Fertility Drugs: Are they worth it?
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Over the past few years there seems to have been an increase in the amount of couples that have used fertility drugs and ended up having nine or more children. The couples' stories have been aired on the news, and when interviewed, many of the couples stated that they only wanted one child, but because one of the spouses was infertile, they were unable to get pregnant. At the advice of their doctor, the couple took fertility drugs, and the result was the rapid expansion of their family. The effectiveness of fertility drugs such as Clomiphene and Bromocriptine are overshadowed by their many, and often very harmful, side effects. Are infertility drugs worth the cost that possible side effects have?
Causes and Solutions to Infertility
Infertility affects 7.1 percent, or 2.8 million couples, of married people in the United States. It is difficult to assess the overall percentage of infertility that exists in the United States, as many individuals do not know that they are infertile until they attempt to have children. In addition, information on the web is confined to addressing infertility among married couples, thus this web paper discusses studies conducted among married couples. Less than a third of married couples seek help from their doctors, even though almost 90 percent of all cases of infertility have one or more causes than can be treated. Infertility's most common causes include egg quality/production, blocked tubes, and the male-factor. (1).
Problems in egg quality/production are the result of poor egg quality, irregular ovulation or failure to ovulate because of hormonal deficiencies or imbalances. A fourth case is polycystic ovarian syndrome, which is a condition in which a hormonal imbalance prevents the egg-containing follicles on the ovaries from maturing and releasing an egg, instead forming sometimes painful ovarian cysts. These problems, especially deteriorating egg quality, are often age-related, and apply most often to women 37 and older. Possible solutions to poor egg quality/production include use of a donor egg, fertility drugs such as Clomiphene and Bromocriptine, and in vitro fertilization (IVF). (1).
Blocked fallopian tubes are often the result of scar tissue, adhesions, and damaged tube ends (fibria). Another common cause is endometriosis, which is the growth of endometrial cells (the tissue that lines the uterus) outside the uterus, most often on the ovaries, Fallopian tubes, or the exterior of the uterus.
About 10 to 15 percent of women of childbearing age have this condition, many of them without symptoms. Even if a woman ovulates regularly, blocked tubes make pregnancy next to impossible, since the egg is unable to reach the uterus. The primary treatment for blocked fallopian tubes is laparoscopic surgery that is used to open the tubes. If surgery is not an option or is unsuccessful, other possible solutions include donor eggs and in vitro fertilization (IVF). (1).
In men, infertility can be the result of a blocked vas deferens, or epididymis, poor sperm quality, low sperm motility (the sperm's ability to move) a semen deficiency, or not having enough, or any sperm to begin with. The most common solution is to undergo an operation to clear the blocked tubes. However, if the operation is unable to cure a man's infertility, fertility drugs may boost sperm production, or a man's sperm can be used to artificially inseminate his partner. Other options include using donor sperm or a procedure called intracytoplasmic sperm injection, which is injecting sperm directly into the egg. (1).
Assisted Reproductive Technologies
Assisted reproductive technologies, or ARTs, refer to IVF and several variations tailored to individual parents' unique conditions. IVF is a process that begins with the woman taking a fertility drug (usually Clomiphene or Bromocriptine) to stimulate her ovaries to develop several mature eggs for fertilization. By the monitoring of blood hormone levels, the woman's doctor can detect when her eggs are mature; an ultrasound confirms that the eggs are ready to be retrieved. Shortly after, the woman will be given a local anesthetic, and her doctor will remove the eggs using a needle inserted through her vaginal wall. Her partner's sperm is then combined with her eggs in a dish in a laboratory. Two days later, her fertilized eggs each become a ball of cells called an embryo. Usually, two to four embryos are inserted into the woman's uterus through her cervix with a thin catheter. (Extra embryos, if there are any, may be frozen in case this cycle doesn't succeed.) In a successful cycle, an embryo will implant in the woman's uterine wall and continue to grow. (In 20 to 30 percent of IVF pregnancies, more than one embryo implants, depending on the number of embryos inserted.) (1).
Other ART procedures include GIFT, ZIFT, ICSI, donor eggs or embryo, and surrogacy. GIFT refers to gamete intrafallopian transfer, which is where a woman's eggs are removed, mixed together with her partner's sperm in a dish in a laboratory, then surgically injected into her Fallopian Tubes. Fertilization happens naturally inside her body and the embryo implants naturally. ZIFT refers to zygote intrafallopian transfer, where collected eggs are fertilized with her partner's sperm in a dish in a laboratory and then surgically placed in her fallopian tubes using a fiber-thin tube called a laparoscope. ICSI refers to intracytyoplasmic sperm injection, where a single sperm is injected into a single egg and the resulting embryo is transplanted into a woman's uterus. With the donor egg or embryo, if a woman is unable to conceive using her own eggs, a donated egg is mixed with her partner's sperm and the resulting embryo is implanted in her uterus. This procedure can also be done with a donated embryo. Surrogacy refers to a procedure where another woman carries the parent's embryo, or a donor embryo, to term and gives the baby to the original couple at birth. (1).
ART procedures are invasive and expensive. Unlike fertility drugs, these techniques aren't rigorously tested before they are introduced to the public. Though no long-term health effects have been linked to children born using ART procedures, or to mother who have had a procedure done (except in the case where fertility drugs were used), most doctors recommend reserving ART as a last resort for having a baby due to the stress placed on the woman's body. Also, many ART procedures, such as IVF, increase a woman's chance of multiple births. (1).
Fertility drugs work by promoting ovulation by stimulating hormones in a woman's brain to get an egg (or several) ready and release it from her ovaries each month. Many fertility drugs have been used safely and successfully for more than 30 years. Unlike many other infertility solutions, such as in vitro fertilization, fertility drugs won't increase the chance of multiple births beyond 5 to 15 percent. The most common fertility drugs include Clomiphene, Human Menopausal Gonadotrophin, and Bromocriptine.
Clomiphene, taken in pill form daily, stimulates the pituitary gland to produce follicle-stimulating hormones, which are the hormones that trigger ovulation. It prompts the ovaries to prepare a number of eggs for ovulation. Once the drug cycle is finished, the hypothalamus gland releases a lutenizing hormone, which instructs the ovaries to release a mature egg from its follicle to the Fallopian Tubes. Women who ovulate irregularly or not at all commonly use Clomiphene. Clomiphene can cause a wide range of side effects, including mood swings, dry cervical mucus, mild ovarian enlargement, stomach pain, breast and ovarian cancer. About 70 to 90 percent of women who take Clomiphene will ovulate, and of those who ovulate, 20 to 60 percent will get pregnant. (1, 2).
Human Menopausal Gonadotropin (hMG) consists of purified follicle stimulating hormone (FSH). When injected into the body, FSH causes a woman to develop egg follicles. After seven to twelve days of shots, the woman receives an injection of human chorionic gonadotropin that stimulates the ovaries to release the egg or eggs that it has just developed. HMG is most often given to women with low estrogen levels who have not responded to Clomiphene. Possible side effects from hMG include abdominal tenderness and weight gain. In rare cases, less than 5 percent of the time, women develop hyperstimulated ovaries, a potentially fatal condition signaled by sudden onset of severe pelvic pain, nausea, vomiting, or weight gain. Due to an excessive number of eggs, the ovaries rapidly swell to several times their size and may leak fluid into the abdominal cavity. Even with careful monitoring, multiple pregnancies and ovarian hyperstimulation can occur. The rate of multiple births is close to 20 percent. About 70 to 90 percent of women who take hGM will ovulate, and of those who ovulate, 20 to 60 percent will get pregnant. (1).
Bromocriptine, which can be taken orally or as a vaginal pill, reduces the pituitary gland's production of the hormone prolactin. Excess prolactin reduces estrogen levels and inhibits ovulation. Women who take Bromocriptine suffer from hyperprolactinemic amenorrhea, which is a condition where ovulation problems are caused by a pituitary adenoma (a benign tumor). Side effects from Bromocriptine include nausea, dizziness, low blood pressure, and headaches. Patients who take the drug vaginally often report fewer side effects. 90 percent of the women who take Bromocriptine will ovulate as long as they continue taking the drug. Of the women who ovulate, 65 to 85 percent will get pregnant. (1).
Are Fertility Drugs Safe?
One major concern surrounding fertility drugs are the instances of multiple births that arise from their use. Multiple births occur in about 50 percent of cases, especially among women in their early 30s or younger. In most cases, risks can be lowered through careful monitoring and controlling dosages of medications. For IVF, if a high number of eggs are seen developing on the ultrasound, doctors are able to remove them and place back two or three embryos. However, as Dr. Valerie Baker states, "in the case of normal or artificial insemination, we have no control. So if we see too many eggs, we may advise the couple to not attempt to get pregnant. But couples sometimes are hesitant to cancel the cycle because they have so much invested in it, both financially and emotionally". In addition, if the couple does not cancel the cycle and four or more embryos implant, the newborn babies have a high risk of neurological complications if they survive. (3).
Multiple births are also risky because they can result in the birth of sickly, premature babies. Premature babies face serious complications, including lung problems and bleeding the head, which can cause long-term physical and mental impairment. (4).
Fertility drugs are often fingered as a risk factor for ovarian cancer. There are several factors that may increase a woman's risk of ovarian cancer. One factor is that an increased number of uninterrupted ovulations in a woman's lifetime increases her chance of developing ovarian cancer. This may explain why events that interrupt the constant cycle of ovulations, such as pregnancy, breastfeeding, and oral contraceptive use, are associated with a decreased risk of ovarian cancer. Another factor is that increased levels of certain hormones associated with ovulation, such as human chorionic gonadotropin, increase the risk of ovarian cancer. Fertility drugs can increase both the number of ovulations and the levels of hormones associated with ovulation. (5, 6).
A conflicting study states that women who take ovulation-inducing drugs in conjunction with IVF are not are increased risk of developing breast, ovarian, or uterine cancer. However, women who seek treatment but do not take fertility drugs have more than twice the expected incidence of uterine cancer, and women with unexplained infertility have elevated rates of uterine an ovarian cancer. This study was based on date on 29, 700 women who registered for treatment at 10 IVF clinics in Australia. This study, however, only refers to increasing the risk of cancers when fertility drugs are taken in conjuncture with IVF, and not the risk of cancer when drugs are taken by themselves. (7).
While multiple children may seem like a good alternative to remaining childless for many couples, each couple must weigh the risks and benefits of using fertility drugs or ARTs to have these children. Fertility drugs and ARTs may cause serious physical damage and have long-term effects on the mother and the child. Consequently, each couple must consult their doctor and follow his/her recommendations to ensure that the use of a fertility drug is safe for the parents and the child. Childlessness can also be resolved by a method that is physically safe for all parties: adoption.
The use of fertility drugs also has many social and ethical implications. It implies that parents are interested in having offspring that are genetically related to them. There are many options available to infertile couples, and fertility drugs are one solution. Fertility drugs often have severe physical side effects, and are often ineffective. Adoption is a choice open to infertile parents, yet adoption has many social stigmas attached to it that often prevents many couple from choosing adoption over fertility drugs. In addition, due to the cost of fertility drugs, it is often upper and middle class parents that are able to choose this option. This has similar social implications as done genetic engineering. Overall, fertility drugs are an effective solution to infertility for many couples, yet it comes with physical and social costs.
1)The Baby Center, Provides information pertaining to all aspects of childcare and childrearing
2)Site of the International Council on Infertility Information Dissemination
3)Site of Health Beat
4)Site of The Reproductive Health and Rights Center
5)Site of the National Cancer Institute
6)Site of Science Ministries Incorporated
7)Site of International Family Perspectives