Infertility Treatments > ART

ART, Assisted Reproductive Technology, encompasses all of the procedures performed in the IVF lab.

The data in the following table is the data JFG submitted to SART (Society for Assisted Reproductive Technology) for 2006. "A comparison of clinic success rates may not be meaningful because patient medical characteristics and treatment approaches may vary from clinic to clinic". (This statement included in compliance with SART guidelines).

* While the donor oocyte rate for 2006 was disappointing, in 2007 30 of 40 (75%) of donor oocyte procedures have resulted in clinical pregnancy.

ART seminar on paper - a patient's guide

• Part 1 (Revised 2/9/07)
• Part 2 (Revised 2/9/07)

This is a comprehensive step-by-step review of an IVF procedure. This should answer most if not all of your questions regarding IVF.

ON THE RISKS OF IVF AND ICSI

There has been a great deal of consternation over the possible risks of IVF and ICSI and a possible association with an increased risk of congenital anomalies. This paper will present the current data pertaining to this issue.

CONCLUSION

When evaluated in total, we believe the existing data shows:

1. ICSI is safe, and although there may be some increase in sex-chromosome abnormalities (related to paternal abnormalities), ICSI does not significantly increase the risk of congenital abnormalities.
2. ART (IVF and related procedures) may increase the risk of congenital abnormalities by a risk factor of 1.3. This means that, if the risk of an abnormality in the general population is 3-4%, the risk may be as high as 3.9-5.2% following IVF.
3. There is an increased risk of premature labor and early delivery in women who have undergone IVF. (data not shown here)

We put the conclusion here for those of you who don’t want details. For those who do, the studies and papers are listed below.

www.ivf-infertility.com/ivf/standard/outcome.php concludes “there is no significant difference in the incidence of congenital and chromosomal abnormalities after IVF compared to children conceived naturally”.

The Practice Committee of the American Society for Reproductive Medicine concludes: “..current data do not suggest that ICSI carries an increased risk of genetic disorders in the offspring…” and that ICSI is a “safe and effective therapy”. Concerns over the possible transmission of sex chromosome related abnormalities was raised, particularly when ICSI is used for micro-deletions of the Y chromosome. (2004)

The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology write that “…recent studies…have not detected any differences in the development or the abilities of children born after ICSI, conventional IVF or natural conception”. They also write: “The prevalence of sex chromosome abnormalities in children conceived via ICSI is higher than observed in the general IVF population, but the absolute difference in prevalence between the two groups is relatively small (0.8-1.0% in the ICSI offspring vs. 0.2% in the general IVF population.” They conclude: “ICSI appear to be a safe and effective therapy for the treatment of male factor infertility.” (2006)

A study of over 8,000 children from Germany concluded that there was an increased risk by a factor of 1.24. With a background rate of 6.1%, this means the risk of an abnormality after ICSI was 7.5%.

A review published in Fertility and Sterility in 2003 concluded that while “there is likely an increased rate of sex-chromosome abnormalities …related to either inherited paternal …abnormalities or abnormal spermatogenesis, …there is probably no significant increase in congenital malformations.”

A review of over 22 scientific articles published in the International Journal of Epidemiology in 2005 concluded that there was a 1.12 fold increase of congenital anomalies after ICSI when compared with standard IVF. They conclude: “Our analysis does not indicated that the ICSI-procedure represents significant additional risks of major birth defects…”.

A review in Human Reproduction in 2005 concluded that there was a “30-40% increased risk of birth defects associated with ART”. (Risk factor of 1.3-1.4).

A Swedish review of over 16,000 children found an increased risk of 40% following IVF, but felt many of these were due to parental characteristics.

A review in The European Journal of Medical Genetics found the highest increased risk as a result of ART, that being a risk factor of 1.75.

Perhaps the most all-inclusive study, from the Journal of Assisted Reproduction and Genetics, which reviewed over 3,000,000 infants, concluded that the risk of ART was 1.29.

Letrozole for poor responders

One of the most difficult groups to successfully work with are women with compromised ovarian response. In other words, women whose ovaries do not function well and do not produce eggs in response to standard approaches to ovulation induction. Achieving ovulation in these individuals can be challenging, and many different approaches have been tried. We have recently had success with the combination of oral contraceptives for two to three weeks, followed by Letrozole for 5 days, followed by maximal doses of gonadotropins. What follows is an abstract in preparation regarding this approach.

Rationale: It is known that Letrozole use results in decreased estrogen production by the ovaries because of its inhibition of aromatase. The resulting decrease in estrogen levels results in an increase in gonadotropin production. There is also evidence that Letrozole specifically sensitizes FSH receptors in the ovary, thus making the ovary more sensitive to FSH. Finally, Letrozole accomplishes these actions without the prolonged anti-estogenic effects of clomiphene. (Letrozole inhibits aromatase reversibly, while clomiphene depletes estrogen receptors. It takes a long time for estrogen receptors to regenerate.)
Micro-dose Lupron is utilized because it results in increased endogenous production of FSH from the pituitary. Maximal FSH is then administered. In this manner, both endogenous FSH and exogenous FSH stimulation are provided. If Letrozole use results in increased FSH production, perhaps it can be used to replace micro-does Lupron for maximal stimulation.

Between Dec 04 and Sept 05, 13 “poor-responders” underwent stimulation with micro-dose Lupron and 13 with Letrozole. These patients are characterized in the following chart.

Letrozole seems to be very effective for use in the treatment of low responders. While it may seem to take longer and require more FSH with letrozole, the above data would suggest that this is due to the fact that FSH is not started until day 7 with this protocol. This novel approach seems to hold great promise for use in the treatment of women with poor ovarian responsivity.

© 2005 Jarrett Fertility Group