by Dr Gavin Sacks | Apr 9, 2019 | Blog
In January 2019, there was an excellent randomised trial published on endometrial scratching prior to IVF.
This procedure goes back many decades when women had a curette and many seemed to be more fertile afterwards. The idea of a scratch as a more refined procedure was taken up enthusiastically but this latest excellent study suggests that it should not be used so widely. However, we must also remember that the uterus is an essential place for the pregnancy to develop and we must always be thinking about its suitability for embryo implantation.
This requires some kind of examination and the benefit to IVF may be more complex than simply scratching the lining. For example, the passing of a catheter or tube through the cervix to dilate the cervical canal can make embryo transfers easier or can help the Clinician in determining whether there is a problem in the cervix. Many scratch biopsies are done in the context of a hysteroscopy when other important problems such as polyps or adhesions or uterine congenital abnormalities can be discovered and treated.
Furthermore, an embryo scratch biopsy can also be used for tissue diagnosis for critical factors such as hyperplasia, endometritis and immune studies.
Clearly, the routine undertaking of the scratching went too far and it would be wrong to think scratches should be done prior to every cycle as this data shows. Equally though, especially in those with repeated IVF failure, further exploration of the uterus is essential. It should be done on a limited number of occasions and the Clinician should try to obtain as much information as possible from such an invasive procedure.
In summary, a scratch should be reserved for those that repeat IVF failure and then as part of a wider assessment.
Original article by medical reporter Sophie Scott
IVF scratching: Are women putting themselves through a painful procedure for nothing?
Key points:
- A global study found endometrial scratching is not effective in boosting fertility in IVF
- Patients are charged up to $700 for the add-on treatment
- The IVF peak body says doctors should stop recommending it to couples
Michelle Ross would have done anything to have a second child.
After enduring years of heartbreak and disappointment, the 33-year-old finally turned to IVF for help.
“I lost eight babies in 12 years. We had tried for so long. We were happy to do anything we could to get pregnant,” she said.
She said doctors told her it was unlikely she would have another baby because she had severe endometriosis.
When she was told a painful procedure called endometrial scratching might boost her chances of conceiving, she did not hesitate.
“They told me the scratching made the uterus more sticky during IVF,” she said.
A doctor inserted a catheter into Ms Ross’s uterus and used it to superficially wound the lining.
The theory is that the scarring causes inflammation, which makes it easier for embryos to implant in the uterus.
Ms Ross described endometrial scratching as eight out of 10 on the pain scale.
“I was in pain for a week,” she said.
She got pregnant a month after the procedure, and went on to have a healthy baby girl she named Jessica.
But a new global study has cast doubt on whether the procedure played any role in Ms Ross’s successful pregnancy.
Experts find no evidence that endometrial scratching works
A group of fertility researchers from around the world compared the number of live births from women who underwent endometrial scratching to those who didn’t.
Of the 1,364 women studied, 180 women had babies in the group that had endometrial scratching, while there were 176 births in the control group.
Researchers concluded that the procedure, which is widely offered by clinics across Australia, did nothing to boost a woman’s chances of getting pregnant through IVF, describing it as “painful and pointless”.
Study lead Professor Cindy Farquhar from the University of Auckland said it was clear the procedure did not boost a woman’s chance of giving birth.
“On the basis of this study — which is the biggest and most robust to date — we would encourage IVF clinics to stop offering it,” she said.
The research has been published in the prestigious medical journal, the New England Journal of Medicine.
More than 80 per cent of Australian fertility clinics offer endometrial scratching, usually to couples who have failed to get pregnant after several rounds of IVF.
The procedure can cost up to $700.
“This study provides the opportunity to tell patients that the evidence doesn’t stack up,” said Louise Johnson, head of the Victorian Assisted Reproductive Treatment Authority (VARTA).
VARTA offers support and information to couples struggling with fertility.
Ms Johnson believes many would-be parents are desperate for success, and may put themselves through dubious procedures in a bid to get pregnant.
“Couples going through IVF are extremely vulnerable, and clinics have an obligation to inform patients about treatments that can cause pain and won’t increase the chance of conception,” she said.
Obstetrician Professor Ben Mol from Monash University said doctors had been offering couples the scratching procedure for many years, despite a real lack of strong scientific evidence that it worked.
“It is great news that we now know that this technique does not help,” he said.
“Luckily, we didn’t find it caused any harm, apart from bleeding and pain.”
He said other add-on IVF treatments such as steroids and treatments to reduce immune cells in the uterus should also undergo better evaluation.
“The concern is that there are more of these add-on therapies offered without a sound scientific base, and many will turn out not to be effective once properly evaluated,” he said.
IVF peak body says it should no longer recommend the scratch
Professor Luk Rombauts from the Fertility Society of Australia, which represents medical staff working in fertility clinics, said the study findings will change what advice is given to IVF patients.
“I would no longer recommend [endometrial scratching] for patients who come through the door for IVF,” he said.
However Professor Rombauts said some patients who had already had the scratching before becoming pregnant through IVF may still want it.
“I would like to think doctors would tell patients about the risks and benefits and the best available evidence,” he said.
“Patients often read a lot online about possible IVF treatments and we will need to educate our patients about this new evidence.”
Ms Ross said she would never know for sure what impact the scratching procedure had on her body, but believed it helped her conceive.
“I really don’t know if it helped, but I would ask for it again if I ever had IVF again,” she said.
by Dr Gavin Sacks | Sep 7, 2017 | Uncategorised
Written by CLAUDIA TANNER FOR MAILONLINE
- Sufferers of the common condition can develop insulin resistance
- Study found women with PCOS are diagnosed with diabetes 4 years earlier
- Average age for those with ovary condition to be diagnosed with diabetes was 31
- Screening for diabetes is important in women who are obese and have PCOS
Women with polycystic ovary syndrome (PCOS) have a quadrupled risk of developing type 2 diabetes, a new study has found.
It was already known the common condition – which affects an estimated one in every five women – can cause insulin resistance, a risk factor for the potentially deadly disease.
But the link with PCOS – which causes irregular periods, acne, weight gain and fertility issues – and the metabolic condition has not been thoroughly researched.
Now, scientists have quantified the increased risk and discovered that women with the ovary-related illness are on average diagnosed with diabetes four years earlier than other patients.
In the study, the average age of a diabetes diagnosis for those with PCOS was 31.
‘Many women with PCOS are obese, but the risk for the development of diabetes in PCOS is unknown,’ explained one of the study’s authors, Dorte Glintborg, from the Odense University Hospital in Denmark.
‘The increased risk of developing T2D [type 2 diabetes] in PCOS is an important finding.
‘Diabetes may develop at a young age and screening for diabetes is important, especially in women who are obese and have PCOS.’
Key findings of the study
The team studied more than 19,500 pre-menopausal Danish women with a diagnosis of PCOS.
The women with PCOS were then compared with other females of a similar age who did not have PCOS, nor a previous diagnosis of type 2 diabetes.
The researchers found that women with PCOS were four times more likely to develop diabetes compared to their counterparts who did not have the condition.
They also discovered that higher body mass index, insulin and glucose levels and triglycerides (fat in the blood) were also associated with development of diabetes.
Exactly how can PCOS lead to diabetes?
Insulin is a hormone that controls sugar levels in the body. When women with PCOS become resistant to the action of insulin, the body tries to cope by producing more of it.
This causes glucose to build up in the blood, which can cause high blood sugar levels. This can lead to the development of type 2 diabetes, which occurs when the pancreas cannot secrete the insulin required to maintain normal blood glucose levels.
High levels of insulin cause the ovaries to produce too much testosterone, which interferes with normal ovulation.
Insulin resistance can also lead to weight gain, which can make PCOS symptoms worse, because having excess fat causes the body to produce even more insulin.
Diabetes can cause complications including kidney failure, heart disease and stroke. As type 2 diabetes usually gets worse, you may eventually need medication – usually tablets – to keep your blood glucose at normal levels.
There’s no cure for PCOS. If you have the disorder and you are overweight, losing weight and eating a healthy, balanced diet can make some symptoms better, advises NHS Choices.
Medications are also available to treat symptoms such as excessive hair growth, irregular periods and fertility problems.
Read more: http://www.dailymail.co.uk/health/article-4844450/Women-PCOS-4-times-likely-diabetes.html#ixzz4wwm6G1RT
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by Dr Gavin Sacks | Sep 12, 2016 | Blog
This article is an important part of an ongoing debate about immune therapy. See my previous article on this (“Enough! Stop the arguments and get on with the science of natural killer cell testing”). It is definitely clear and accepted by most specialists that prednisolone does not improve outcomes for everyone. One reason could be that that while some benefit, some (as described in this article) are harmed (or their chances are decreased). Hence the need for highly specialised immune testing to try to target this therapy to those who are most likely to benefit. Tests such as NK cell testing are technically far more difficult than is often realised, and considerable effort needs too be done by the lab to produce a reliable result with a meaningful reference range. Very few labs in the world are currently able to offer that.
– Dr Gavin Sacks
Researchers at the University of Adelaide are urging doctors and patients to refrain from using a specific steroid treatment to treat infertility in women unless clinically indicated, because of its links to miscarriage, preterm birth and birth defects.
Writing in the journal Human Reproduction, researchers from the University’s Robinson Research Institute, led by Professor Sarah Robertson, say widespread use of the drug is not warranted, given there is a high degree of suspicion that corticosteroid drugs – such as prednisolone – can interfere with embryo implantation, and may have harmful effects on pregnancy and the child.
Corticosteroids are increasingly used to treat infertility in women with repeated IVF failure and recurrent miscarriage. Many women receive the drug in the belief that reducing immune cells called “natural killer” cells will facilitate a pregnancy. However, this belief is mistaken, as despite their alarming name these cells are actually required for healthy pregnancy.
Professor Robertson says there is a great deal of medical and consumer misunderstanding about the role of the immune system in fertility and healthy pregnancy.
“Steroid drugs such as prednisolone act as immune suppressants, preventing the body’s immune system from responding to pregnancy. But by suppressing the natural immune response, these drugs may lead to further complications,” Professor Robertson says.
“The immune system plays a critical role in reproduction and fertility. Natural killer cells and other immune cells help to build a robust placenta to support healthy fetal growth. But if we suppress or bypass the body’s natural biology, there can be dire consequences that don’t appear until later,” she says.
“For example, suppression of the immune system through inappropriate use of these drugs is linked to impaired placental development, which in turn elevates the risk of miscarriage, preterm birth and birth defects.”
Research shows that women taking corticosteroids over the first trimester of pregnancy have a 64% increase in miscarriage; the risk of preterm birth is more than doubled; and their children have an elevated risk of birth defects, including a 3-4 times greater risk of cleft palate.
“Our main message to clinicians and to women hoping to achieve pregnancy is that they should be focused on achieving good-quality pregnancy and the life-time health of the child, not just getting pregnant,” Professor Robertson says.
“Corticosteroids such as prednisolone may impair healthy pregnancy, which may lead to poorer long-term outcomes for the baby.
“We believe IVF doctors should not be offering this treatment to most patients, and should discuss concerns with women who request it.
“The exception would be in specific cases where the patient has a diagnosed autoimmune condition, but those cases are rare,” she says.
Explore further: Study finds variation of the interval between first and second pregnancy
More information: Sarah A. Robertson et al. Corticosteroid therapy in assisted reproduction – immune suppression is a faulty premise, Human Reproduction (2016). DOI: 10.1093/humrep/dew186
by Dr Gavin Sacks | Sep 10, 2016 | Blog
This exciting concept involves harnessing mitochondria from a woman’s ovary (from a biopsy at laparoscopy) and then injecting them into an egg during the ICSI procedure. Mitochondria are the main energy drivers in all cells, and it is believed that such a boost may improve egg quality. It is so new that fewer than a hundred cases have been reported so far, but Dr Sacks is collaborating with the company involved and they are hoping to bring this technology as a trial to Australia soon.
– Dr Gavin Sacks
Groundbreaking research presented in Perth could pave the way for older women to have babies by “freshening up” their ageing eggs.
Canadian reproductive endocrinologist Robert Casper yesterday revealed progress into so-called ovarian rejuvenation, where doctors use healthy young cells from the ovaries to re-energise a woman’s eggs.
The main obstacle for women in their 40s to become pregnant is that they are born with all their eggs, which deteriorate over time.
But doctors believe they can turn back the clock by using egg precursor cells harvested from tiny pieces of tissue removed surgically from the outer edge of the woman’s own ovaries.
The tissue can be quickly frozen and then thawed to isolate active mitochondria, which are the powerhouse of cells.
Professor Casper told a Fertility Society of Australia conference that a woman’s eggs fell in number and quality in a way that could be likened to a torch being left on a shelf for 40 years.
“That’s about the time it takes for a woman to expire the number of eggs with which she was born,” he said.
“Using the flashlight analogy, the torch itself is OK but the batteries are running flat.
“The focus of our research is on energising old cells, by adding younger and more powerful mitochondria collected from precursor cells lining adult ovaries.”
Professor Casper said the technique would allow a woman with poor egg quality to use her own energised eggs for in-vitro fertilisation.
Researchers initially used the technique on mice to prove it worked, before adapting it for women on IVF programs in Toronto who had failed to conceive because of poor embryo development.
Using the women’s own egg precursor cells, they were able to help many of the women conceive and have healthy babies.
Professor Casper said he hoped the new technique would help more older women and those with premature ovarian ageing to have children.
Article originally posted on The Western Australian on September 8, 2016. Written by Cathy O’Leary.
