Unexplained infertility is by far the most frustrating of all conditions I see. To get this diagnosis, all the testing patients have undergone show that everything is normal. There are adequate sperm for the male, and female patients seem to be ovulating or “making eggs.” The “plumbing” has been checked through an ultrasound and hysterosalpingogram, or “dye test,” and there are no abnormalities. We cannot find a medical reason for failure to conceive. 

I have sat before many patients with this diagnosis, including many that are in the medical profession, and the look of utter frustration is intense. They say “Everything checks out, so why won’t it all work?” The fact is that as many as 20 to 30 percent of all the patients we treat for infertility are not truly explained. The patients look to us for a treatment plan, but what are we treating? Doctors, as a general rule, like to know what and why they are doing things before they do anything. But unexplained infertility defies that rule because the lack of a plan of action is unacceptable. So, we need guidelines.

Clearly, if you do not know what you are treating then anything you do is empiric. In other words, we will rely on observation and experience rather than clear cut science. The general rule is if the woman is 35 or younger, and there is a normal semen analysis, doctors should provide Intrauterine Insemination (IUI) three times. That yields about a 30 to 35 percent overall pregnancy rate after three attempts. 

If IUI fails, you move on to IVF for 3 attempts. The combined IUIx3/IVFx3 yields between 85 and 90 percent success rate. But, if the semen analysis is significantly abnormal, or if the woman is older (or there is evidence of a diminished egg reserve), you should recommend going straight to IVF. 

Obviously, patients have choices. There have been many patients who have insisted on trying IUI first, and some who wanted to skip the IUIs and go straight to the most effective tool we have, In-Vitro Fertilization. Medical ethics dictate that the choice must be made by affirming “patient autonomy” and the “Doctor’s Beneficence.” That means the patient should be involved in making the choice, but the doctor can only do what has a real chance of working.

Before I initiate a treatment plan, I review the history closely, especially the family history. It is my experience that many unexplained infertility patients are in fact getting pregnant, but they are miscarrying and do not know it. Incredibly, a study showed that probably 70 percent of all pregnancies never make it. The woman may get her menstrual cycle on time or may not. It may come a few days late, the patient may feel that the breasts are tender and may think to themselves that it doesn't come tomorrow I will run out and buy a pregnancy test. Then the menstrual cycle starts. 

In other words, I believe that many of these patients are in fact getting pregnant but repeatedly losing pregnancies. Recurrent pregnancy loss, however, is the subject of an entire different blog. Regardless, I very often if not always look at the possibility that the patient is experiencing recurrent pregnancy loss. It’s extremely important - imagine finding out you have a treatable recurrent miscarriage condition after losing viable IVF pregnancies. 

Unfortunately, no doctor can find answers for every patient. Sometimes unexplained infertility, despite our best efforts and the use of the latest technology and tests, stubbornly remains unexplained. For those patients, gestational carriers or adoption may be their best paths to parenthood. As disappointing as this can be, the good news is that more than 50,000 people in the U.S. every year become parents through these methods. The path to parenthood can be a rocky one, and those who battle unexplained infertility certainly have among the rockiest of journeys, but in most cases there can be a happy ending.

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It’s another week and another “IVF linked to cancer” study: a recent study from the Netherlands has raised the possibility that in vitro fertilization may heighten the risk of ovarian cancer in patients who have undergone the fertility treatment. Obviously this is going to cause great concern in a large and growing population of patients who've accessed advanced reproductive care – but as always, I’m urging caution as you consider this study.

First, it is important to state that the researchers thought the results were preliminary only and recommended that much larger studies be done. In other words, there is no confirmation yet that this risk is in fact true. Secondly, it is important to remember that women who never give birth in their lifetimes (i.e. nulliparous) are at increased risk for ovarian cancer. Pregnancy, as well as birth-control pills, actually helps protect women from this deadly disease. In fact, women who have a strong family history of ovarian cancer are actually advised to be on birth control pills until they bear children. Once they are done having children, I usually recommend that these women undergo a preventative removal of their ovaries. 

So is there cause for concern? The first question to consider is if there is biological plausibility to the idea that IVF can cause ovarian cancer – and there is biological plausibility. The current thinking about certain types of ovarian cancer is that it occurs because of the “injury theory” – if the ovary is incessantly exposed to ovulation, it increases the risk of cancer. Again, birth-control pills help reduce the risk because most women don’t ovulate while on the pill, and pregnancy also helps for the same reason. With IVF, we put a needle into the ovary to retrieve eggs, which in theory causes an “injury” to the ovary. Does this mean we should stop doing IVF? And, does this mean that women who cannot bear children should stop the attempts to build the family? I don't think so.

In my opinion, we should do more research to see if this risk is real. If a concrete link is found, then current IVF protocols will need to adjust. There are some very simple adjustments that can be made, such as putting women back on the pill if they complete an IVF cycle and don’t get pregnant. Also, we can closely monitor women post-IVF for ovarian cancer with yearly ultrasounds and (although some disagree) the CA 125 blood test.  

My final thoughts on this topic are that, with anything in medicine, there is always the potential for side effects, and unfortunately sometimes those side effects can be serious. Diligent, ongoing study to continuously refine and improve our treatments, diagnostic tests and overall medical care are absolutely vital and must be continued around the world. I know I’ll be following ongoing studies very closely, but I certainly would not discourage anyone from pursuing their dream of having a baby because of one preliminary study.

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I’ve been following the events surrounding E! News personality Giuliana Rancic’s recent diagnosis of breast cancer with much concern. There is so much at stake here for women trying to build a family, and Ms. Rancic’s unfortunate diagnosis could be used to confuse many people. 

Obviously I hope all goes well for Ms. Rancic. For those unfamiliar with her story, Ms. Rancic’s fertility specialist ordered a mammogram for what appears to be screening purposes and found what is believed to be an early cancer in a 36-year-old woman who had undergone IVF twice before. This raises two questions that need to be addressed. First, did the IVF cause her breast cancer? The answer is no. Fertility treatments do not increase the risk of breast cancer. In fact, successful fertility treatments could potentially lower the risk if the mother breastfeeds. A number of studies have shown that breastfeeding reduces the incidence of breast cancer. By helping facilitate a successful pregnancy, we can help women access this proven preventative measure as well as the dream of family. There is no convincing data that proves that fertility treatment increases the lifetime risk, although the researchers are diligently following this.

The second question is much more serious and potentially controversial: can fertility treatments accelerate early, as yet undetected, breast cancers? I searched the literature and could not find any definite proof that this is true. But, the pragmatist in me has to admit that this concern has a lot of biological basis to be concerned. For example, breast cancers very often have receptors for estrogen and progesterone, two hormones that rise dramatically during fertility treatments and the subsequent pregnancy. In fact, cancers discovered after a recent pregnancy are associated with a poorer prognosis, but ironically these are cancers that lack these receptors. 

So we know that pregnancy can worsen a diagnosis of breast cancer, even though the treatment to get pregnant may not. As many of our patients are older and requiring help to conceive, I think it is fair to assume that we could be accelerating or worsening the prognosis of an as yet undiagnosed breast cancer. How do we best help our patients with this issue? Mammograms are the obvious screening tool, but unfortunately, debate rages over when women should begin mammogram screening. The U.S. Preventive Services Task Forces recommends breast cancer testing start at age 50, although the American Cancer Society advises yearly mammograms beginning at age 40 for women with an average risk. Some earlier studies even suggested age 35. I believe that any patient who is at increased risk, (i.e. family history) be screened, perhaps as early as age 30. Perhaps we need to screen everyone who goes through IVF treatment, and certainly those ages 35 and older; however, the benefit of this is again controversial.

Giuliana Rancic’s diagnosis has certainly brought this important issue to the forefront, but I’m not happy with the fact that this story is fodder for all those constantly looking for ways that advances in medicine can hurt us. The sensationalist press also will irresponsibly try to raise fear solely to increase their readership. At the end of the day, we need to realize that there are no free rides, no sure things, and no easy answers in medicine. Drugs have side effects and surgeries have complications. IVF has helped millions of people around the world, and we must stay diligent to make sure the risks are minimized. 

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If you’ve been following this blog or Fertility Partnership, you probably know that I created this clinic specifically to help as many people as possible have the baby of their dreams at the most affordable cost that  I could provide. I’m proud of the success we’ve had in doing that since we opened in December 2009; most notably, not only has Fertility Partnership offered IVF approximately 30 percent lower than the national average, but other St. Louis area fertility clinics have lowered their price since we entered the market. 

I am always looking for opportunities to make fertility treatments even more accessible, so that’s why I am excited to announce that Fertility Partnership will be giving away one free IVF cycle at the Midwest Infertility Awareness (MIA) Conference on Saturday, Nov. 12. The package we’ll be giving away is valued at more than $9,000 and will be handed out at the end of the conference to one attendee who must be present to win. 

For more details or to register for the conference, please visit the MIA website or Facebook page. I’ll be at the conference as well, and I’m looking forward to meeting as many of the attendees as possible as well as speaking at the event. I hope to see you there, and I look forward to meeting the winner of the IVF cycle giveway.

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Recently, yet another major article was published in the fertility literature that demonstrates the negative impact of being severely obese on infertility treatment outcomes. Piggybacking on that, Canada is currently debating whether obese women should even be allowed to undergo In Vitro Fertilization (IVF). As we have long known, being extremely obese (i.e. a BMI over 50) greatly impacts a woman’s chances to conceive. Obesity reduces the body’s ability to respond well to fertility medications, can make egg retrieval a nightmare, reduces the pregnancy rate after IVF, and increases the possibility that the woman will miscarry. 

So now what? Do we just tell overweight women that they are out of luck unless they can diet and exercise, throwing guilt into the frustration and sadness that they already have regarding their inability to conceive? The reality is that most of these women have dieted and tried to control their weight for many years. In fact, many have a metabolic condition that makes it extremely hard to lose weight. 

So what is the best way to help these heavy ladies? Weight loss, exercise, and diet plans work for some, but even with the motivation brought on by their desire to have a baby, they rarely can acheive the goals. It also takes time to institute lifestyle changes, which is a big problem when you’re talking about having a baby. In many cases, time is of the essence, since egg quality and quantity decline so rapidly after age 30. How do we get these patients to lose weight quickly in order to proceed to fertility management? 

There are number of approved prescription medications available that currently are in use. Some have been used and reported in the fertility literature, but the only drug I have found useful is phentermine, of Phen-Fen infamy. Go with me for a moment on this. In the Phen-Fen debacle, the treatment regimen included two drugs: fenfluramine which tragically caused some fatalities and is rightfully off the market; and phentermine, which has been on the market for over 40 years and has been shown to be very useful with rapid weight loss. 

Unfortunately for patients, however, the use of phentermine is largely vilified in the medical community. Why? In my opinion, it is frowned upon because it is perceived as a quick fix and, while results will include rapid weight loss, the dependence on a drug rather than lifestyle changes virtually guarantees the weight will go right back on post-medication use.

Most doctors probably think, “What's the point of using a weight loss drug if the patient will gain it all back right soon after?” But in the field of fertility, that’s really exactly what I’m trying to achieve with my patients. I want my patients to lose enough weight to successfully and safely get pregnant, then gain weight (albeit carefully and by making healthy choices) as their baby grows. 

Under the watchful eye of a careful doctor, phentermine can work very well. A well motivated patient who exercises 3 times a week for 30-40 minutes, watches carbohydrate intake and takes the prescribed dose of phentermine daily can lose 40 pounds or more in six months. Many patients who typically do not ovulate on their own will start to do so after losing that much weight, and some even conceive spontaneously. 

Is phentermine safe? Yes. I have now had over 500 patients on a regimen that included phentermine and have found many of the bad press the drug has received to be unfounded. Other than the annoying side effects of “cotton mouth” and constipation, my patients have done extremely well with short-term, carefully monitored use of the drug.

There is no doubt that if you are very overweight, your fertility journey is going to be harder and less successful. Instead of turning you away, however, as some other infertility clinics do, Fertility Partnership will work with you to safely and effectively manage your weight and help you get pregnant. We have seen great results from our philosophy that well-supervised weight loss programs - which include the short-term use of medications like phentermine - are very successful in getting the weight off quickly in preparation for achieving the dream of having a baby.

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