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Facts
of Life
Facts of Life:
Issue Briefings for Health Reporters
Vol. 11, No. 8
August 2006
By Becky Ham, Science Writer
Fertility Treatments: Fraught With Uncertainties
The Issue
The Facts
Infertility on the Internet
Expert Sources
References
The
Issue:
For 80 percent of couples trying to have a baby, pregnancy occurs within the first six months of having intercourse during a woman's fertile period. 1 But for others, the wait for a baby can be long and loaded with medical complications and uncertain outcomes. Increasingly, people who have trouble conceiving after one year and same-sex couples seek medical treatment. Although technologies such as in vitro fertilization dominate the headlines of reproductive medicine, 85 percent to 90 percent of infertility cases are treated with drugs or surgical repairs, according to the American Society of Reproductive Medicine. 2
Standards and Practices
Fertility treatment use has grown since the 1980s as the technology of reproductive medicine has advanced. Some researchers believe this growth may fuel demand for better regulation of the technologies and transparent reports of success rates. 3,4,5 Insurance coverage for the often-costly therapy is spotty; 15 states have passed laws requiring insurers to cover some form of fertility treatment. 6
Other Frontiers
Fertility treatments now include pre-implantation services, such as sorting embryos created in vitro by gender or performing single-cell biopsies of an embryo to diagnose potential birth defects and inherited diseases. Pre-implantation diagnosis is probably the most controversial aspect of fertility treatment, but the federal and state governments only indirectly regulate the procedures. 7 The potential to use surplus embryos in U.S. clinics for embryonic stem cells could bring further government scrutiny to fertility treatment.
The
Facts:
- Despite a plethora of small studies, there is still limited information on whether ovulation-inducing drugs such as clomiphene citrate increase the risk of cancers. 8
- A 2005 systematic review found no evidence that injecting sperm directly into the uterus (intrauterine insemination) is an effective treatment for overcoming cervical mucus problems that might lead to infertility. 9
- A 2004 systematic review of studies found no significant difference in pregnancy rates between women who received one or two intrauterine inseminations during their fertile periods. 10
- A 2005 review of studies suggests that single births conceived by in vitro fertilization have higher rates of premature birth, low birth weight and congenital defects compared to naturally conceived single births in similarly aged mothers. 11
- Nearly 95 percent of triplets and higher order multiple births conceived with the help of fertility treatments were low birth-weight babies, according to U.S. data from 2003. 12
- Rates of babies born from in vitro fertilization procedures are not significantly different from rates of live births from artificial insemination, according to a 2005 systematic review. 13
- Women who have fibroids inside the uterus have a significantly lower rate of implantation of an embryo during in vitro fertilization compared to those without fibroids. 14
- Soft catheters guided by ultrasound are associated with higher pregnancy rates than hard catheters for transfers of in vitro fertilization embryos to the uterus. 15
- Although studies show smoking can have a negative effect on in vitro fertilization success rates, few studies exist on the effects of other lifestyle factors such as stress, alcohol and caffeine. 16
- Men who have sperm DNA damage can father children through fertility treatments, but the damage decreases this likelihood, a 2004 review concludes. 17
- There is little conclusive evidence that antioxidant therapy (usually vitamin megadoses) is a beneficial treatment for male infertility. 18
- There is no evidence that treating varicocele, a network of distended blood vessels in the scrotum, can improve a couple's chances of conception, according to a 2004 systematic review. 19
- Evidence linking infertility and exposure to environmental contaminants is more conclusive for animals such as mice and frogs than for humans, according to a 2005 review. 20
Infertility on the Internet
"Free second IVF cycle" "Optimize sperm now." These are some of the first words to pop up onscreen when "infertility" is typed into an Internet search engine. Such promises are not uncommon on medical Web sites, but they may pose a special problem for people seeking fertility treatments -- which are often unsuccessful as well as expensive.
People who visit fertility treatment sites are looking for information on therapies, second opinions and support from an online community of fellow patients. 21 Bryan Cowan, M.D., a professor of obstetrics and gynecology at the University of Mississippi Medical Center, says many of his infertility patients use the Internet to gather basic information before treatment. "They're trying to get how the process goes and what it feels like, and then they try to figure out which clinic is the right place to go."
But the information on most of these sites has not been vetted by experts. "In the majority of fertility clinic or center Web sites, the contents are not reviewed by an editorial board," says Togas Tulandi, M.D., chair of reproductive medicine at McGill University in Montreal.
In their recent report on the quality of fertility clinic sites,22 Tulandi and colleagues looked at how well the Web sites met the American Medical Association's guidelines for Internet health information. Only 23 percent of the sites featured statements on patient privacy, which might actually be an overestimation, Tulandi says. "It has been shown in previous studies that although many health information Web sites state privacy policies, most of the Web sites do not follow them."
Tulandi says that patients are often afraid that information they send to site will be shared with others.
Accurate information is a must for infertility patients, who in most states must pay 100 percent of their own treatment costs. "Without insurance coverage, my patients are making economic decisions" as well as medical decisions, Cowan says.
Tulandi points out a recent study that showed people with lower incomes were more likely than those with high incomes to say that Internet searching influenced their choice of fertility clinic. 22
Tulandi and colleagues say professional organizations such as the American Society of Reproductive Medicine should offer guidelines for reproductive health information on the Internet. But Cowan says these associations shouldn't be in the business of offering a "seal of approval" to fertility treatment sites.
"It would mean that they would put themselves in a position to review every yellow page ad, every banner, all the things that people are trying to do to attract business. That's not their job, to act as policemen," Cowan says.
Still, Tulandi and Cowan say they encourage their patients to gather information on the Internet before coming their appointments.
Patients "much prefer an interactive conversation, but now they come in with better questions. I prefer that people come in with information, because it means that I can get right to the heart of things," Cowan says.
"In the past several years, patients have had more knowledge about their condition. This is a positive development," says Tulandi.
Expert
Sources:
References
1. C. Gnoth et al. (2005) Definition and prevalence of subfertility and infertility. Human Reproduction, 20, 1144-1147.
2. American Society of Reproductive Medicine Web site. "Frequently Asked Questions
About Infertility." Last accessed 7/21/06 at http://www.asrm.org/Patients/faqs.html.
3. A. Pinborg et al. (2004) What is the most relevant standard of success in assisted reproduction? Is there a single 'parameter of excellence'? Human Reproduction, 19, 1052-1054.
4. Ethics Committee for the American Society of Reproductive Medicine (2004) Fertility treatment when the prognosis is very poor or futile. Fertility and Sterility, 82, 806-810.
5. W.Y. Chang and A.H. DeCherney (2003) History of regulation of assisted reproductive technology (ART) in the USA: a work in progress. Human Fertility, 6, 64-70.
6. RESOLVE: The National Infertility Association Web site. "Fast Facts about Infertility." Last accessed 7/21/06 at http://www.resolve.org/site/PageServer?pagename=fmed_mcff_ffi.
7. K.L. Hudson (2006) Preimplantation genetic diagnosis: public policy and public attitudes. Fertility and Sterility, 85, 1638-1645.
8. L. A. Brinton et al. (2005) Ovulation induction and cancer risk. Fertility and Sterility, 3, 261-274.
9. F. M. Helmerhorst et al. (2005) Intra-uterine insemination versus timed intercourse for cervical hostility in subfertile couples. The Cochrane Database of Systematic Reviews, Issue 4.
10. C. Osuna et al. (2004) One versus two inseminations per cycle in intrauterine insemination with sperm from patients' husbands: a systematic review of the literature. Fertility and Sterility, 82, 17-24.
11. S.D. McDonald et al. (2005) Perinatal outcomes of singleton pregnancies achieved by in vitro fertilization: a systematic review and meta-analysis. Journal of Obstetrics and Gynaecology Canada, 27, 449-459.
12. V.C. Wright et al. (2006) Assisted reproductive technology surveillance--United States, 2003. Morbidity and Mortality Weekly Report. Surveillance Summaries, 55, 1-22.
13. Z. Pandian et al. (2005) In vitro fertilisation for unexplained subfertility. The Cochrane Database of Systematic Reviews, Issue 2.
14. C. Benecke et al. (2004) Effect of fibroids on fertility in patients undergoing assisted reproduction. A structured literature review. Gynecologic and Obstetric Investigation, 59, 225-230.
15. E.G. Wood et al. (2000) Ultrasound-guided soft catheter embryo transfers will improve pregnancy rates in in-vitro fertilization. Human Reproduction, 15, 107-112.
16. H. Klonoff-Cohen (2005) Female and male lifestyle habits and IVF: what is known and unknown. Human Reproduction Update, 11, 179-203.
17. A. Agarwal and S. S. Allamaneni (2004) The effect of sperm DNA damage on assisted reproduction outcomes. A review. Minerva ginecologica, 56, 235-245.
18. A. Agarwal et al. (2004) Role of antioxidants in treatment of male infertility: an overview of the literature. Reproductive Biomedicine Online, 8, 616-627.
19. J.L.Evers and J.A. Collins (2004) Surgery or embolisation for varicocele in subfertile men. The Cochrane Database of Systematic Reviews, Issue 3.
20. E.V. Younglai et al. (2005) Environmental and occupational factors affecting fertility and IVF success. Human Reproduction Update, 11, 43-57.
21. J.Y. Huang et al. (2003) Internet use by patients seeking infertility treatment. International Journal of Gynecology and Obstetrics, 83, 75-76.
22. J.Y. Huang et al. (2005) Quality of fertility clinic websites. Fertility and Sterility, 83, 538-544.
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2006, Center for the Advancement of Health
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