Can IVF Cause Cancer?
Today’s post addresses a question that I am often asked at the clinic – Can IVF cause cancer?
This concern very likely stems from a study done 12 years ago, which has since been well-publicised. It reported that the use of Clomid, which is a fertility medication widely used to treat ovulatory dysfunction in women, might increase the risk of breast and uterine cancer.
Understandably, this has caused some infertility patients to wonder if the treatments they will undergo are safe. Therefore, today I’d like to reassure you by providing references to other studies on the subject.
It’s important to note that since that study was first published, more studies have been conducted and most have found no significant link between Clomid use and cancer risk. One such study, which in fact offers the strongest evidence that Clomid and other ovarian-stimulating drugs do not increase the risk of ovarian cancer, comes from the Cochrane Review.
Published in 2013, the review looked at studies from 1990 to February 2013 that involved 182,972 women. The review not only found no evidence of increased ovarian cancer in women who use any fertility drug, but also pointed out that studies claiming there is an increased cancer risk were unreliable. This is because their sample sizes were too small for drawing conclusions and they did not take into consideration other potential risks for cancer.
For example, if a woman has never experienced pregnancy, her risk of cancer increases. Certain causes of infertility can also cause an increased risk of cancer, for example obesity, PCOS and endometriosis. So in fact, the increased risk of cancer noted in those studies may not be related to the medications at all.
In fact, ironically, some studies showed a decreased risk of developing breast and uterine cancer among infertile women on Clomid, in comparison to infertile women who did not seek treatment for infertility.
There are two other studies, with substantial sample sizes, which included 25,108 women from the Netherlands who received IVF treatment between 1980 and 1995, found that there was no increased risk of breast cancer. Another study, by the Institute of Child Health at University College London, which involved over 250,000 British women undergoing IVF between 1991 and 2010, also found no increased risk of breast or uterine cancer in those patients. However, they learned that IVF patients had a slightly higher risk of ovarian cancer – 15 in 10,000 odds, as compared to women who had never undergone IVF, who had 11 in 10,000 odds.
So as a consensus, from the studies quoted above and others like them, you can rest assured that fertility drugs like Clomid do not increase your risk of developing breast or uterine cancer. However, because infertility itself is a cancer risk factor, it is best that you undergo the necessary follow-up after your infertility diagnosis.
Should you have any concerns on the medications and treatments for infertility, please don’t hesitate to speak to your infertility consultant.
Endometrial scratching to improve IVF success rates
Couples who are struggling with infertility often seek In-Vitro Fertilisation (IVF) treatment in order to improve their chances of starting a family. But what happens when you have gone through multiple unsuccessful IVF cycles? Is there something else you can try?
Many patients who’ve experienced this first hand, have asked me this question, eager to try out something new to enhance their chances in the next IVF cycle. Therefore, today, I’d like to tell you more about a procedure called endometrial scratching, which has become increasingly popular in recent years.
What is it?
Endometrial scratching is a procedure that involves agitation of the endometrium, which is the mucus membrane that lines the uterus. For conception to occur, a fertilised egg has to successfully implant itself into the wall of the uterus. Sometimes, implantation fails, usually due to the quality of the embryo or the receptivity of the endometrium. In endometrial scratching, a fertility specialist passes a special thin catheter or pipille through a woman’s cervix. The pipille is then moved up and down to gently make tiny scratches or scrapes in the uterine lining. The similar effect can also be achieved by introducing a hysteroscope through the cervix to visualised the lining of the uterus during polyps removal.
Why is it done?
In theory, endometrial scratching is believed to trigger the uterus to repair itself and develop a new lining, which will be more receptive to an embryo implanting. While the effectiveness of the procedure needs further investigation, studies that have been done on endometrial scratching in recent years have shown encouraging results.
One such study was conducted by the University of Nottingham, UK, which involved 158 women who had undergone unsuccessful IVF procedures. The women were divided into two groups, with one group given the endometrial scratching procedure. As a result, they found the women who had undergone the scratching procedure achieved a 49% pregnancy rate, compared to 29% in the other group.
In another study involving 1000 women, presented at the annual meeting of European Society of Human Reproduction and Embryology (ESHRE), endometrial scratching is said to increase pregnancy success rates for couples trying to conceive naturally or with Intrauterine Insemination (IUI).
When is it done?
The endometrial scratching procedure is usually recommended for patients who’ve experienced multiple unsuccessful IVF cycles or Intracytoplasmic Sperm Injection (ICSI) treatment. The procedure is best performed prior to a woman’s period or right after the period. It is done before an IVF or frozen embryo transfer (FET) cycle begins.
Does it hurt?
While the endometrial scratching procedure has been described as generally painless, requiring no anaesthetic, some women do experience discomfort during and after the procedure. The pain is similar to period cramps and there may be slight bleeding afterwards. To help with possible discomfort, patients are advised to take over-the-counter pain medication about an hour before undergoing the scratching procedure.
If you’ve gone through several IVF attempts and are keen on learning more about endometrial scratching, take the next step and ask your fertility specialist if it is right for you.
What you should know about AMH
When you seek medical advice for infertility issues, one of the hormone tests that you be advice to take is the Anti-Mullerian Hormone or AMH test. This test measures the AMH levels in your blood, which helps doctors determine your ovarian or egg reserve.
In this post, I’ll explain what egg reserves and AMH tests are, as well as what you can do if your AMH levels are low:
About egg reserves
Humans are born with a limited amount of eggs. To be precise, a girl is born with between one to two million immature eggs or follicles in her ovaries. But not all these follicles will survive into adulthood. In fact, throughout a woman’s life, the majority of her immature eggs will die in a natural process called atresia.
Did you know that by the time a girl has her first period, only about 400,000 follicles are left? And with each subsequent period, she loses about a thousand follicles, while just one matures into an ovum or egg. This means, throughout her reproductive life, a woman will develop only about 400 ovum. The number of developing follicles a woman has left, is called her “ovarian or egg reserve.”
Egg reserves and the quality of those eggs vary from one woman to another, due to factors such as age and infertility. Over time, both the quantity and quality of a woman’s eggs gradually decreases. Therefore, when seeking treatment for infertility, it is important for a woman to gain insight into the remaining quantity of her egg reserve and fertile years.
What is AMH?
When follicles develop in a woman’s egg reserve, her body release the Anti-Müllerian Hormone (AMH). AMH levels, therefore, can give us a good idea of the state of a woman’s ovarian reserve. Since AMH levels are determined by the number of developing follicles in a woman’s ovaries, low AMH levels are an indication that the ovarian reserve is depleted.
Fewer developing follicles mean slimmer chances for a mature and healthy egg to be released and fertilised. As such, when a woman knows the state of her egg reserve, she can determine how urgently she requires treatment.
While egg reserves generally decline in the mid to late 30s, leading to low AMH, age is not the only factor. Environmental factors can also cause low AMH, such as cancer treatment and inherited genetic causes. AMH levels can be easily assessed with a blood test, but like most diagnostic tests, it has its limitations. For example, it cannot indicate the quality of the eggs that are left, which requires a separate test. However, as AMH levels remain fairly constant in a woman’s cycle, she can have the test at any time.
What Can’t AMH tells you
As much as we would like to believe that AMH is ‘the ultimate test’ for ovarian reserves, however, it only tells us some aspect of your fertility performances but not all. AMH does not tell you the quality of your eggs. Therefore, some women who have plenty of eggs and high AMH level may not perform well in an IVF treatment cycle because of poor egg quality.
For women who take oral contraceptive pills, AMH level may not be a true reflection of their ovarian reserves. Those who were taking the pill had 19 percent lower levels of AMH and 16 percent fewer early-stage follicles.
Recently, there has been clinical studies which reported that there is a significant variation in serum AMH levels across the menstrual cycle regardless of ovulatory status. This variability, although statistically significant, is not large enough to warrant a change in current clinical practice to time AMH measurements to cycle day/phase.
What you can do
If you should take an AMH test and find that your level is low, do not lose heart! Your AMH level is just one piece in a complex jigsaw puzzle. Your best course of action is to discuss matters with your infertility specialist. Ask your doctor how you can protect your egg count and health, as well as discuss the best possible solution to your problem. For example, DHEA supplementation and well-managed IVF protocols have been shown to be effective in improving IVF pregnancy rates in women with low AMH. Maintain a positive outlook and don’t give up on your dreams of having a baby!
Can IVF bring on early menopause?
One of the most common question patients like to ask about IVF is that whether the treatment itself will bring on Menopause earlier. This is probably by far one of the greatest myths about IVF which we would like to clarify.
A woman’s ovaries contain immature eggs sacs known as follicles, which have the potential of developing into mature eggs. However, most of these follicles will be lost without having fulfilled their purpose.
Women are born with millions of eggs in their ovaries. These eggs are quiescent in the ovaries until the women reach the age of menarche (when they get their first menses). At that time, the eggs in the ovaries started to come up after hibernating for 10-16 years. This is due to a pulsatile release of hormones from the organs below our brain called hypothalamus and pituitary. So, at the start of our menses, our ovaries will recruit around 10-20 eggs at one go. However, after the menses, our body will only choose one egg to grow. The rest of the eggs will regress and die off. With the help of our hormones, the particular ‘chosen’ egg with grow to a certain size and maturity, and then ovulation will occur. Hence, we only release one mature egg every menstrual cycle.
But of these many follicles, only one of them will become dominant and mature. The others that do not get a chance to mature and release an egg, will simply disintegrate and be lost in a natural process called atresia. The loss of these follicles during each menstrual cycle means that several undeveloped eggs are also lost.
Therefore, throughout a woman’s reproductive life, her ovaries will release only around 400 eggs, despite being born with millions of eggs. So basically, we ‘wasted’ around 12-20 each menstrual cycle, until the day when we reach menopause, whereby there is NO eggs in our ovaries
So if a woman can naturally produce only one egg per menstrual cycle? How do IVF specialists harvest several eggs at once?
For a woman who is undergoing an IVF treatment, the use of injectable fertility drugs (hormonal drugs) will stimulate her ovaries to overcome the natural tendency of choosing one dominant egg and ‘wasting’ other eggs produced during this particular cycle. In this scenario, the hormonal injections will stimulate all the eggs recruited during this particular cycle to grow simultaneously. Once these eggs reached a certain size and maturity, they are being harvested during an egg retrieval procedure
When a woman undergoes IVF, she will be prescribed with injections containing FSH. The amount given will be several times higher than what her body would naturally produce. This high amount of FSH will stimulate a lot more follicles than usual and help more of them to mature into eggs. An important thing to understand is that FSH will only act on the follicles that a woman’s body will naturally produce each month. Therefore, there is no depletion of the overall egg supply. And when those eggs are harvested during an IVF treatment, they have actually been spared from atresia that would have occurred during that menstrual cycle.
It is also important to note, that whether or not they undergo IVF, women who struggle with infertility are usually already at risk of having poor ovarian reserve and reaching early menopause. One of the tests that can be used to detect low ovarian reserve is the Anti-Mullerian Hormone (AMH) blood test. Egg reserves and AMH levels usually decline with age and can be affected by environmental factors such as cancer treatment or ovarian surgery, as well as inherited genetic causes, endometriosis, tumors, immunological conditions and high body mass index.
With that in mind, studies conducted by research teams around the world, including the British Fertility Society, Queensland University, Australia, and Cornell University, US have confirmed that IVF, even with multiple cycles, does not lead to egg depletion nor early menopause.
Having studied hundreds of IVF patients through the years, these researchers have concluded that IVF does not affect the timing or severity of menopause symptoms. In fact, many IVF patients reach menopause at the average age of just over 50, which is comparable to most national averages and closely resemble that of their own mothers’. The studies also found that most respondents had given birth to at least one child as a result of IVF.
Dr Helena Spoke against Child Marriage & Advocated for Women’s Right on TV2, ‘What Say You Programme’
The occurrence of identical twins after a single embryo transfer
Even after many years of being a doctor, it still brings me immense joy to announce to my patient that she is indeed pregnant following a successful infertility treatment. And sometimes, the happiness is multiplied, as there isn’t one, but two buns in the oven!
In general, it is widely known that the occurrence of multiple births is much higher following assisted reproductive technologies (ART) as compared to incidences of twins in natural or spontaneous pregnancies. This is directly related to the number of embryos transferred back to the uterus. In general, if 2 embryos are transferred back into the uterus, the chance of having twin pregnancies is around 20-30%. As we all know, twin pregnancies carries more risks to the expecting mother as well as the babies. The risks of miscarriage, bleeding in pregnancy, high blood pressure, diabetes in pregnancy, Placenta Praevias, Caesarean Sections are some of the significant obstetric risks. The babies are also at risk of preterm births, stillbirths and complications associated with preterm deliveries such as cerebral palsies.
Therefore, in many countries especially in the west, it is mandatory that the patients are informed of these risks before an embryo transfer. Some countries had restricted the number of embryos transferred to one. This move had significantly reduce the incidence of twins following an IVF and had reduced the economic burden associated with medical care of pregnancies associated with twins
However, in recent years, it had been reported that there is a higher incidence of identical twins following single embryo transfer.
While the incidence of fraternal twins following the transfer of two embryos is an easily understandable consequence of IVF, the causes for identical twins after ART remain speculative at best. However, there is some evidence that attributes the phenomenon to the micromanipulation techniques, length of culture and culture medium used during treatment, as well as the genetics of the parents.
Identical twins, also known as monozygotic twinning or MZT, occur when an egg and a sperm unite to form a single zygote that divides into two embryos or separate individuals. It is a rare phenomenon, which occurs in only about 1% of natural conceptions. However, in assisted conceptions, the occurrence of monozygotic twinning almost doubles.
The splitting of the zygote into separate embryos can occur at any time during the first 2 weeks after fertilisation. However, the timing of the split will influence the type of identical twin. For example, in around 1/3 of MZT cases where the split occurs within 72 hours of fertilisation, the result is two placentas and two amniotic sacs. In the remaining 2/3 of MZT cases, the splitting occurs 4-8 days after fertilisation, resulting in one placenta and two amniotic sacs. And in about 5% of MZT cases, where splitting occurs 8-13 days after fertilisation, the outcome is one placenta and one amniotic sac. In very rare cases, the outcome is conjoined twins.
Although the prospect of having twins is certainly exciting, couples must also understand that twin pregnancies are considered high risk. They can lead to various pregnancy complications with long-lasting and even permanent effects for the children. These include caesarean section, premature birth, low birth weight, Twin-Twin Transfusion Syndrome (TTTS), pre-eclampsia, gestational diabetes, fetal abnormalities and congenital abnomalies. In view of the complications that can arise from a twin pregnancy, do speak to your infertility consultant about the risks involved should you have any worries.