The American Society of Reproductive Medicine Meeting (ASRM) is the major fertility meeting in the United States.  The meeting is held once a year and highlights the latest developments in fertility treatment. This year, several members of the Pacific Fertility team where able to attend the conference in Denver, Colorado.   

The major presentation at the meeting was an update on the FASTT (fast track and standard treatment) trial. This is a study of 500 couples with unexplained infertility in women 39 years of age or younger.  Couples were randomized to either standard treatment or fast track treatment. Standard treatment was 3 cycles of clomiphene/IUI (fertility pills), 3 cycles of FSH/IUI (fertility injections), then in vitro fertilization (IVF). The fast track treatment followed the same protocol, but omitted the FSH/IUI.  Couples in the fast track group achieved pregnancy sooner, with fewer treatment cycles, and at less cost. 

IVF programs, like our program at Pacific Fertility Center, are achieving excellent pregnancy rates by transferring one or two embryos in an IVF procedure.  This fast track approach also reduces the risk of multiple pregnancies by excluding FSH/IUI treatment; a protocol that poses a significant risk of multiples.  Pregnancy rates remained good through the first 3 IVF cycles; 78% of patients became pregnant in the fast track group.  When completed, this study should help couples decide between FSH/IUI treatment and IVF.

Preimplantation genetic diagnosis (PGD) continues to be an active area of research.  PGD has been very effective in helping patients at risk of having a child with a genetic disorder. However, it has been controversial as to whether PGD improves pregnancy rates in couples with infertility and no genetic disorders. Older studies indicated no benefit, but we have come to realize that the older technology was inaccurate and incomplete. The older studies used fluorescent in situ hybridization (FISH) for chromosome testing. In this process, only a portion of the 23 chromosome pairs could be analyzed and the accuracy of the test was very poor.

The latest techniques are now very accurate and complete. New techniques use DNA fingerprinting technology, where all 23 pairs of chromosomes are analyzed. One of the first randomized controlled trials of PGD was presented at this meeting. In this trial, the pregnancy rate was much higher in the treatment group.  Embryos were biopsied on day 5.  This protocol allowed the cells for biopsy to be taken from the trophectoderm, the part of the embryo that develops into the placenta. This technique may prove to be safer for the embryo and decrease the chance of a misdiagnosis due to mosaicism.  However, challenges still remain. The current technology in its most common form requires biopsy on day 5, freezing of all of the embryos, and then thawing normal embryos for transfer after the genetic diagnosis is complete. As the speed of the evaluation improves, biopsy and transfer on day 5 will become more common, and there will be no need to freeze and thaw the embryos.

PFC has been very active in helping women preserve their fertility when facing chemotherapy for breast cancer.  Letrozole is a medication used to help grow eggs and keep estrogen levels low during stimulation in IVF cycles. Women have the option to do an emergency IVF cycle, which allows them to preserve their eggs or embryos and use them after their breast cancer treatment is completed. In a recent study, which proved to be very reassuring, 129 women used this protocol to collect eggs. They were followed for up to 7 years. Relapse rates of breast cancer were compared to a similar group of women who opted not to do IVF prior to chemotherapy. The relapse rate in the IVF group was lower than the group that did not undergo IVF, 2% vs. 25%. The pregnancy rates in the IVF group were very good, resulting in 36% per frozen embryo transfer. Women with breast cancer can be safely offered this protocol when undergoing fertility preservation prior to chemotherapy.

Insulin resistance is common in women with polycystic ovarian disease (PCOD). In these women, the insulin does not work as well, resulting in higher insulin levels to maintain normal blood sugar levels; similar to Type II diabetes.  Metformin is a medication that improves insulin function and has been used to improve pregnancy rates in women with PCOD.

In a recent study, women with 2 previously failed IVF cycles and without PCOD were randomized.  One group went through one cycle of IVF with metformin, and the other group without metformin.  The metformin group had higher pregnancy rates, 33% vs. 2%. Insulin resistance is associated with aging and stress, which are common among women who repeatedly fail with IVF. As a result, metformin may help women without obvious signs of insulin resistance.

Adenomyosis was the topic of another very informative session. Adenomyosis is a benign disorder where the endometrium (the lining of the uterus) grows into the muscle of the uterus. It may be the single most common undiagnosed gynecological condition and the most common cause of gynecological pain. Adenomyosis may be a normal part of uterine aging.  Adenomyosis is commonly associated with fibroids and endometriosis, and is more common in women who have already had a pregnancy. The most common symptoms are: heavy menses, painful menses, pelvic tenderness, and infertility.  In the past, an MRI scan was needed to make the diagnosis. However, new studies show an ultrasound is just as accurate, both sensitivity and specificity, as MRI. Adenomyosis can be found in up to 25% of infertile women. The role of adenomyosis in causing infertility remains controversial. However, current studies indicate large areas of adenomyosis and adenomyosis near the endometrium can decrease fertility.  Now that an ultrasound can be  used more commonly and can accurately diagnosis adenomyosis, the impact of adenomyosis on fertility will be better defined.

Attending this annual meeting of professionals in the field of reproductive technology is always informative. We look forward to meeting with colleagues from around the country and sharing the latest research. Several of the research projects currently in progress at PFC were discussed at this meeting.

Microarray Preimplantation Diagnosis (MA-PGD) created much excitement and interest at three recent meetings attended by Dr. Schriock; Pacific Coast Reproductive Society, The Midwest Reproductive Symposium, and the IVF Comprehensive Update.

PGD is a technique used to diagnosis genetic disorders by performing a biopsy of the embryo on day 3 or 5. PGD can diagnose single gene or chromosomal defects. PFC has been doing embryo biopsy for over 10 years. During this time the major method of diagnosing chromosomal disorders has been fluorescent in situ hybridization, FISH. FISH uses a fluorescent color to label individual chromosomes. This technique lacks accuracy and is now seldom used to screen embryos for the presence of missing or extra chromosomes. (refer to Fertility Flash Vol. 5 Issue 2). This technique, however, is still valid for identifying the gender of the embryo. MA-PGD uses a new technology, Single Nucleotide Polymorphisms (SNPs). SNPs are single bases, the building blocks of DNA, which can be in a different sequence in different individuals. Six to ten million SNPs have been characterized. This is the technology used in DNA fingerprinting in criminal or forensic work. Compared to FISH, where only one color marker identifies the chromosome, SNPs havethousands of markers per chromosome.

FISH can only identify 8-12 of the 24 unique chromosomes; MA-PGD will identify all 24 chromosomes, similar to amniocentesis. Identifying both single gene defects and chromosome abnormalities from one embryo cell was not possible with the older techniques, but can be done with MA-PGD. MA-PGD will identify whether the abnormal chromosome came from the mother or father. If from the mother, it will determine if the error was in meiosis I or II, or mitosis. In other words, it can identify in which stage of early cell division the genetic error occurred. Using MA-PGD, it may be possible to determine which embryo produced the baby when more than one embryo is transferred. The most important advance, however, will be the accuracy of the result. New research using MA-PGD shows that FISH is inaccurate over 40% of the time. MA-PGD appears to be nearly 100% accurate in diagnosing abnormal embryos.

This new technology is also helping to answer scientific questions. 50 – 70% of embryos with one missing or extra chromosome still develop to a healthy-looking day 5 blastocyst. This helps explain why beautiful blastocysts do not always turn into healthy pregnancies. MA-PGD will also raise new questions: Only 55% of chromosomally normal embryos turn into successful pregnancies in 30-year-olds, only 25% in 40-year-olds. Why do these embryos with a normal number of chromosomes fail? There is more to the embryo than chromosomes and more research is needed to determine what factors allow an embryo to develop into a healthy baby. Current areas of investigation include RNA production (transcriptomics), protein production (proteomics), and metabolic by products (metabolomics).

We will continue to update readers on PFC’s experience with MA-PGD in future Fertility Flash issues.

Question: I’m a heavy coffee drinker, consuming five cups per day. I’m concerned that my addiction to caffeine will hurt my chances of getting pregnant. How much caffeine is acceptable?

Answer: Moderate caffeine intake for women trying to conceive is acceptable. As a general guideline, women trying to conceive should limit intake to 3 cups of coffee (or 300 mg of caffeine) per day (Organization of Teratology Information Services (OTIS) 2001). Results from large published studies have not demonstrated that moderate caffeine intake adversely affects fertility (International Food Information Council (IFIC) August 2002). Furthermore, caffeine consumption has not shown to have an impact on fertility or birth defects for the male partner or sperm donor (OTIS 2001).

For women who are pregnant, there have been several studies analyzing the affect of caffeine and pregnancy with the conclusions of those individual studies being mixed (IFIC August 2002). Keep in mind that if you are pregnant or breastfeeding, the caffeine you consume may transfer to the infant. As such, guidelines for caffeine intake of pregnant or breastfeeding women are a little more rigid. The recommendation by OTIS and Motherisk is that consuming less than 1.5 cups of coffee (or 150 mg of caffeine) per day is not likely to increase the chances of miscarriage or a low birth weight baby. The American Academy of Pediatrics states that: “no harm is likely to occur in a nursing child whose mother drinks one cup of coffee a day.”

For more information on the affect of caffeine on fertility, visit the National Toxicology Program-Department of Health and Human Services website. The website provides a more detailed look at some of the clinical studies referenced above. Additionally it provides a chart showing the levels of caffeine in certain food and drinks. This information is available at: http://cerhr.niehs.nih.gov/common/caffeine.html.  

Polycystic ovary syndrome (PCOS) is the most common endocrinologic disorder in women of reproductive age. Approximately 5-10% of reproductive age women have PCOS. The various symptoms of PCOS can be irregular or absent menstrual cycles, infrequent or absent ovulation, excess facial and body hair, obesity, and infertility. The key components defining this disorder are chronic anovulation (inability to ovulate an egg), clinical hyperandrogenism (elevated male type hormones) and more recently discovered, insulin resistance.

Insulin resistance, the precursor state to diabetes, is present in 35-40% of women with PCOS, even if they are not overweight. Insulin resistance is diagnosed by blood testing, either as fasting glucose to insulin ratio, or as a complete glucose tolerance test. Long term follow up of women with PCOS reveals that up to 40% develop impaired glucose processing or diabetes by age 40. The prevalence of diabetes in women with PCOS is seven times higher than for the non-PCOS population. Excessive insulin production is thought to promote excess male hormone production, though the actual mechanism explaining this observation is still unclear. Insulin resistance may increase the long-term risks of heart disease and hypertension.

Interventions that reduce circulating insulin levels in women with PCOS may restore normal reproductive endocrine function. Non-pharmacologic methods, such as weight loss and exercise, have clearly led to reduced insulin and male hormone levels, resulting in resumption of ovulatory function. However, these regimens are at risk for poor compliance and, over time, the benefit of weight loss is rarely maintained.

Insulin-sensitizing (anti-diabetic) medications can be used to decrease insulin levels, which may help restore the normal ovarian hormone profile (i.e. reduce male hormone), thus allowing for spontaneous ovulation to occur in about 75% of patients. The most commonly used medication is metformin (Glucophage®). Side effects of metformin include gastrointestinal symptoms, which are dose-related and tend to resolve after several weeks. While there are no well-controlled studies of safety during pregnancy, metformin has been administered to a small number of women with diabetes throughout their pregnancies, and no fetal abnormalities have been described⁽¹⁾.

Clinical studies have shown that metformin (500 mg three times per day or 850 mg twice daily with meals) administration to women with PCOS increased the frequency of spontaneous ovulation, menstrual cyclicity, and ovulatory response to clomiphene citrate (CC) (Clomid^®). Benefit has been demonstrated with metformin treatment in PCOS patients both with and without insulin resistance⁽²⁾. Metformin alone may be less effective in obese PCOS women.

Women with PCOS are considered to be at increased risk of miscarriage, as high as 30 – 50 %. When women were treated with 1000-2000 mg daily of metformin throughout pregnancy, rates of early pregnancy loss were 11.6% in the metformin group compared with 36.3% in the control group (p < 0.0001). Administration of metformin throughout pregnancy to women with PCOS may decrease miscarriage rates⁽³⁾.

Controversy exists when comparing metformin to clomiphene citrate (CC) for treating infertility. A well-designed study showed metformin is better for ovulation induction than CC alone and equivalent for pregnancy achievement. The authors suggest that metformin can be used first for ovulation induction in patients with PCOS regardless of their weight and insulin levels because of its efficacy and known safety profile⁽⁴⁾. Alternatively, another study found benefit with metformin if obese (BMI >30 kg/m⁽²⁾ subjects and women older than 34 years were excluded⁽⁵⁾. Another paper pooled the results of 6 studies to examine whether metformin is efficacious when given to patients resistant to CC. They found the addition of metformin in the CC-resistant patient is highly effective in achieving ovulation induction⁽⁶⁾. Most studies showing benefit were small with fewer than 100 patients.

Conversely, two large multicenter trials, one conducted in the US (PPCOS)⁽⁷⁾ and one in the Netherlands⁽⁸⁾, have shown no benefit from metformin either as a single agent or as adjuvant therapy in combination with clomiphene for the treatment of infertility in women with PCOS. They found metformin increased the occurrence of ovulation but did not increase the chance of becoming pregnant. The PPCOS study is large and well designed, with 626 participants. It differs from other studies by using the extended release form of metformin. One very notable result was the absence of any statistically significant effect of this extended release form of metformin on insulin levels or insulin resistance. There were none of the expected metabolic effects of metformin. Extended-release metformin has not previously been studied in women with PCOS. Thus, it has not been ascertained that its efficacy is comparable to regular metformin in PCOS⁽⁹⁾.

Additionally, metformin and clomiphene citrate (CC) differ in their therapeutic time frames (the period of time from initiating therapy to achieving maximum effectiveness). CC produces higher rates of ovulation and pregnancy in the early months of treatment than that of metformin and might be preferable to women who wish to become pregnant quickly ⁽⁵⁾. However, a patient with more time to become pregnant may benefit from metformin’s metabolic effects. During the 3 to 6 months that it takes for metformin to become maximally effective, the patient can prepare for pregnancy by losing weight through diet and exercise. Reducing a patient’s weight might considerably optimize her pregnancy⁽⁹⁾.

Metformin induces normal ovulation, and the risk of multiple gestation is no more than that in the general population. Conversely, CC can precipitate the release of multiple eggs in a given menstrual cycle and carries a risk of multiple gestation: in the PPCOS study, multiple gestation was 6% in the clomiphene group and 0% with metformin.

Metformin may significantly increase the incidence of multiple pregnancy when used in combination with gonadotropins⁽¹⁰⁾.

Short-term co-treatment with metformin for patients with PCOS undergoing IVF/ICSI cycles does not improve the response to stimulation but significantly improves the pregnancy outcome and reduces the risk of ovarian hyperstimulation⁽¹¹⁾.

Conclusions:

• PCOS patients should be screened for diabetes before becoming pregnant. Hemoglobin A1c levels should be normal.
• Metformin alone can induce ovulation and may improve the effectiveness of CC. Extended release metformin may not be as effective.
• Metformin may decease miscarriage rates.
• Weight loss may improve the effectiveness of metformin.
• Time to achieve pregnancy may be longer with metformin than CC.
• Metformin may be less effective in older women.
• Metformin does not increase multiple pregnancy rates when used alone.
• Metformin may increase multiple pregnancy rates and decrease ovarian hyperstimulation when used with gonadotropins.
• Long-term benefits of metformin in preventing hypertension and heart disease need further study.

Eldon Schriock, MD

References:

1. The Practice Committee of the American Society for Reproductive Medicine Committee Opinion. Use of insulin sensitizing agents in the treatment of polycystic ovary syndrome. Fertility and Sterility
2. Nawrocka J, Starczewski A. Effects of metformin treatment in women with polycystic ovary syndrome depends on insulin resistance. Gynecol Endocrinol. 2007 Apr;23(4):231-7.
3. Khattab S, Mohsen IA, Foutouh IA, Ramadan A, Moaz M, Al-Inany H. Metformin reduces abortion in pregnant women with polycystic ovary syndrome. Gynecol Endocrinol. 2006 Dec;22(12):680-4.
4. Neveu N, Granger L, St-Michel P, Lavoie HB. Comparison of clomiphene citrate, metformin, or the combination of both for first-line ovulation induction and achievement of pregnancy in 154 women with polycystic ovary syndrome. Fertil Steril. 2007 Jan;87(1):113-20.
5. Palomba S, Orio F Jr, Falbo A, et al. Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2005;90:4068-4074.
6. Siebert TI, Kruger TF, Steyn DW, Nosarka S. Is the addition of metformin efficacious in the treatment of clomiphene citrate-resistant patients with polycystic ovary syndrome? A structured literature review. Fertil Steril. 2006 Nov;86(5):1432-7.
7. Legro RS, Barnhart HX, Schlaff WD, et al. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med. 2007;356:551-566.
8. Moll E BP, Korevaar JC, Lambalk CB, van der Veen F. Ovulation induction in women with polycystic ovary syndrome: A randomized double blind clinical trial comparing clomiphene citrate plus metformin with clomiphene citrate plus placebo. BMJ. 2006;332:1485.
9. Baillargeon JP, Legro RS. Should metformin be used as front-line therapy for fertility in women with PCOS. Sexuality, Reproduction, and Menopause 2007; 5(2):17-19.
10. Shibahara H, Kikuchi K, Hirano Y, Suzuki T, Takamizawa S, Suzuki M. Increase of multiple pregnancies caused by ovulation induction with gonadotropin in combination with metformin in infertile women with polycystic ovary syndrome. Fertil Steril. 2007 Jun;87(6):1487-90.
11. Tang T, Glanville J, Orsi N, Barth JH, Balen AH. The use of metformin for women with PCOS undergoing IVF treatment. Hum Reprod. 2006 Jun; 21(6): 1416-25.

While many factors leading to female factor infertility are out of a patient’s control (genetics, for example), there are several measures patients can take that will help optimize their chances of conception.

At the forefront is receiving routine gynecological care. During the preconception phase, it is important that the patient have an up-to-date Pap smear and mammogram. Furthermore, the patient should undergo testing for infectious diseases (Hepatitis C, Hepatitis B, syphilis) and immunization status for varicella and rubella and hormones which can affect ovulation (prolactin and TSH). Any fibroids or polyps the patient has should be evaluated to make sure they wouldn’t adversely affect the chances of conception. Also, the patient should be taking essential prenatal vitamins as prescribed by her OB/GYN.

Certain behavioral factors should also be assessed and, in some instances, eliminated prior to trying to conceive. Smoking and drinking should be eliminated and exercise should be moderated. Incorporating a regular exercise program along with a balanced diet is recommended. The diet should include lean proteins, a colorful variety of fresh fruits and vegetables, combined with a limited intake of processed and fatty foods.

Women who are extremely thin or very heavy should seek the help of a nutritional counselor to attain a healthy weight without fad or crash diets. Embarking on a new, strenuous exercise regimen or crash diet just before attempting to become pregnant is not recommended. Medications being taken for preexisting medical conditions should also be evaluated to ensure they won’t compromise a pregnancy.

If the patient requires a fertility specialist, it is recommended the following tests be performed prior to seeing a specialist. This will streamline the diagnosis process and expedite them on their path to proper treatment. This includes testing of the ovarian hormones, follicle stimulating hormone (FSH), Estradiol; a semen analysis (for the male partner) and an HSG (dye study) to assess tubal patency. See more about fertility testing…

Age is a critical factor in the outcome of infertility treatment and it is important for patients to be more proactive the older the patient gets. At Pacific Fertility Center (PFC), our guideline for patients is to seek help from a fertility specialist after: 1 year of trying for women less than 35 years of age; 6 months of adequately timed intercourse or inseminations for women ages 35-39; 3-6 months of trying for women over 39. See more about age and fertility…

Again, time is of the essence when it comes to getting treatment from a reproductive expert, and, keeping that in mind, there are several tests that we do not encourage patients to take prior to seeing an infertility specialist based on their limited usefulness.

They include:

• Post coital test
• Sperm penetration assays
• Endometrial biopsy
• Serum antisperm antibodies
• Cervical cultures
• Laparoscopy
• Autoimmune factors

Ultimately, conceiving through assisted reproductive technology (ART) is a team effort involving the patient, OB/GYN, and fertility specialist, with the process beginning several months before the patient steps foot in an IVF clinic.

Click here for more information on pregnancy preparation.

– Eldon Schriock, MD

Question: I’m a heavy coffee drinker, consuming five cups per day. I’m concerned that my addiction to caffeine will hurt my chances of getting pregnant. How much caffeine is acceptable?

Answer: Moderate caffeine intake for women trying to conceive is acceptable. As a general guideline, women trying to conceive should limit intake to 3 cups of coffee (or 300 mg of caffeine) per day (Organization of Teratology Information Services (OTIS) 2001). Results from large published studies have not demonstrated that moderate caffeine intake adversely affects fertility (International Food Information Council (IFIC) August 2002). Furthermore, caffeine consumption has not shown to have an impact on fertility or birth defects for the male partner or sperm donor (OTIS 2001).

For women who are pregnant, there have been several studies analyzing the affect of caffeine and pregnancy with the conclusions of those individual studies being mixed (IFIC August 2002). Keep in mind that if you are pregnant or breastfeeding, the caffeine you consume may transfer to the infant. As such, guidelines for caffeine intake of pregnant or breastfeeding women are a little more rigid. The recommendation by OTIS and Motherisk is that consuming less than 1½ cups of coffee (or 150 mg of caffeine) per day is not likely to increase the chances of miscarriage or a low birth weight baby. The American Academy of Pediatrics states that: “no harm is likely to occur in a nursing child whose mother drinks one cup of coffee a day.”

For more information on the affect of caffeine on fertility, visit the National Toxicology Program-Department of Health and Human Services website. The website provides a more detailed look at some of the clinical studies referenced above. Additionally it provides a chart showing the levels of caffeine in certain food and drinks. This information is available at: http://cerhr.niehs.nih.gov/common/caffeine.html.

– Eldon Schriock, MD

The public’s appetite for promising pills that purportedly slow down the aging process is stronger than ever. Sensationalized claims revolving around Dehydroepiandrosterone (DHEA), a natural steroid hormone produced from cholesterol by the adrenal glands, has followed this trend.

DHEA is a hormone secreted by the adrenal gland whose level in the body peak at early adulthood and then decline with age. As the most abundant steroid in the body, DHEA is chemically similar to testosterone and estrogen.

Because low DHEA levels brought on by aging also correlate with age-related diseases, DHEA supplements are openly marketed to prevent the effects of aging. Because a woman’s fertility declines with her age, it is no surprise that DHEA has been associated as a “promising” drug to offset age-related infertility. Yet there have been no scientific studies or evidence revealing that adjusting DHEA levels changes the development of age-related diseases. Nor has there been evidence that DHEA slows down the decline in fertility. Simply stated, there is no evidence that increasing DHEA slows down, stops, or reverses the aging process.

Some past rodent studies indicated DHEA was effective in controlling obesity, and prevented cancer, arteriosclerosis and diabetes. As a result, DHEA was quickly promoted as a miracle weight-loss drug. Yet no human studies have duplicated these results.

Nevertheless, DHEA has received considerable acclaim, with some authors touting it as a “superhormone” or “the youth and health hormone.” Articles on DHEA abound. In fact, DHEA received over 850 citations in a Medline search and 52 publications come up on an Amazon.com search.

A search of serious scientific research examining DHEA’s impact on fertility is scanty. There are less than a handful of scientific presentations or papers on the topic. Just last year a study (Fertil Steril. 2005; 84(3):756) conducted at the Albert Einstein College of Medicine announced: Increased oocyte production after treatment with dehydroepiandrosterone. This paper focused only on one 42 year old woman, whose number of oocytes retrieved increased after undergoing eight IVF cycles over the course of a year with DHEA supplementation. Not only did she take a DHEA dietary supplement, she also underwent acupuncture. Since she froze her embryos, it is not reported whether any of her eggs led to a successful pregnancy.

To date, no sound or controlled scientific studies have been designed to examine whether DHEA is able to reverse the results of aging on ovarian reserves.

A research paper was presented at the 2005 ASRM conference (O-101 by D. H. Barad and N. Gleicher). This retrospective cohort study examined 45 women previously diagnosed with decreased ovarian reserve who were treated with 25 mg DHEA for 4-48 weeks before undergoing ovulation induction for IVF. The study concludes that DHEA increased oocyte production and quality. Yet no pregnancy or live birth outcomes were reported. Both Drs. Barad and Gleicher are already offering “DHEA Therapy” in their practice.

Very little of the encouragement to self-administer DHEA is coming from the physician community, especially those who are initiating viable scientific research. Elizabeth Barrett-Connor, MD, professor and chair, department of family and preventive medicine at University of California, San Diego calls DHEA “a modern day snake oil”. Her initial research revealed that higher natural levels of DHEA in older men may help protect them against heart disease yet she recognizes the need for more studies.

Self-medicating by using DHEA supplements is a form of testosterone therapy. It is not likely to affect each individual in the same way due to variable existing androgen levels in the body and a lack of consensus on what are normal or benchmark levels. Increasing DHEA (and thus testosterone) may well lead to additional facial hair and possibly acne for women. Until more is known, taking DHEA is a risky gamble based on insubstantial evidence.

The hype about DHEA as a way to improve fertility will only continue as the public seeks information that they want to hear. An entire chapter is devoted to DHEA in an online book called “Mothers over 40”. If there were such an easy panacea to reverse the impacts of aging on infertility, the benefits would have been known much sooner.

– Eldon Schriock, MD

PFC continues to be at the forefront of pioneering research in assisted reproductive technology and was the recipient of the 2005 California Pacific Medical Center (CPMC) Foundation Wishes for Wellness Grant. Through this grant, PFC will embark on a research project assessing the efficacy of a new IVF egg freezing method, vitrification.

The CPMC Foundation selects outstanding CPMC physicians in the fields of obstetrics and gynecology and pediatrics to be honored at their event Wishes for Wellness. PFC’s Eldon Schriock, MD and Carl Herbert, MD were among those selected in 2005. These honored physicians have the privilege of identifying needs and/or directing purchases and programs which will be funded by the Wishes for Wellness Grants.

Egg freezing has been successful in creating a handful of pregnancies, but the process is still very inefficient. Many eggs do not survive the freezing process. While the technology for freezing sperm and embryos has been used for decades and is very successful, the technology for egg freezing is still emerging.

The key to successful egg freezing is determining a technique that will not damage the fragile chromosomes of the egg. The eggs in the ovaries are held in “suspended animation”, until they are stimulated to grow and ovulate. During this state, the chromosomes of the egg are vulnerable to damage, including damage from the exertion of the freezing and thawing process. Past freeze/thaw techniques have been very inefficient because of the chromosomal damage incurred. The vitrification freezing technique seems to be a gentler technique, and therefore leads to less chromosomal damage. This then improves efficiencies in the thawing, fertilization and embryo development steps; and ultimately better pregnancy rates.

Our study is designed to study whether vitrification can improve the efficacy of freezing eggs. The study is designed is such a way that results should be obtained in a timely manner. Egg donors who have had previous IVF cycles resulting in pregnancy will be recruited to have eggs frozen. The results of fertilization, embryo development, implantation and pregnancy rates using the embryos resulting from egg vitrification will be compared to the pregnancy rates obtained in previous cycles using embryos obtained from fertilized fresh eggs.

PFC is excited and honored to be involved in this research. The potential benefits of egg freezing are substantial and our research team looks forward to sharing results with you, as soon as they are available.

– Eldon Schriock, MD

A Few Good Eggs; Two Chicks Dish on Overcoming the Insanity of Infertility is one of the best books about infertility written from the patients’ perspective. Julie Vargo and Maureen Regan have written a very readable and entertaining book presenting the entire gamut of the infertility experience covering diagnosis, procedures and the psychological challenges faced by patients – mainly women – facing infertility.

The book is organized chronologically starting from the early disbelief after realizing that one might be infertile, through the testing procedures, physician diagnosis and ultimately treatments.

Back-up options for those women and couples for whom treatments are unsuccessful are also explored. Along the way, the authors provide stories of their own experiences as well as the experiences of other women with whom the authors have met and talked in order to write the book. These two women personally went through many of the procedures and shared the same emotions that most fertility patients experience, their unique perspective brings a human touch to their writing. This is a refreshing contrast to the books written for the consumer by physicians or other health care professionals that work in the field.

However, because the book is written by patients and not reproductive endocrinologists (REs), there are some areas that not all REs will agree with, such as their perspective on immunology and infertility. The authors also seem to have gone through their treatments some years ago as the list of drugs is not current with some of the drugs now commonly used for ovulation induction. For example, they mention Pergonal, which is not currently available and do not cover the recombinant FSH medications most commonly used today, Gonal-f and Follistim. Plus, I doubt that a reproductive endocrinologist proofread the chapter on medications because they misnamed Repronex as “Repromax.” I also think their description of the side effects of these drugs is frightening and not typical of the side effects experienced by most women using them in treatment.

The book does provide a lot of useful information in a personal and accessible fashion. Most of the facts are correct. And most of all, the publication encourages women not to wait to get help if they think they may be infertile.

– Eldon Schriock, MD

The U.S. marketplace is punctuated with products and services trying to lure desperate parents into believing that somehow, someway, it must be possible to predict and even select the outcome of the baby’s gender through various hocus pocus methods. Perhaps not coincidentally, many products and services, such as www.fortunebaby.com, appear to be subsidiaries of companies based in China and India where male babies are prized over baby girls.

In the line-up of such products, Baby Gender Mentor blood test hit the marketplace with great Public Relations fanfare including a brief interview on the Today Show and a headline in the Boston Globe. Sadly, both of these popular press outlets focused squarely on the debate about gender selection ethics and never seriously questioned the accuracy of such a test. As a result, millions of viewers and readers may have assumed the expensive test results were accurate. Acu-Gen charges $275 to mail order the test.

This was in June. Now, three months later, enough women who were lured into buying the test and assured by the company’s guarantee that it will reimburse misdiagnoses with 200% of their money back, are asserting the test doesn’t work. Many women are trying to get refunds and are being told by Acu-Gen that a “vanishing twin” may have caused the test to fail.

National Public Radio, taking a more critical stand, recently broadcasted a story pointing out that Acu-Gen offers little proof of its claims and admits that it is not required to undergo FDA testing to verify accuracy. On its web site, the company describes how the process purportedly works.

Gender-specific DNA from the fetus floats around in the mother’s blood stream after having crossed over the placental walls. The presence of the Y chromosome in the female blood via a finger-prick blood tests indicates a “male-positive” baby.

A visit to Acu-Gen’s Gender Mentor test web site reveals some other questionable assertions. Men are not allowed to be anywhere near the pregnant woman as she is having her blood drawn for the test. Acu-Gen also lists on its web site the names and publications of noted experts on fetal DNA testing, some whom NPR interviewed and deny any involvement with the company.

The notion that just five weeks into a pregnancy a simple blood test can accomplish what amniocentesis or ultrasound can do much later in a pregnancy is at this point wishful thinking. A dedicated web site: www.in-gender.com takes a more comprehensive and critical look at the claims of many sex-prediction and selection techniques and includes descriptions of the high-tech methods that do work.

– Eldon Schriock, MD