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Surgical options should be considered before clinicians offer women in vitro fertilisation (IVF), experts recommended at a conference last week on obstetrics and gynaecology.
In vitro fertilisation is not a “universal panacea” for all fertility problems, said William Ledger, professor of obstetrics and gynaecology at the University of Sheffield.
He showed data from York University Health Economic Consortium on the most cost effective preferred solution for infertility. Out of tubal disease and endometriosis, anovulation, male factor, and unexplained infertility, in vitro fertilisation came out top for only severe tubal disease and endometriosis.
“The media's fascination with IVF is as if there is no other option,” he said. “Many patients pick that up, and you have to try to convince them to try something else because they think, ‘I'm infertile, I have to do IVF.' This is not the case. In an audit of our practice in Sheffield only just over half of the pregnancies we had in a year were IVF, the rest come from these easier techniques.”
The problem is that many junior doctors won't get sufficient training to carry out techniques such as surgery for adhesions or fibroids in the future he told delegates.
“My concern is that if we don't train younger doctors in these techniques, they will disappear and all we will have to offer is IVF.”
Nor was preimplantation genetic screening the solution for improving live birth rates in older women, Peter Braude, head of women's health at St Thomas's Hospital, in London, pointed out.
Results from a recent study on the use of the technique in 408 women undergoing three cycles of in vitro fertilisation with or without preimplantation genetic screening found that only 49 had live births in the preimplantation genetic screening group compared with 71 in the group who had not had screening (New England Journal of Medicine 2007: 357:9-17 doi: 10.1056/NEJMoa067744).
Taking a biopsy of embryos before transferring the best ones subjected them to more interference, he said. If transferred back to the uterus without screening, some embryos with minor abnormalities would go on to develop normally anyway.
Preimplantation genetic screening is increasingly being requested by women for whom it is not clinically necessary, noted Roger Gosden, a professor of reproductive medicine at the New York-Presbyterian Hospital, in the United States. He had patients younger than 30 years old asking for it.
His talk focused on the preservation of fertility in patients who had had their reproductive systems compromised in treatment through illness.
“There is a rising awareness of this among patients. Haematologists and oncologists are concerned about any liability for them if they don't tell patients that there is a technology that might help them because their treatment might sterilise them,” he said.
He categorised various treatments as high, medium, low, and very low risk of permanently or temporarily damaging fertility—with chemotherapy treatments such as cyclophosphamide at the top and antirheumatic drugs such as methotrexate at the bottom.
For women who did go on to have children, he was concerned about lack of long term follow-up because the implications of such treatments for offspring were not known.
Older studies of the children of patients who had had cancer had reassuring results, he said, but added, “These drugs are mutagenic, so it is very likely that there will be some damage that has not destroyed a resting egg or spermatagonial stem cell. It is going to be recessive, but the genetic burden of mutations is likely to be higher.”
Methotrexate is offered to some women after ectopic pregnancy if concentrations of the beta subunit of human chorionic gonadotropin hormone are below 5000 mIU/ml but is not available everywhere, and surgery is still the mainstay of treatment.
Jaime Friebe and colleagues at York Hospital, in Maine, presented a cost-benefit analysis using case notes for patients retrospectively identified as having suspected tubal pregnancies, over two years in a hospital with only a surgical management protocol.
Of 100 patients identified, 51 could have avoided surgery if methotrexate had been available, with only 34 needing salpingectomy rather than 62. Also 171 bed days and costs of £37500 (€55000; $76000) could have been saved, they found.
For more information see www.bcog2007.co.uk.