You are currently browsing the Dr Licciardi blog archives for September, 2006.

Is LH Important for IVF Success?

The research says no. This is very sensitive subject for many doctors. Some doctors genuinely believe that LH is necessary, and I am ok with that. Some doctors don’t know but find that they can attract patients by promoting LH as the secret ingredient to success and I don’t like that.

The history of infertility drug sales and marketing tells us LH may not be a factor. The first fertility injection drug in the US was Pergonal. This was mostly FSH , but had a small amount of LH. Soon there was another drug, Metrodin that had more LH, and the Metrodin and Pergonal were used in combination . For years this was the most popular IVF drug treatment. Then the company stopped making Metrodin, so significant amounts of LH were not available to IVF patients. The drug company spent millions of dollars telling doctors and patients that higher doses of LH were not necessary, and there was research to back it up. Then Pergonal became replaced by Gonal-f, a drug that contains no LH. Again the drug companies did studies (some times with the doctor you are currently using) to show LH didn’t matter. There was data, and strong marketing push.

I use some LH. I do not feel a LH cycle is any better than a cycle of pure FSH, but if I have a patient who did not do well with pure FSH, I will add some LH next time. I have not observed a difference in pregnancy rates, but there may be some people who do better with LH, and some who do better with no LH. My partner, Dr. Berkeley, researched the NYU success rates in women who did and did not use LH. There was no difference in the pregnancy rates between the two groups.

So if your doctor does not use LH, he is not causing you any harm. If he uses LH, again no harm, as either way seems to work well. If one way doesn’t work, try the other.
and…Please read disclaimer 5/17/06. Dr. Licciardi

References:

  • European and Israeli Study Group on Highly Purified Menotropin versus Recombinant Follicle-Stimulating Hormone. Efficacy and safety of highly purified menotropin versus recombinant follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a randomized, comparative trial. Fertil Steril. 2002 Sep; 78(3):520-8.
  • Westergaard LG, Erb K, Laursen S, Rasmussen PE, Rex S. The effect of human menopausal gonadotrophin and highly purified, urine-derived follicle stimulating hormone on the outcome of in-vitro fertilization in down-regulated normogonadotrophic women. Hum Reprod. 1996 Jun; 11(6):1209-13.
  • Andersen AN, Devroey P, Arce JC. Clinical outcome following stimulation with highly purified hMG or recombinant FSH in patients undergoing IVF: a randomized assessor-blind controlled trial. Hum Reprod. 2006 Dec; 21(12):3217-27.

Hysteroscopy 101

Hysteroscopy is a procedure whereby a doctor slides in a long narrow scope, about the size of a drinking straw, through the cervix and into the uterus. There are a few things at the far end of the scope. One is a light. The light is actually a few feet away, but the light rays are carried to the scope via a fiber optic cord, and then through the fiber optic strands inside the scope. At the end is also a hole. Out of the hole comes a water-like fluid that shoots out under pressure into the uterus. This distends the uterus so the doctor can look inside. A lens at the end of the scope allows the doctor to see. A camera is placed over the lens so everything inside the uterus becomes visible on a TV screen.
At times there are problems with hysteroscopies. One is getting in. To get this straw from the vagina to the uterus, one needs to go through the cervix. In most cases the cervix needs to be opened, or dilated, because the cervical canal is normally too narrow for the scope. Some patients have asked me how we dilate the cervix. It is done using metal rods of different diameters. We start with a skinny one, and then use one that is a tiny bit wider, then a little wider, until the cervix is open enough for the scope to fit in. We may need 5-10 dilators if increasing diameter to get the job done.
A woman who has had a child will have a cervical canal that is a little wider than a woman who has not. Scopes come in different diameters, so if the scope is very narrow, no or little dilation is needed. If the doctor is removing tissue at the time of a hysteroscopy, as is the case when removing a fibroid or septum, the scope needs to be wider and more dilation is necessary.
Some women have a cervix that is very difficult to dilate. This could be due to scarring as a result of previous surgery. Some women with endometriosis have scarring in their cervix. Others have a cervix that is normal diameter, however the canal may be very angled, making it very difficult for the scope to get into the uterus. All doctors have had or heard of cases where the hysteroscopy could not be performed because the cervix could not be safely dilated. I will write about other potential problems with hysteroscopies next time.

References:

  • Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol. BW, Mathieu C, D’Hooghe T.  The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update. 2010 Jan-Feb; 16(1):1-11.
  • Baggish, MS, Valle, RF, Guedj, H. Hysteroscopy: Visual perspectives of uterine anatomy, physiology, and pathology, 3rd ed. Lippincott Williams, & Wilkins 2007.

Psychologists are Available: Consider Using Them

If you don’t think stress, even severe stress, is part of the infertility package, you are significantly mistaken. Stress is the attached twin of infertility. Each of us reacts differently to stress. Some do quite well, but most people have some difficulty, and some have great difficulty, dealing with the issues.
Stress magnifies smaller problems and it allows older problems to resurface. Problems that don’t seem so big enlarge during stress. Unresolved issues that we have learned to ignore become the focus of resentment during stress. All of this occurs without us being able to put two and two together. Many of us don’t see the relationship between the new stress and heightened sensitivity to old issues until we really are crazy.
Seeing a psychologist is the best way to lower the stress levels. I like ancillary, alternative methods of stress reduction, but I believe in starting with a good psychologist. The fertility world is full of dedicated psychologists who are familiar with the specifics of infertility.