Wednesday, October 26, 2011

Does it make any sense to use IVF to treat recurrent pregnancy losses

One of the most frustrating problems to treat in reproductive medicine today is that of recurrent pregnancy loss. This is frustrating for both patients as well as for doctors because we have many questions and very few answers . Because we often cannot determine the reason for the pregnancy loss in an individual patient , we often end up grappling in the dark. What makes matters even more confusing is the fact that this frustrating condition has a surprisingly high spontaneous cure rate ! This seems completely counterintuitive , but many studies have shown that even women with three or four repeated pregnancy losses for unexplained reasons have a better than 75 percent chance of having a healthy baby, even if they are treated only with tender loving care. This means that practically any treatment is likely to give gratifying results. This is why there are so many potential treatments for this problem, and why every doctor swears by their own particular preferred remedy.

Since we are not very good at pinpointing what the exact problem is in an individual patient, we are forced to rely on medical experience in order to treat these patients. This is called empirical therapy. There are many kinds of empirical therapy ranging from low-cost treatment with low-dose aspirin all the way to extremely expensive and complicated treatment using intravenous immunoglobulins and lymphocyte immunization therapy.

One of the treatment options for these patients is that of IVF. This may seem quite surprising, given the fact that most of these patients have no difficulty conceiving on their own. After all, if they can get pregnant on their own and if the problem is that they cannot carry the pregnancy beyond 12 weeks, then how on earth is IVF going to help them ? What sense does this make ?
Interestingly , we do know that the commonest reason for a miscarriage is a genetic problem in the embryo ; and that a miscarriage is usually nature's defense mechanism to prevent the birth of the normal baby. This is why recurrent miscarriages are common in older women. They have poor ovarian reserve, also known as oopause, because they have older eggs which contain more genetic abnormalities because they have aged in vivo. Theoretically it's possible to use IVF to help them to grow better quality eggs and better quality embryos. It's possible that super ovulation , as well as treatment with supplementation such as DHEA , helps to improve ovarian reserve and therefore helps them grow better quality eggs, which are more likely to be genetically normal and give rise to genetically normal embryos.

Also, since there is much more aggressive luteal phase support given during an IVF cycle, IVF treatment can help to prevent recurrent miscarriages which are a result of hormonal problems .
One of the biggest advantages of IVF is that it allows patients to telescope time. If they continue to try in the bedroom, they would produce just one embryo every month . Whether or not this embryo would be genetically normal is purely a random matter of chance . Doing IVF allows the doctor to superovulate the woman , and therefore create multiple embryos at one time. Since we allow these embryos to compete amongst themselves, we can then select the embryos which grow the best. There is evidence to show that rapidly developing blastocysts have a better chance of being chromosomally normal as compared to slowly growing embryos.

For the future, as the technology for embryo biopsy and comparative genomic hybridization improves, we will be able to treat these patients with a much more scientifically sound basis. Doing an embryo biopsy will allow us to identify the chromosomally normal embryos and then selectively transfer only these embryos , thus systematically reducing the chance of a miscarriage because of genetic abnormalities.

For now , however , the fact remains that there are still lots of unanswered questions. One advantage of doing IVF is that it helps patients to have peace of mind that they have taken advantage of whatever reproductive technology is available, even though it does have its limitations.

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1 comment:

  1. hi Dr,

    I've done IVF twice, both instances, out of 7 eggs I got only 2 embryos. 1st IVF day 2 transfer, 2nd ivf day 3 transfer. Both times it did not work out.

    I'm 33, PCOS condition. hubby 34, low sperm count.

    I controled my insulin levels before 2nd ivf. still there's not much of a difference in results.

    How can we both improve our chances? ie what can we do to improve egg and sperm quality?

    Thank you

    ReplyDelete

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