institute of Medicine finally suggested that women obtain contraceptive care with full insurance coverage and without large co-pays. From one perspective, it was about time. Nearly half of all pregnancies are unintended and families should be expanded when there is true intent and not because contraception was not available. Also, since men have medications for erectile dysfunction covered by insurance, it's seemed only fair.

That stated, there might be a downside. Since no co-pays will be obtained, will the insurance companies increase payment to make up the difference (doubtful) or will the physician’s office loose the income in an already existing atmosphere of dwindling reimbursements (more likely)?

Will the frequency of unwanted pregnancies and abortions really fall? Even though condoms have been made available at some clinics for free, having the contraception easily available didn’t mean it was used at all or used correctly. When one provides something for free, is as appreciated as when one has to pay an amount, no matter how small, to increase personal responsibility?

When care becomes free or nearly free, there is almost always an increase in utilization. Is contraception one area of medicine that we would welcome increased utilization? Most, except the religions that do not believe in contraception, will agree this is ultimately a step in the right direction. Even so, there is no free lunch. Will insurance companies increase the premiums to pay for the office visits and the contraceptive medications and pass the costs to everyone else? We suspect the answer is probably yes.

At first glance, requiring insurance companies to pay for female contraception seems like a great idea but there is the issue of unintended consequences. Please share your thoughts on our Facebook pagewhere we've started the discussion. We’d love to hear from you!

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Dr. Craig Sweet, August 10th 2011 | Tags: , , , ,
Posted in Family Planning, Health Care, In The News, Medical Ethics, Politics, Reproductive Politics

What to Say & What Not to Say to the Infertile Patient

By: Dr. Craig R. Sweet, Medical Director & Founder

(Reprinted from Florida Parenting News, February, 1994, revised September, 1999 and again April, 2011.)


Introduction:

Infertility affects nearly one in six couples. Approximately 40% of the time, the problem is related to the female partner, another 40% is related to male difficulties and 20% of the time both partners will have medical problems. Most of the time, infertility is a symptom of an underlying disease process, a disease process that the infertile patient has no control over. To these patients, infertility can be a crisis of the deepest kind. Every menstrual cycle represents a failure and is a time of grief for the potential child that never came to be.

The infertile patient or couple will often express their feelings through anger, frustration, feelings of inadequacy, depression and guilt. Relationships with family members who have children can suffer, marriages and relationships are strained and well-meaning friends and family can overload the patient with advice and pressure. Family and social gatherings become a reminder of infertility. Baby showers can be a traumatic experience. Mother's and Father's Day are often very, very difficult.

We want to offer some tips that provide support to patients who have not yet had the blessing of a beautiful child to love. With your assistance, most patients going though the process of trying to conceive can maintain a positive attitude.


What Not To Say…

Don't ask a childless person when they are going to have a child. They may be going through the process of trying to conceive, but have not yet achieved success. Asking them only reminds them of their problem and they need no extra reminders.

Don't relate stories of your fertility to them. Hearing “my husband just has to look at me and I get pregnant” is very annoying. While well meaning, the statement is insensitive and unhelpful.

Don't give advice such as “just relax,” “you are trying too hard” or “take a vacation.” All of these very common comments imply that patient has control of their fertility. Most of the time, these patients have absolutely no control over their fertility. Implying control leads to feelings of failure and guilt when this advice doesn't work. It simply is not their fault and they are doubtfully doing anything wrong in what they have done thus far.

Don't offer advice such as sexual timing, position, herbal medications or other totally unproven therapies. There are literally hundreds of old wives’ tales that, when followed, can drive an infertile patient nearly crazy. Their physician will have covered those natural aspects of their care that may maximize their chances for conception. Once again, please to not imply that they have a sense of control as they lost it long ago.

Don't express your derogatory personal opinions regarding insemination procedures, test-tube babies or adoption. Sometimes, these are their only hope for having a child. These are your opinions and uninvited advice is rarely neither desired nor constructive. You are absolutely entitled to your opinion; simply keep it your own. If they ask for your advice, then feel free to state your opinions, but do so in a kind and considerate manner.  Please, do not be judgmental.

Don't place blame by accusing the couple of exercising too much, eating the wrong foods or drinking alcohol. These patients may already be blaming themselves. Their physician will have already covered the medical and reproductive consequences of obesity, smoking, alcohol and recreation drugs. Support them in the cessation of these activities and minimize the guilt associated with their consumption. The guilt rarely leads to cessation but often moves the individual to increased consumption.

What You Can Say and Do…

Do provide couples with plenty of emotional support by saying “It must be difficult to go through this” and “I'm here to listen if you need to talk.”

Do remember that men can be just as emotional about the problem, sometimes even more so. They may feel their masculinity is at risk. Be sensitive to their egos and personality traits.

Do understand the couple's need for privacy.

Do try to understand that if they are your employees, frequent doctor's appointments may be necessary during business hours. Please try to accommodate them as much as possible. Not doing so may also be construed as a form of discrimination and place you at legal risk.

Do understand why they may not make it to a baby shower or a holiday event. These frequent events can become overwhelming for an infertile patient.

Do tell the infertile couple that there is hope.

Conclusions:
Please remember that the vast majority of infertile patients have minimal control of the diseases that causes their infertility. Giving them emotional support during this trying time is a wonderful way to assist them. Giving them subtle hints that they have control plants the seeds of personal failure in the minds of the infertile patient.

Please be kind, be thoughtful and always be supportive.

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Dr. Craig Sweet, May 5th 2011 | Tags: , ,
Posted in Diseases and Complications, Family Planning, Infertility, Questions & Answers

No Longer Silent – National Infertility Awareness Week

national infertility awareness weekEach year, physicians such as myself, fertility patients, their caregivers and families dedicated to raising awareness about the disease of infertility which affects 7.3 million Americans. RESOLVE, the national infertility association, has coordinated this week, April 24 through the 30 and we fully support it and encourage you to speak up in support as well. For information on how you can get involved in infertility awareness projects around the country and upcoming Advocacy Day on May 5, visit RESOLVE at www.resolve.org/takecharge.

At SRMS, we are committed to providing the highest quality care and support to patients and their families. Infertility is a disease, it is important and we are working to raise awareness on your behalf. For more information, visit www.dreamababy.comor call 239-275-8118.

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Dr. Craig Sweet, April 20th 2011 | Tags: , ,
Posted in Diseases and Complications, Events, Fertility, In The News, Infertility

In Memory of the Perfect Imperfect Pregnancies

Pregnancy Loss Remembrance Day – October 15, 2012

Craig R. Sweet, M.D.
Reproductive Endocrinologist
Medical and Practice Director
Specialists in Reproductive Medicine & Surgery, P.A.

Over the Past 27 Years:

Starting my OB/GYN residency in 1985 with completing my fellowship in reproductive endocrinology, infertility & genetics in 1991, I can recall hundreds of pregnancy losses over the past 26 years. There were so many tears, emergency D&Cs, and especially, so many unanswered questions in the tear-filled eyes of my patients.

Nearly all of the women seemed to blame themselves. They felt it was something they did wrong. Perhaps it was the sex they had with their partners. Did they cause the loss by not resting enough? Did they worry the pregnancy into destruction? Was it punishment for a prior pregnancy termination? Was there really a vengeful God? Whose fault was it? What did they do wrong? The questions went on and on. I wanted to find some answers.

The Beginning of my Research:

In 1988-9, the last two years of my OB/GYN residency, I began one of my first real research studies into the causes of pregnancy loss. At that time, we thought that about one-half of all pregnancy losses were genetically abnormal. The method used to provide this estimate was flawed requiring the laboratory to grow miscarriage cells. When the pregnancy didn’t grow well inside a perfect womb, the chances for growth in the laboratory were severely hampered. Not only did the cells frequently fail to grow with no answers provided, the most common reported result was 46,XX (normal female). The 46XX result was was reported twice as often as the 46,XY result (normal male). Understanding that there aren’t twice as many girls born as boys, we suspected that the healthier maternal cells, which are always mixed in with the miscarriage cells, overgrew the poorly growing baby’s cells in culture. Since the two different cell lines didn’t come “color coded,” there was no easy way for the laboratory to tell if the results reflected the mother’s cells (often) or the baby’s true chromosome makeup, termed karyotype. Overall, we found the karyotype truly reliable in only 30%+ of the spontaneous loss cases.

My research goal was to examine recurrent miscarriage tissue directly without growing the cells using a device called a flow cytometer. This research took many months to complete but we learned two extraordinary things:

  1. Direct analysis worked well and we were able to identify pregnancies with missing or extra chromosomes using the flow cytometer.
  2. Many of the reported “normal” 46,XX results were actually the mother’s chromosome makeup with the pregnancies themselves found to be severely genetically abnormal.

In reality, we discovered a new method to evaluate miscarriages finding answers where few had previously existed.

Quite unexpectedly, I received an award for the research in my residency and was asked to present my data at the American Fertility Society meeting (now the American Society for Reproductive Medicine) in San Francisco, in 1989, during the first year in my sub-specialty fellowship. It was this research and work performed by many others which helped us to finally understand that 70%+ of all first trimester spontaneous losses were genetically abnormal. Later, during my fellowship, I also complemented my previous work becoming co-author on research examining autoimmune pregnancy loss wherein acquired antibodies attacked the pregnancy resulting in a miscarriage. I was still seeking answers for my patients understanding that we had a very long way to go.

My Motivation: The Parents of the Perfect Imperfect Child

No matter how imperfect the pregnancy was found to be in the laboratory, these were perfect children to the hopeful parents. These innocent and extraordinarily young lives never kept a parent up all night, vomited on their favorite dress or screamed until any sane adult would cry uncle. These pregnancies and children were flawless. They were always beautiful, always bright and always wonderful. These pregnancy losses were perfect beings in the eyes of the parents as they contained every hope and dream they held for their future children. They were potential NFL football players, fishing buddies, best friends and even future Presidents of the United States. They were everything the parents ever dreamed their children might become. It makes perfect sense that they were and, even to this day, often called angels. It was so hard form my patients to loose such a perfect being.

These pregnancy losses were perfect beings in the eyes of the parents as they contained every hope and dream they held for their future children.

In Memory of my Patients and Their Perfect Imperfect Child

We still lose about 25% of all of our pregnancies and it is heartbreaking. While we certainly try their pain, no words seem to do justice for a parent experiencing such grief. For over two decades, though, my practice has been making charitable donations in memory of their pregnancy loss. It was our little way of having something good coming out of such a sorrowful event. While I doubt it made a tremendous difference in the hearts and minds of my patients, I think it gave them some level of comfort. On this 2012 Pregnancy Loss Remembrance Day, I would like to offer a gentle challenge to all of my peers to consider paying it forward by making a similar charitable donation, or performing some other act of kindness, in memory of all of our patient’s pregnancy losses. I believe it would be appreciated by our grieving patients, good for our own souls and would serve the public in a productive and kind manner.

In the Present:

Fast-forward to last year in 2011 where I was involved in a study, now 22 years later following my first flow cytometer study, using newer technology to once again examine the pregnancy tissue directly. This newer technology was called microarray analysis. Using the microarray analysis, we now obtain reliable results 80-90% of the time again providing answers where only guesses existed in the past. I now use the less expensive, rapid and extraordinarily reliable technique on nearly all of our pregnancy losses in the practice. Showing the patients that it wasn’t the food they ate, the swim they took or the short walk they had which caused the miscarriage, but rather, a terrible but uncontrollable flaw in early development of the embryo and fetus, their perfect imperfect child is extraordinarily valuable and does provide some solace.

Sill, We have Only Just Started:

I know we have much more work to do to not only understand why pregnancies are lost but what we can do to change their destiny. Will we someday be able to treat eggs, sperm and early embryos thereby healing the genetic problems before the pregnancy advances to a point of no return? We can only hope for future intervention.

I am fully aware that answering the question of why these perfect imperfect children were lost doesn’t answer all the questions or fully diminish the self-blame that is so commonly felt, but it is a good place to start.

To the memory of all of those we lost and may they keep those of us in the field of reproductive medicine humble and motivated driving us to answer the questions our patients ask of us regarding why they lost their perfect imperfect pregnancies.

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admin, October 11th 2010 | Tags: , , , ,
Posted in Diseases and Complications, Fertility, Miscarriage, Pregnancy, Reproductive Technology, Research, Stories, Uncategorized

Compassion, Understanding and Respect are Desperately Needed While We Discuss Three Important Perspectives on Gamete & Embryo Donation

I will admit that I was a bit overwhelmed with all that transpired recently on this blog.

My original goal to discuss the potential gender discrimination existing regarding the recommended ages for gamete donation was usurped into a rather emotional discussion on merits and evils of gamete donation itself. Some of the posts were so inflammatory that I have been advised by others to wipe out all the comments so as to do no harm to others that may eventually read them. For at least now, they will remain.

So many very complex issues were discussed simultaneously; some that were reasonable while others quite unreasonable and I was not even sure where to begin. To carefully start, I believe there are three perspectives that need to be better understood involving the gamete donor, the gamete recipient and the donor-conceived offspring.

The gamete donor’s perspective

Donors may donate for a host of reasons that may include monetary reimbursement, but nearly all will donate, at some level, so that individuals who might not otherwise raise a child can do so. Many donors will already have children or may have somehow been touched by infertility though a family member, friend, loved one, or even through media stories.

Some donate blood and/or their time and others donate their money. The difference with egg and sperm donation is that they involve individuals clearly giving a part of themselves. Do donors all understand the long-term effects of the donation? Perhaps some do, but not all. Do they wonder about the children their DNA helped to create? Perhaps, yes for some. Do they regret the donation? A vocal group will say “yes” but the many gamete donors who are content, at peace and even proud of their decision are silent in the wings, not feeling the need to make their past decision to donate known. Does that mean they are embarrassed by their past decision? Perhaps a few but I suspect most will simply state it was a private decision and not for others to judge or be involved in.

Was it wrong for them to have donated eggs or sperm as some might lead us to believe? I would emphatically answer “no.”

The gamete recipient’s perspective

Most patients who accept donated eggs and sperm do so reluctantly. Single women and same-sex couples may not have many options available to them and may enter the process more willingly. For the majority using donor gametes though, they are doing so because they or their partner are unable to use their own gametes to create and raise a child. Reluctance is the common denominator in their decision.

To simply state patients seeking donor eggs and/or sperm should adopt is naive. Many patients can’t adopt for a host of reasons including age, social situations, overall costs or personal medical history. Still, adoption is a viable option for some and infertile patients go through adoption all the time.

Others patients still want to experience pregnancy and birth. Is it selfish that they want this? I do not believe it is inherently selfish to want to experience something so basic in life as reproduction. It is a drive that goes to the core of all species. The reproductive process brings them and their partner (when they exist) closer in ways that are difficult to otherwise replicate. If one condemns reproduction using donated gametes as selfish, I suppose one should condemn all reproduction as basically selfish, especially when there are existing children who could be adopted. Many patients feel that reproduction comes close to an inalienable right that is not to be interrupted or disturbed by those who disagree.

Patients that reproduce using donated gametes are not “social parents,” as some would like us to believe while trying to diminish the importance of these parents. They are parents in every sense of the word. As I have written before, being a parent has to do with being there emotionally, physically and financially for future decades to come. Being a genetic parent may only take a few quick minutes of sexual activity. I will state the genetic contribution is important, but in the scheme of things, only a very small part of the creation of a child and a family.

DNA does not a family make – it is only part of the equation.

The donor-conceived offspring’s perspective

This is where the issues of gamete donation become so complex. As I have written before, I feel that my field has not paid enough attention to the perspectives of these individuals because they were never our patients. In fact, their very existence would not be was it not for our work bringing donors and recipients together. As a result, we have an inherent responsibility to donor-conceived offspring, having assisted in their creation.

Is it better that they never should have been conceived and born, eventually experiencing all that the world has to offer? I don’t see how that could ever be thought of as true. Inherent good is created when these special individuals grace our world.

Do they have a right to know their genetic background? Perhaps they do have a moral right to know, but this frequently comes into conflict with the right of privacy of the gamete donors and recipients. Would I want to know? I think the answer is “yes.” If I were a recipient of a donated gamete, be it eggs, sperm or both, would I want to be able to make the decision about telling my donor-conceived child? I also think the answer is “yes.” So, how can we possibly reconcile these potentially conflicting rights?

We need compassion, understanding and respect.

Compassion

We need to be better aware of how donor-conceived offspring feel. They will be curious about the donors. They will be interested in connecting with half-siblings, especially when they have no other siblings in the family in which they were raised. We need to consider how the donor-conceived offspring will tell their future or current partners about their genetic family. We need to understand that they will want to tell their own children about their ancestry.

Understanding

We need to better understand how disclosure will affect all parties involved. There is a great deal of angst and fear regarding disclosure with the recipients fearing most that their donor-conceived child or children will not love them anymore after they find out they were a product of gamete donation or after they connect with the gamete donor. We need to help move society and religion forward so donors and recipients will not be at risk for condemnation by friends, family or retaliation from their own religion. This will take a great deal of time and patience.

We need follow-up and well-designed research examining the effects of disclosure on all parties. Only by gathering information can we can share with donors, recipients and donor-conceived offspring the likely outcomes of disclosure and open-identity. We need to move from uncertainty to knowledge and from fear to hope.

Respect

There is a great deal of disrespect abounding on the topic of gamete donation and passions are running very high as was evident in the recent comments on my blog. The perspectives have almost become religious in character with extraordinarily narrow and unbending belief systems incapable of contemplating another viewpoint. Zealots want to indoctrinate all, bringing everyone to their own perspective, which they view as the only right one. We all need to take a step back and breathe. If we all realize that we are in this together, trying to do what is best dealing with all three perspectives, then we will work through our differences and come up with alternatives that will work best for the greatest number of people. We will never please the zealots but we can try to care for the greatest number possible.

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Possible solutions

I don’t pretend to have all the answers here and I’m not even sure I have asked the right questions yet. Having worked in this field for almost 23 years though, perhaps I have a perspective that could have some value.

Registry

A central registry, where information about donors, recipients and donor-conceived offspring could be stored, is an alluring concept but important practical issues abound. Who will pay for it, what information will be stored, who will have access to the data and will the information be truly secure are all questions that need to be answered before we undertake such a venture and before we put patients and families at risk. Understanding that we have already succeeded in collecting and reporting ART data though the CDC/SART, I do feel that we might be able to successfully build a data collection system for egg, sperm and embryo donation procedures. A multi-disciplinary discussion guided by the ASRM or a yet-to-be-formed special interest group is probably the best place to start working closely with our peers in other countries who have already initiated this process. I am concerned if we do not do this voluntarily, politicians who may have a meager understanding of the true issues will force it upon us.

Open identity

Creating gamete donation procedures with expanded open identity options would seem potentially to be the best of all worlds. It doesn’t mean that all donations must be open identity (i.e., it shouldn’t be mandated or legislated) for if we force this option on all, we take choice out of the hands of those involved and risk depletion of the gamete pools that are needed for so many.

I do not necessarily agree that open identity will be the answer for all of the problems but it could, most of all, benefit the donor-conceived offspring. Additional work must be done to also decide how and when the identity of the donor should be presented to the donor-conceived offspring. If we are creating an open gamete donation option for the children’s good, it is hard to argue that this information must not be released until they reach age 18 or 21. For the good of the child, having some sort of connection to the donor might indeed be best if initiated in the truly formative years and, certainly, before age 10.

Summary comments

Egg, sperm and embryo donation procedures are not inherently evil. They build families where they would otherwise not exist, an inherent good. We all need to better understand the three perspectives of donors, recipients and the donor-conceived offspring and, through compassion, knowledge and respect, work better together for the betterment of all the parties involved. This issue is a moving target and I beseech all those that feel so strongly on this topic to honor and listen to the opinions of others, understanding there is no right answer for everyone any more than there a single correct religion. I ask all to try to reign in all the emotion and focus this valuable energy towards discussion rather argument, compassion rather than condemnation, education rather than persuasion and respect rather than intolerance.

We have a long way to go but I feel we can get there together by understanding that each of us has much to learn from each other.

Craig R. Sweet, M.D.
Reproductive Endocrinologist
Moderator, www.SweetFertility.com

P.S. For those that would like to review a somewhat scholarly summary on disclosure in embryo donation from the perspective of the embryo donor, embryo recipient and the donor-conceived offspring, I encourage you to read one of my somewhat long, but comprehensive reviews on the topic by visiting my embryo donation blog by clicking here.

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admin, October 11th 2010 | Tags: , , , , , , , , , , , , , ,
Posted in Egg Donation, Embryo Adoption, Embryo Donation, Fertility, Health Care, Infertility, Medical Ethics, Uncategorized

Do The Risks Of Ovarian And Borderline Ovarian Cancer Increase With IVF Treatment?

Does infertility treatment cause ovarian cancer?

We are commonly asked if IVF increases the risk of ovarian cancer. Studies conducted over the past 20 years have tried to answer this question. A recent publication by van Leeuwen, et al., examined this issue carefully and produced some very interesting results.

What were the study basics?

The study published recently in Human Reproduction involved a very large retrospective analysis (data collected from the past) in the Netherlands of 25,152 infertile women (19,146 IVF and 6,006 non-IVF infertility patients) who received their infertility treatment between 1983 through 1995. The extensive follow-up period, which averaged about 15 years, made this study unique amongst others.

Why might infertility treatment result in ovarian cancer?

It has been theorized that the risk for ovarian cancer, which is estimated to be a 1/72-lifetime risk in the US, would increase because of ovarian stimulation and/or multiple ovulation sites forming across the surface of the ovary. Partially dispelling these concerns, this study did not show any increased risks for ovarian cancer for non-IVF infertile patients treated with either oral or injectable fertility medications. Also, further debunking the theory was the fact that the risk for ovarian cancer did not increase as the number of IVF cycles increased.

Is there something special about the IVF patient that increases her risk for ovarian cancer?

We also have wondered if the IVF patient simply has something wrong with her ovaries that predispose her to infertility, IVF treatments as well as ovarian/borderline ovarian cancer. The fact that there was a much larger percentage of “unexplained infertility” patients in the IVF-treated group suggests the IVF and non-IVF patient groups were indeed very different from each other.

Also understanding that borderline ovarian cancers normally make up only 20% of all ovarian cancers and are not anywhere as lethal as the more common ovarian cancers, it was somewhat unexpected to find that 46% of all ovarian cancers identified in the infertility patients in this study were borderline cancers. This high percentage of borderline lesions also suggests that something was unusual about the IVF-treated patient population.

What were some of the important findings in the study?

In reading this paper carefully, I was able to identify the following important points, some of which were not emphasized in the study:

  • Tubal infertility IVF patients (i.e., past and/or chronic pelvic infections) were twice as likely to have invasive or borderline ovarian cancers.
  • Those IVF patients who never conceived were twice as likely to have any ovarian cancers and three times more likely to have borderline ovarian cancers.
  • In the study, the actual risk for any ovarian cancer by age 55 was estimated 1/141 (0.71%) in the IVF group compared to 1/222 (0.45%) for the normal population, an overall increased risk of 1/3rd but still a very rare event.
  • Also in the study, the actual risk for borderline ovarian cancer by age 55 was approximately 1/600 for the IVF patients compared to 1/1,200 for the general population, essentially doubling the risk. Still the actual incidence was still very, very rare.

What did we really learn from the study?

While I feel the authors did an amazing job collecting and analyzing the data, I felt the discussion section missed a few very important points:

  • Those that underwent IVF, especially unexplained infertility patients, may still differ in some way which may increase their risk for both prolonged infertility and ovarian/borderline ovarian cancers.
    • In other words, it may not be the IVF procedure itself as much as the underlying characteristics of the IVF patients, which predispose them to ovarian cancer risks.
  • Acute or chronic pelvic infections may very well increase the risk of borderline ovarian cancer.
    • The fact that IVF-treated patients were far more likely to have past pelvic infections may have been responsible for many of the findings described in this study. To the best of my knowledge, this has not been described before. Interestingly, chronic inflammation in other areas of the body also predisposes to some forms of cancer. Perhaps the pelvis is the same.
  • If one conceives through IVF, the risks for ovarian and borderline ovarian cancers drop to normal levels.
    • Either the pregnancy helps reduce the ovarian cancer risks or those who conceive are inherently at a reduced risk for ovarian cancer compared to those who never conceive.
    • This point has been found to be true with past studies that showed an increased risk of borderline ovarian cancers with the use of oral clomiphene citrate when used for more than 12 cycles without an eventual pregnancy. Once pregnancy occurred, even resulting in a miscarriage, the borderline ovarian cancer risks normalized (Rossing MA, et al. 1994).
  • Current regimens used to stimulate the ovaries are very different from those used prior to 1995.
    • The current risk factors could be better, worse or the same as those described in the study because IVF protocols have significantly changed since 1995.

In summary:

The risks for ovarian and borderline ovarian cancer for infertility patients undergoing IVF may be incrementally increased compared to the non-IVF population. Interestingly, far less lethal borderline ovarian cancers are found in a greater percentage in this very special patient population. Confounding factors, such as tubal factor infertility with acute/chronic infections, may increase the risk for ovarian malignancy in this patient population.

No matter how statistically significant the findings are, one still must note that the actual risks described in this study for women age 55 are still extraordinarily rare: 1/141 for any ovarian cancer and 1/600 for borderline ovarian cancers. These risks also are unlikely to deter a highly motivated infertility patient. Keep in mind that the average risk for a genetically abnormal child in IVF-treated patients is probably closer to 1/100, which is far higher than any of the risks for cancer listed in the current study. Let us all keep our perspective.

Still, we need to collect further data as many of the women in the study were only in their middle 50’s and the risks for ovarian cancer generally increase with age.

Above all, an IVF conception may very well reduce the ovarian cancer risks significantly. If conception never occurs, this may signal physicians to monitor the unsuccessful patients more carefully for future potential ovarian malignancies, although the actual incidence of the disease may still be quite rare.

Congratulations to the researchers who put an amazing amount of work into this study and we thank them for their dedication to infertile patients and to those of us who care so much for them.

Craig R. Sweet, M.D.
Reproductive Endocrinologist
Specialists in Reproductive Medicine & Surgery, P.A.
Fertility@DreamABaby.com

References:

van Leeuwen FE, Klip H, Mooij TM, van de Swaluw AM, Lambalk CB, Kortman M, Laven JS, Jansen CA, Helmerhorst FM, Cohlen BJ, Willemsen WN, Smeenk JM, Simons AH, van der Veen F, Evers JL, van Dop PA, Macklon NS, Burger CW. Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort. Hum Reprod. 2011 Dec;26(12):3456-65.

Rossing MA, Daling JR,Weiss NS, Moore DE, Self SG. Ovarian tumors in a cohort of infertile women. N Engl J Med 1994;331:771–776.

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admin, October 11th 2010 | Tags: , , , , , ,
Posted in Diseases and Complications, Health Care, In Vitro Fertilization (IVF), Questions & Answers, Research, Uncategorized

Why This Florida Infertility Doctor is Concerned About Mississippi Initiative 26

Today, the good people of Mississippi will go to the polls to exercise their constitutional right to vote. One of the items they will cast their ballot on is Mississippi Ballot Initiative #26, which would give “personhood” to a fertilized egg. If enacted, this law will cause a chilling effect that will be felt throughout the infertility field as other states like Florida and Ohio, to name just two, gear up for similar referenda in 2012. The passage of Mississippi Initiative 26 will signal the start of a dangerous precedent, that if it gains momentum, will cause dire consequences for many of my patients.

This isn’t just about abortion, although this is what the proponents would like you to believe. Let me be clear, I don’t think the intention of the well-meaning individuals who may vote for this Initiative want to do harm. In fact, I am certain, people voting for the initiative probably feel they are saving lives. The problem is that Initiative 26’s proponents have not given the voters the right facts about the law’s devastating consequences in the state of Mississippi. The list of unintended consequences extends far and wide and involves women’s healthcare, the legal world and the infertile patient as well as the providers of their medical care.

Consequences to Women’s Healthcare

The following are very likely consequences of the passage of the amendment:

  • – The total outlawing of abortion, even in the cases of incest and rape.
  • – Outlawing of the vast majority of contraceptives including the IUD, the “morning-after pill” and Depo-Provera. Even hormonal contraceptives including oral contraceptives, patches and rings will thin the uterine lining preventing implantation. If interpreted as such, they will be outlawed. The only contraception that will probably remain will be condoms and we know how much men like to take a shower with a raincoat on….
  • – How can a physician surgically remove a tubal ectopic pregnancy thus terminating the life of an “embryo-person”? No, really, could someone tell me how a physician will be able to care for a patient with a life-threatening ectopic pregnancy?
  • – Are we really going back to the “good old days” when women were dying on a regular basis from botched backstreet abortions? Who will take care of the orphans?

Consequences to the Legal World

There are literally thousands of instances where the word “person” is written in the Mississippi statutes, each of which will have to be carefully reviewed to see how three-day old eight-cell stage embryos fit in. Think of the possible consequences:

  • – How will cryopreserved embryos inherit? Exactly what rights will they have?
  • – If embryos are created in Mississippi by a couple visiting from another state or another country, are they instantly going to be US citizens or citizens of the state of Mississippi?
  • – Will all embryos that do not survive have to undergo a burial? If they die unexpectedly, are they to undergo an autopsy?
  • – Women who smoke, drink in excess or use recreational drugs are at an increased risk for miscarriages. Are they to be charged with manslaughter or perhaps even murder if they are aware that their behavior could end the life of an “embryo-person”?

Disastrous Consequences to the Infertility Patient and Provider

It is clear that the proponents of initiative 26 feel the infertile patients are expendable. They don’t care that women and men’s lives and the families of Mississippi will be severely affected:

  • – Embryologists might be charged with manslaughter if embryos fail to survive in the laboratory.
  • – Will the laboratory even try to thaw frozen embryos understanding that at least 10-20% of them will not survive the thaw? Will the less expensive frozen embryo transfer procedures just disappear?
  • – If the physician transfers the embryos but the patient doesn’t conceive, will the physician be blamed? Will the doctor be accused of manslaughter for the failed implantation?
  • – Will frozen embryos be able to be moved outside of or into the state of Mississippi? Will Fedx take the chance of being accused of manslaughter should a transport tank fail in transit?

What will probably happen is that IVF will continue but physicians will only remove 2-3 eggs in a cycle. This will greatly increase the cost of the infertility treatment and result in much lower success rates. Those that can afford will go elsewhere. Who cares? For one, I do and I will bet every one of my patients will if Initiative 26 passes in Mississippi and they move on to other states, including Florida.

Well-Meaning Intentions With Unintended Consequences

This initiative is a really bad idea and has far more unintended consequences that I can even outline here in this short blog. The abortion decision is a personal decision between a woman, her partner, her conscience, her religion and her creator. We’ve been through this for years and years and the majority of Americans agree with this statement.

If Mississippians pass this law today, I know my work fighting the consequences of the Personhood Movement has just begun. Florida most likely will be one of the next states in their crosshairs. I will be forced to spend time, money and effort fighting these initiatives that I could otherwise devote to building families by encouraging the donation of unused embryos to patients in need. Instead of helping bring children into this world, I will be working diligently so I can prevent similar misguided political acts from destroying my patients’ dreams. Let’s hope the voters of Mississippi don’t find out too late that their actions have stymied the very goal they were trying to achieve – building loving families that would otherwise not exist.

Vote “No” on Initiative 26.

Craig R. Sweet, M.D.
Medical & Practice Director
Reproductive Endocrinologist
Specialists In Reproductive Medicine & Surgery, P.A.

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admin, October 11th 2010 | Tags: , , , , , , , , , , , , ,
Posted in Fertility, Health Care, In The News, In Vitro Fertilization (IVF), Medical Ethics, Politics, Reproductive Politics, Research, Uncategorized
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