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Minimal Stimulation

Does taking a lower dose of fertility drugs improve your chances of becoming pregnant with IVF? I think not, but I can tell you of some exceptions. Mostly I have had some very good experiences with patients confirming that lower is not better.

How do I know?

Well, as it turns out over the past few years I have been seeing more patients from Europe. There are a few things that have contributed to this. One is the blog. It’s been fun getting e-mails and seeing patients from around the world. The second is the exchange rate: for some, New York is now a “reproductive tourism” destination. The third has to do with laws in Italy, Germany and other countries that restrict IVF and donor egg.

Anyway, the European doctors give their patients a much lower dose of drug that we do in the US. Part of this is due to the fact that they may not be allowed to fertilize more than a few eggs, so they don’t bother trying to get more. Another reason may just be due to a general philosophy that less drug is better.

So the typical European woman that sees me has done IVF many times, usually making just a few eggs on a lower dose of drug. Unless she has had a fantastic response, I increase the dose for her IVF cycle with me. In most cases, the egg yield is much higher (still in a safe range) and the pregnancy rate in these women is very high. So the point is that in these women, a higher dose is better because it increases the number of eggs, and therefore there are more embryos available for selection.

Do some women make more eggs with a lower dose? I have seen a few cases of this. This is typically the woman who was given a lower dose for IUI and develops more follicles than she did with her higher dose IVF cycle. Should we go back to the lower dose for the next IVF cycle? It’s a gamble and it takes a little courage. It is really hard emotionally to go into an “experimental” IVF cycle.

Many patients considering this have had many attempts and may not be ready to give up a couple months for a “let’s see” cycle. If you and your doctor can stomach it, you can give it a try. I can tell you I have one woman, who had been through many cycles, who wanted to give it a go, and she did better with less. Was that her month to make more, regardless of drug dose? Who knows, but let’s give her the credit.

But I do think starting on a minimal dose, just because your doctor thinks it’s more homeopathic and will result in better quality embryos, is not correct. To return to our common theme, if one of the self proclaimed experts in minimal stimulation wants to take 100 women and give them minimal stimulation, and take another 100 and give them regular stimulation, and then show us that minimal is better, great. But until this happens we have to say that it’s not better, and may be worse for most people. I know some of you can tell me that you did minimal and got pregnant. I just feel that my experience has shown that overall, regular may be better.

Please read disclaimer 5/17/06, and thanks again, Dr. Licciardi

References:

  • Zarek SM, Muasher SJ. Mild/minimal stimulation for in vitro fertilization: an old idea that needs to be revisited. Fertil Steril. 2011 Jun 30; 95(8):2449-55.
  • Fauser BC, Nargund G, Andersen AN, Norman R, Tarlatzis B, Boivin J, Ledger W. Mild ovarian stimulation for IVF: 10 years later. Hum Reprod. 2010 Nov; 25(11):2678-84.

More About Fibroid Surgery

So why not just remove all fibroids to treat infertility and to prevent pregnancy complications? Because the operation is not without discomfort and risk. Overall, myomectomy is a safe procedure, however complications are possible.

One complication is bleeding. If the surgeon is meticulous, the odds are bleeding are lower, however you doctor can’t control everything. Even in the best of hands, transfusion may be necessary. The odds are related the to number of fibroids being removed. Most people with a few fibroids do not need transfusions. If there are more than 10-20 fibroids, your odds will be much higher.

Transfusion risk can be lowered using a machine called the “cell saver”. This machine takes blood you lose during an operation and recycles it back into your veins.

Can a myomectomy make infertility worse? In some cases yes. There is about a 30% chance that a myomectomy will cause scar tissue to form around the tubes, ovaries or uterus. During the fibroid surgery incisions are not made in the ovaries or tubes. However, as the uterus heals, scar tissue can form throughout the pelvis that can envelop the ovaries and tubes. This scar tissue, also called adhesions, can make it more difficult for an egg to get from the ovary to the tube.

This can be dealt with in different ways. A few months after the myomectomy, a hysterogram can be performed to look for tubal blockage. If blockage were present, you would have the option of a laparoscopy to evaluate and possibly treat the adhesions. Or, you could bypass the laparoscopy and go straight to IVF.

What about pregnancy? There are cases where the fibroid is clearly the cause of premature delivery, but these cases are not that common. Here the fibroids grow considerably during pregnancy. Most do not, and even those that do grow are usually not a problem. But again, its impossible to predict which ones will be problematic.

Another problem is degeneration. If the fibroid grows quickly during pregnancy, it can outgrow its blood supply. This causes the center of the fibroid to die, and this can cause considerable pain. As a result, inflammatory substances are produced, and these can trigger premature delivery.

Throughout this post I have been somewhat fibroid sympathetic, but I need to be clear. Yes I believe that some myomectomies may be unnecessary. However, any fibroid needs to be taken seriously. I perform myomectomies. There is an important place for fibroid surgery.

Pros of myomectomy are that the surgery is rather routine. The procedure is not much different than a c-section. If there was any problem with pregnancy related to fibroids, the patient would have wished she had the myomectomy before getting pregnant. Therefore some would recommend having the surgery from the get go.

As usual, the main point here is do your homework, and get second opinions.
Please see disclaimer 5/17/06.

Dr. Licciardi

References:

  • American Association of Gynecologic Laparoscopists (AAGL): Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol. 2012 Mar-Apr; 19(2):152-71.
  • Giatras K, Berkeley AS, Noyes N, Licciardi F, Lolis D, Grifo JA. Fertility after hysteroscopic resection of submucous myomas. J Am Assoc Gynecol Laparoscopy. 1999 May; 6(2):155-8.
  • Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008 Apr; 198(4):357-66.
  • Munro MG. Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management. Obstet Gynecol Clin North Am. 2011 Dec; 38(4):703-31.