TREATMENT RISKS

Treatment Risks

You should discuss all medications that you are taking with your Barbados Fertility Center physician. It is also important to contact the physician who originally prescribed your mediations to let them know that you are attempting to get pregnant. You should avoid taking nonsteroidal anti-inflammatory drugs around the time of ovulation since these medications can interfere with ovulation and implantation. Paracetamol is a safe alternative. Taking herbal remedies should be discussed with your fertility specialist first, since their effect on fertility and pregnancy is unknown.

Here are a description of medications used at Barbados Fertility Center:

  • Ovarian Hyperstimulation Syndrome
  • Multiple Pregnancy
  • Cancer
  • Birth Defects
Ovarian Hyperstimulation Syndrome

Women contemplating ovarian stimulation should be aware that the procedure carries risks that are comparable with the risks of elective surgery.

All women undergoing ovarian stimulation, such as during an IVF treatment cycle, experience enlargement of their ovaries and a complex change in their hormone balance. The condition is often marked by weight gain, as excess fluid is retained. For this reason it is important to note your weight at the beginning of each IVF cycle.

For up to 5% of stimulated women this can be quite unpleasant with abdominal bloating and pelvic discomfort, however, for <1% of stimulated women, the abdominal pain and fluid retention is so severe that admission to hospital is necessary. Symptoms may include marked abdominal swelling, nausea, vomiting and diarrhea, lower abdominal pain, and shortness of breath. Please contact your nurse coordinator at Barbados Fertility Center if you have these symptoms. Hyperstimulation varies in severity and rarely requires treatment in hospital, but you must contact the Barbados Fertility Center clinic if you notice any of the above symptoms so that we can monitor you closely.

“Ovarian Hyperstimulation Syndrome” (OHSS), usually presents a few days after embryo transfer; symptoms being provoked by the hCG injection (Pregnyl/Profasi).

Severe symptoms require:
– bed rest
– correcting the fluid imbalances with an intravenous drip
– relieving pain and nausea
– Injections of heparin to counter the tendency of the blood to clot abnormally.
Fortunately this condition is self-limiting. It usually resolves after several days, with a natural excretion of the abnormal accumulation of fluid, however it may persist for weeks, especially if a pregnancy has been achieved. Once the condition has resolved the pregnancy can be expected to proceed normally.

On RARE occasions very serious complications have been associated with OHSS:
1. Abnormal blood clotting has caused strokes
2. Blood clots have migrated to the lungs, a complication that can be fatal
3. Enlarged ovaries can twist or bruise, requiring surgery
4. Weeping of fluid into the abdomen may be accompanied by a similar collection of fluid about the lungs and heart, interfering with their proper function
5. Liver or kidneys may stop working effectively.
There have been individual case reports of blood clotting and stroke complications of severe OHSS. One and a half million IVF babies have been born world wide with only four deaths that have been reported in world medical literature.
NOTE: If you think you may be experiencing symptoms of OHSS please contact your patient coordinator as early in the day as possible..

Multiple Pregnancy

Management of IVF in Barbados, is characterized by a conservative approach to embryo transfer, in order to reduce the likelihood of multiple births. Generally between one to three embryos are transferred in each attempt, depending on the individual patients history.

Although the world’s first IVF baby was born from a natural cycle with spontaneous ovulation, controlled ovarian hyperstimulation is now the norm. Consequently, multiple pregnancy has become common, and it has been estimated that in total, 45% of IVF babies born are from multiple pregnancies, with twinning rate of nearly 25%, triplet rate of 2-3% and quadruplet rate of 0.5% of pregnancies worldwide.

Unfortunately, neonatal and perinatal mortality rates are 3 to 6 times higher for twins when compared to singleton births, and 5 to 15 times for higher order multiples, and the risk of cerebral palsy is six times higher for twins, and twenty times higher for triplets. Multiple pregnancy also places greater physical strain on the mother, with an increased incidence of miscarriage, high blood pressure, bleeding during pregnancy, increased risk of vomiting during pregnancy, and premature birth.

The complication of being born prematurely includes difficulty with breathing, higher incidence of jaundice, and feeding difficulties. Twins also have a higher incidence of congenital abnormality. Triplets are almost always delivered by Caesarean section, and twins far more often. Even if the babies are born normal, caring for two, three or more babies can be a challenge, with extra emotional, physical and financial stresses.

To reduce the risk of multiple pregnancies we have to limit the number of embryos transferred. In deciding how many embryos are to be transferred, we need to consider the number of previous pregnancies, woman’s age, the duration of infertility, the reason for the fertility problem, the number of previous attempts, the number of fertilized embryos, and the cleavage stage and quality of embryos replaced. Excess embryos that are of good quality can be frozen, stored, and used in a subsequent cycle, if necessary.

Cancer

Infertility occurs in about one in six couples.  Cancer occurs in approximately one in three women.

Breast Cancer

Of the cancers of the sex organs, breast cancer is most common, occurring in one in eight Barbadian women.

The cause, or aetiology of breast cancer is unknown. Various factors or diseases make breast cancer more likely. Breast cancer in a mother or sister increases the risk, as does some types of non-cancerous (benign) breast lumps.

Breast cancer is more common in infertile women. Some medical research suggests that cigarette smokers are at increased risk.

Monthly breast self-examination is recommended for all women. All lumps should be investigated immediately. Most breast lumps are benign.

There is no screening method for breast cancer, although mammography detects small cancers.

Ovarian Cancer

Occurs in about one in 90 women. Its aetiology is also unknown.

May also occur in families in 10-15% of cases.

It is more common in infertile women.

The oral contraceptive pill decreases the risk of cancer of the ovaries. This remarkable advantage of “The Pill” occurs, not only while the woman takes The Pill, but also for at least five years after stopping The Pill. There is no effective screening method for ovarian cancer. Every woman is advised to have a gynecological examination and “Pap Smear” every two years to minimize the risk of ovarian, uterine and cervical cancers going undetected.

Cervical Cancer

The lifetime risk of cervical cancer is one in 95 women.

Cervical cancer can be screened by cervical cytology, by the Pap smear.

The aetiology of cervical cancer is related to sexual activity. For this reason, every woman having sexual intercourse should have a Pap smear every two years. An increased number of sexual partners and a papilloma or wart virus infection can also increase the general risk of development of cervical cancer.
A Pap smear every two years, as well as regular gynecological and breast examinations, are currently the best methods to prevent or detect women’s cancers.

Cancer After Infertility and IVF

Doctors have used fertility drugs worldwide since the 1960s, triggering women’s ovaries to produce eggs. This approach proved successful in assisting many women with fertility problems to become pregnant and have children.

In the past 20 years the use of fertility drugs has increased markedly following the development of IVF.

Findings of an Australian Study relating to incidence of Cancer and IVF.

Background

The growth in the number of women seeking help to become pregnant provided an opportunity for a study, the largest of its type anywhere in the world.

The study followed up 29,700 women referred to any of ten participating Australian IVF clinics between 1978 and 1993. Of this total:
– 20,656 women received fertility drugs during IVF (the “treated group”)
– 9,044 women referred for IVF did not end up having fertility drug treatment (the “untreated group”).
– Depending on the year that women joined an IVF program, the duration of follow-up ranged from one to 22 years, with the majority followed up for five to ten years.

This study was conducted to address concerns that the use of fertility drugs might be associated with an increased risk of cancer.

Study’s Aims

To see whether there was any increase in the number of cancers of the breast, ovary and uterus in women on IVF, compared with the number expected among women of the same age, followed up over the same period in the general population.

In the event that there were more of these cancers than predicted, how this might be explained.

Findings

The major finding was that cancers of the breast and ovary were no more common in IVF patients overall than in the general population. Of 29,700 who joined IVF programs, researchers predicted 155 breast cancers and found 143. For ovarian cancer, 13 cases were predicted and 13 were found.
Cancers of the uterus were more common than predicted in untreated IVF patients but were no more common than predicted in the treated group. (Among the 9,044 women in the untreated group, three cases were predicted and seven found).

More women than predicted in the treated group had breast cancer diagnosed in the first year after treatment with fertility drugs. This finding disappeared with time and is discussed below. (Among the 20,656 women, 9 breast cancer cases were predicted in the first year after treatment and 17 were found.)
Women with unexplained infertility had a significantly higher incidence of ovarian and uterine cancer, whether or not they were exposed to fertility drugs, than the general population. (Out of 3,800 women with unexplained infertility, two cases of ovarian cancer were predicted and five were found. With regard to uterine cancer, one case was predicted and five were found).

There was no evidence of any link between the number of treatment cycles or type of fertility drug used and increased cancer incidence. Changes in the types of drugs used in IVF and the amount of ovarian stimulation do not appear to have had an overall impact on cancer in participating women.

Conclusions

The findings provide reassurance that the incidence of breast and ovarian cancers in IVF patients are the same as that for women of the same age in the general population when considered over a five to ten-year period.

The evidence of increased numbers of cancers above, predicted in small numbers of women, in particular subgroups, needs further study. While there was no overall increase, the occurrence of above expected numbers of breast cancer in the first year after treatment is consistent with other research showing a small increase in diagnoses of breast cancer shortly after women give birth. The same effect has been seen in recent users of The Pill and hormone replacement therapy. Possible explanations for this finding after IVF treatment include earlier detection of abnormal breast changes due to close medical supervision, the biological effects of fertility drugs, or both.

Explanations for the relationship between unexplained infertility and the increase in ovarian and uterine cancers are harder to come by but research is continuing. In a bid to explore such issues, the research team has started a more detailed investigation of about 700 IVF patients, some of whom have cancer and others who do not.

Summary

The risk of cancers in women is best reduced through regular women’s health check-ups, breast examination, Pap smears and gynecological examinations – and by the use, at other times, of The Pill. The most effective way of minimizing the risk of breast and ovarian cancers in infertile women is to help them to have a baby. However, the study does reinforce the importance of women having medical check-ups at regular intervals after fertility treatment.

Birth Defects

It is important to remember that any medical or surgical treatment has risks, adverse effects and side effects. Couples should be aware that one baby in 20 born worldwide will have a birth defect. There is no clear evidence that infertility medicines, if properly used, increase this risk.

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