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LIterature Updates

More evidence of the adverse effect of cigarette smoking

An abstract by Drs. Burkman et al presented at the ASRM meeting demonstrated that cigarette smoking resulted in a significant decrease in the fertilizing capacity of sperm. It has been known for some time that smoking has an adverse effect on sperm morphology, but this study demonstrates that smoking may also impair the ability of the sperm to penetrate the egg.

Letrozole - Does it have significant risks?

Letrozole is marketed and approved only for the treatment of post-menopausal women with breast cancer. It has, however, been extensively used worldwide for ovulation induction. In many programs it has replaced clomiphene altogether because it has far fewer side effects and is more successful. After a very small Canadian study demonstrated a higher risk of "adverse pregnancy outcomes", concerns arose about the safety of Letrozole. Most experts feel this issue has been blown way out of proportion, and no other data about any increased risks with Letrozole for ovulation induction exists. Clearly care must be taken not to use Letrozole in women who are already pregnant (this is also the case for clomiphene). However, when used in the early follicular phase for ovulation induction, Letrozole is still very effective and seemingly very safe. There is now good evidence that Letrozole may be safer even than clomiphene.

Treatment options for men with a high sperm DNA fragmentation index

Men with a high level of sperm DNA fragmentation face a difficult issue. Clearly associated with an increased risk of infertility and early pregnancy loss, this problem is one that until now had few treatment options. If a man has sginificant toxin exposure (smoking, excessive alcohol, etc), avoidance of these will result in improvement of the fragmentation index. And there is some evidence that taking extra Vitamin C and Vitamin E in addition to regular vitamins may be helpful. But now there is data from two studies showing that much of the sperm DNA fragmentation may result from ejaculation and that sperm obtained directly from the testes have significantly less fragmentation. In both of these studies fragmentation was significantly less with sperm obtained by aspiration from the testicles. While this implies that IVF and ICSI are necessary to achieve pregnancy, there is at least now a good alternative for men with high DNA fragmentation levels. Copies of studies available upon request.

Laparoscopic treatment of endometriosis

A study from Stanford University published in the December 2005 issue of Fertility and Sterility demonstrated dramatic improvements in conception rates after the laparoscopic treatment of endometriosis.Twenty-nine patients with multiple unsuccessful IVF attempts underwent laparoscopy. Twenty-two of these patients subsequently conceived (76%). For many years IVF seriously brought into question the role of laparoscopy in infertility treatment. Laparoscopy was often avoided and couples would proceed directly to IVF instead. The data from this study brings this approach into question. Elimination of endometriosis, and reduction of the humoral factors produced by endometriosis, seems to significanly improve pregnancy rates, even in a very difficult group of patients. Copies of studies available upon request.

Evaluation of Ovarian reserve

The clomiphene citrate challenge test, once considered the "gold standard" for evaluating ovarian reserve, is no longer the best indicator. Ovarian reserve represents the number of oocytes remaining in the ovaries and is an indicator of one's chances of successful conception. Ovarian reserve can now be assessed by simply do an ultrasound on day 3 of the cycle and counting the number of antral follicles (small developing follicles in the ovaries) and by measuring Anti-Mullerian Hormone (AMH). AMH is a hormone produced by young developing follicles in the ovary. AMH assays are not generally available, but are available to JFG patients.

Improvement of Ovarian Function

There is no way to increase the number of follicles and eggs in the ovaries (a woman is born with all the eggs she will ever have), but now there may be a way to improve the response to the use of fertility medications/hormones. Drs. Gleicher and Barad have convincingly demonstrated that taking 25 mg of DHEA three times a day prior to ovulation induction improves the number of oocytes retrieved at the time of IVF. This is a treatment we recommend for all women with any compromise of ovarian response.

Clomiphene and Endometriosis

According to an abstract presented at the Society for Gynecologic Investigation, clomiphene treatment in women with mild endometriosis and otherwise unexplained infertility may actually decrease pregnancy rates. We have long-believed this to be the case, and there is evidence to suggest that using clomiphene or other forms of ovulation induction may increase the rate of progression of endometriosis. clomiphene should not be used in women with regular cycles and endometriosis.

Paternal Age and Risk of Pregnancy Loss

It is well known that increasing maternal age is associated with an increased risk of miscarriage. There is now evidence that increasing paternal age increases the risk as well. A study by Kleinhaus et al (Ob & Gyn 2006;108(2):369). For fathers older than forty, the risk of pregnancy loss was 1.6 times as high as that fro fathers ages 25-29.

© 2005 Jarrett Fertility Group