The development of better cancer treatments has resulted in much improved survival rates for cancer patients, which in turn, has led to many new options and concerns. One of the many concerns for young female cancer patients is the high risk of premature ovarian failure as a result of the life saving cancer treatments. The risk of ovarian failure varies depending on many factors:

•The patient’s age
•Area or field of  irradiation

Additionally, the type of chemotherapy used plays a huge role, with the group called alkylating agents posing the greatest risk. This group includes:

•Busulfan
•Chlorambucil
•Cyclophosphamide
•Ifosfamide
•Nitrosoureas
•Melphalan
•Procarbazine

Bone marrow transplantation is thought to be most responsible for ovarian failure with 80% of patients experiencing premature failure.

New Treatment Therapies
Until very recently, fertility treatment centers could offer those patients very few options. Today, one of the most exciting and promising treatment options is the cryopreservation of ovarian tissue as a method of preserving fertility. This treatment option is best for patients too young or are otherwise not a candidate for egg or embryo banking.

What is Cryopreservation of Ovarian Tissue?
Cryopreservataion of ovarian tissue is performed before radiation or chemotherapy treatments and does not require ovarian stimulation. Performed at a fertility treatment center or at an oncofertility center, an ovary is removed from the patient and then frozen. The outpatient laparoscopic procedure takes under an hour, is simple, done under general anesthesia and is not especially painful. Recovery time is minimal and patients can begin cancer treatments in a few short days after the procedure.

Usually within 5 years, after the patient is cleared of cancer, the ovarian tissue is then grafted back onto the patient’s fallopian tubes, and in many cases, restores fertility.

Areas of Concern
Patients should make sure that their physician is very familiar with medical oncology, histopathology and reproductive endocrinology. Although no cancer recurrance from ovarian grafts has been reported has been reported yet to date, it is still a concern. Not every patient is a candidate for the procedure and type of cancer plays a critical role in whether or not this therapy is a suitable option. Of particular concern is breast cancer, as this cancer metastasizes haematogenously.

A thorough evaluation of the tissue must be made to rule out any metastasis.  Additionally, a physician may find the procedure is not an option for young breast cancer patients as the patient may be harboring certain gene mutations which may also harbor a co-existing primary ovarian cancer.

The occurrence of ovarian cancer in women under the age of 35 is rare, but it is still a risk that should be considered. Patients with endometrial cancer are also not considered candidates. As promising as the treatment may be, not every treatment is right for every patient. Cryopreservataion of ovarian tissue is still a very new procedure and any concerns should be discussed with your fertility treatment center reproductive endocrinologist.

Fortunately for those who have experienced difficulty conceiving, many significant advances have been made in reproductive diagnosis, treatment and technology. These advances have helped fertility treatment centers to determine the individual causes of infertility and develop an optimum treatment strategy for many couples.

Endometriosis and Unexplained Infertility
However, even in light of these advances, some causes and contributing factors in infertility remain elusive or disputed. Endometriosis, for example, remains a source of controversy. While it is widely accepted that advanced stage endometriosis causes a significant disturbance of the pelvic anatomy which can cause infertility. The impact of early endometriosis is not as clear.

What Is Endometriosis
Endometriosis is a common gynecological disease which occurs in  3-10% of women of reproductive age. In women experiencing infertility, the rate increases to between 20 and 40% of that population. It is defined by the American Medical Association, as the presence of endometrial cells outside of the uterus that may result in pain and infertility.

How Does Endometriosis Develop?
Although not fully not understood, it is thought that the disease develops as a result of the drainage of menstrual debris, cells and blood, back into the abdomen and pelvis through the fallopian tubes. Genetics are likely to also play a contributing role, as women with close relatives suffering from the disease are nearly 7 times more likely to develop the disease.

Clinical Diagnosis
There are several possible ways of diagnosing endometriosis, with varying levels of accuracy. A fertility treatment center may base a diagnosis on the presence of pelvic pain, excessive menstrual pain, and painful intercourse. However, not all patients, even with advanced cases experience pain. A physical examination confirm the presence of the disease, but also may not be reliable or conclusive. Frequently, a diagnosis is reached based on the exclusion of possibilities. The most reliable form of diagnosis is surgical.

Does Surgical Treatment of Endometriosis Improve Fertility?
Many studies have been done to determine the pregnancy rate between women who were surgically treated for endometriosis and those using controlled ovarian hyperstimulation and intrauterine insemination, and the verdict is still out. Part of the problem is that a clear understanding of the association has yet to be determined.

However, it has been established that the management of the disease through medications alone does not positively impact a person’s ability to become pregnant. The question then becomes, which is more effective; surgical treatment or COH- IUI? In many randomized trials, fertility treatment centers found that women with early stage endometriosis and surgically treated did see an increased rate of pregnancy, as did those using COH-IUI.

Fertility Treatment Centers Help Develop Treatment Strategy
There is much data to support that ablative therapy is as effective as surgical therapies but must be considered on a case by case basis. Most fertility treatment centers agree that management plans for couples experiencing unexplained infertility and endometriosis must be individualized based on many clinical factors, such as:

• The stage of endometriosis
• The age of patient
• The anatomy
• The duration of infertility
• Other contributing factors

Based on your individual clinical profile, your fertility treatment center will develop a plan that is most likely to yield positive results. Discuss your options with your physician.

The Emotional Process of IVF
Since IVF has the highest success rates, and often considered the last course of action, it  is difficult to leave room for the possibility of failure. Seemingly endless trips to the fertility treatment center, shots, date checking, temperature taking, and scheduling all take the forefront of the relationship leaving little room for much else. The days are filled with expectation, and the relationship is consumed with this one goal.

Financial Factors
In addition to the monthly cycle of high hopes and deep disappointments, the couple often begins to feel financial pressures mounting. No doubt most couples would give up anything to have a child, but it does not mean that it will come without difficulty, or that other unexpected expenses will not arise.

After Failed IVF
Many couples experience a wide range of feelings after an IVF failure. There are likely strong feelings of grief, disappointment, and even guilt. The woman may not only feel a deep loss for herself, but also a terrible guilt in not being able to conceive and carry a child her partner so longs for. There may be some secret resentments, however unreal, unreasonable or unfair.  There may be some regret in investing so much of their  time, money and energy into something, only to be so terribly let down.

Grief
As hard as the in-vitro fertilization process can be, while in it, there is always at least the hope of future success. If the IVF process has not been successful, the emotions can range from deep disappointment to a deep depression. Initially, the hopelessness can be overwhelming. Grief has as a schedule unique to each person that can not be forced, hurried or ignored. The good news is; grief does have an end. The time spent in the fertility treatment process with all the hopes and dreams, will remain important and vivid, but the emotions will eventually become bearable.

The Good News
While experiencing depression is a real and reasonable reaction, it does have an end. Studies show that even though infertility can shake the foundations of a relationship, most develop a core strength that others, not experiencing the hardship, do not have. One study notes that an overwhelming majority of couples successfully take an alternate path to parenthood.
Getting on Track
The key to getting through the most difficult times is getting the right help. After  and unsuccessful procedure, the fertility treatment center is like to be able to connect you to professionals that deal specifically with the issues you are facing. Most fertility treatment centers also have support groups to offer the unconditional support of common experience.

One of the most common concerns about fertility treatment is whether or not there is a connection between fertility medications and ovarian cancer. Early reports suggested a strong link, but those reports have since been challenged. This concern has been at the center of debate and research for over a decade with experts falling on both sides of the argument.

Recent Studies in ovarian Cancer and Fertility Medications
One of the most in depth studies to date exploring the possible link between fertility medications and ovarian cancer found no convincing association between the two. The study, which was published in the February 2009 British medical Journal followed a group of women under the care of a fertility treatment center and given either gonadotropins, clomiphene citrate, human chorionic gonadotropin, or gonadotropin-releasing hormones, and were compared with women who were not given the drugs.

The study, which is consistent with other recent studies, did calm some fears but did not completely rule out a possible cancer link. The study did note a slight elevation in the instances ovarian cancer and the use of clomiphene, but so low that it cold be a statistical aberration.

The Early Data
One of the major flaws in 1990s research was that it compared statistics from the general population of mostly fertile women with data collected from women being treated at fertility treatment centers, which makes the data skewed. Conversely, critics also note that the study did not follow women long enough and many cases of ovarian cancer occur past the age of 45 where the study ended.

Most Resent Studies
Another recent study suggested that there may be an increased risk of ovarian cancer for those who took clomiphene citrate for more than 12 cycles, compared to those who took the medication for less than 12 cycles. Though the results are unclear and the actual incidence of ovarian cancer very low, it is recommended that individuals considering fertility treatments consult their physician and ask about the fertility treatment center’s practice regarding clomiphine citrate.

Understanding Ovarian Cancer
The risk for developing ovarian cancer in a woman’s lifetime is between 1-2%. Women with certain conditions that may cause them to seek the help of a fertility treatment center such as endometriosis or “unknown infertility” are at a higher risk of developing the disease.
The known causes are multifactorial and include:

• Early onset of menses
• Irregular cycles
• History of untreated infertility
• Never having children

The study also notes that some factors may help reduce a woman’s risk of developing ovarian cancer. Some of those factors include:

• Use of oral contraceptives
• Removal of ovaries
• Late onset of Menses
• Early onset of menopause
• Repeated pregnancies
• Prolonged lactation

Though most studies either find no link, or the incidence is low and the connection unclear, most fertility treatment centers will suggest each patient weigh the desire of having a child against any possible risks.

About Tubal Ligation Reversal Surgery
Tubal ligation reversal is a procedure that rejoins the segments of the fallopian tubes so that eggs can become fertilized. It was once primarily performed in an inpatient situation, requiring 3 hours of surgery, several day hospital stay and month long recovery though things have vastly improved. Fertility treatment centers now perform tubal reversals as an outpatient procedure, frequently using laparoscopy technology; greatly reducing pain, recovery time and procedure expense.

Pregnancy Success Rates After Tubal Ligation Reversal
It is difficult to get specific estimates on the success rates for pregnancy after tubal ligation reversal because not as many studies have been done and, like in IVF, success varies between fertility treatment centers. While studies do suggest that IVF has a higher immediate success rate, it is limited to the amount of procedures a patient can afford, should it not be successful or more children are wanted. The opportunity to conceive after a reversal of tubal ligation is limited only by the couple’s individual contributing fertility factors.

Contributing Factors
As in any course of fertility treatment, it is difficult to know the exact possibility of success or failure. Whether it is success or failure, for the patient experiencing it; it is 100%. It is however possible to know the facts and weigh the possibilities in the balance.

• Before making a decision, it is advisable to know the male partner’s sperm quality. If it is poor and either low in count or motility, it may necessitate and IVF procedure.
• Age of the patient in any fertility treatment is always a consideration. The chances of pregnancy significantly decrease at age 43.
• The status of the tubes also plays an important part. The length of the remaining stumps can determine increase the patients chances if they are longer or decrease the chances if they are shorter. The condition of the fimbria at the end of the tube which essentially pick up the egg upon release, also determines the chances of success.
• Current pelvic conditions. The amount, extent and location of scar tissue can impact the successful outcome after a reversal.

Advantages of Tubal Reversal
There are two main advantages to a surgical reversal of a tubal ligation. One is that because no fertility medication is used, the multiple pregnancy rate is only 2% compared with 25% for IVF treatment. The second major advantage is that there is no need to have another procedure to try to achieve another pregnancy.

When weighing the options, it is important to discuss the options with the reproductive endocrinologist and know the preference of the fertility treatment center, as well as their expertise in tubal reversals.

Choosing the most Common Course of IVF Treatments
Patients come to the fertility treatment center because their greatest hope is to have a child. They are soon met with various treatment options, depending on their individual diagnosis. Very often, the course of treatment chosen is greatly impacted by the affordability of the treatment and whether or  not insurance will cover that particular treatment. Frequently, the less effective treatments are tried repeatedly before resorting to the treatments infrequently covered by insurance. While IVF has the highest success rates, it is often considered a last resort treatment because it is the most expensive.

Standard Protocol

•    3 cycles of clomiphene citrate/intrauterine insemination (CC/IUI)
•    3 cycles of gonadotropin/intrauterine insemination (FSH/IUI)
•    No more than 6 cycles of  in-vitro fertilization (IVF)

Accelerated Protocol

•    3 cycles of clomiphene citrate/intrauterine insemination (CC/IUI)
•    No more than 6 cycles of  in-vitro fertilization (IVF)

New Study  Offers a New Course for Hope
A major study recently found that an accelerated path to in-vitro fertilization (IVF) can offer couples beginning fertility treatments a shorter, more cost effective way to pregnancy. This is great news for fertility treatment centers wanting to offer patients as many options as possible. Elizabeth Ginsburg, President of the Society for Assisted Reproductive Technology, commented in a July 2009 Science Daily article, “This is a very important study that will likely influence physicians to reduce the number of stimulated inseminations for patients with unexplained infertility. Adoption of such an accelerated course of treatment could result in many patients conceiving in less time with less expense.”

The accelerated treatment, know as FASTT for “fast track and standard treatment trial,” eliminates the gonadotropin-stimulated artificial insemination cycle that usually precedes assisted reproductive technology . In the study, 503 couples were divided in to two groups. One group underwent traditional therapy with an average of 11 months until pregnancy. The other, underwent the accelerated protocol resulting in an average 8 months until pregnancy.

Success Rates of Accelerated Infertility Treatments
Fertility treatment centers believe the treatment protocol has a huge potential for many patients. The study showed the results very favorable, with 55.4% of patients achieving pregnancy undergoing standard protocol and 65.4% achieving pregnancy undergoing the accelerated protocol.

Cost Effectiveness
With many patients faced with the economics of infertility treatments at fertility treatment centers, the new study has the potential to put IVF as first choice. The study concluded that the use of follicle stimulating hormones and intrauterine insemination treatment did not add value to the fertility process and therefore could be eliminated, also eliminating added cost. The average savings per delivery of treatment was nearly $10,000 lower than standard treatment, a savings which can open the doors to many patients.

While many couples conceive quickly and naturally, others will experience problems for a variety of reasons. After trying to conceive for some time without result, and initial tests with their gynecologist, a patient will likely seek the help of a reproductive endocrinologist and a fertility treatment center.

After the patient is thoroughly evaluated and the problem(s) identified, a treatment plan is developed specific to those problems. In most cases, a fertility treatment center will start with the least invasive treatments, such as fertility drugs like Clomid or Femara, first. In some cases, such as those where infertility is caused by blocked or damaged fallopian tubes, surgical intervention is likely.

When initial interventions have failed, most specialists will recommend in vitro fertilization (IVF) treatments. While the process is not easy, for some couples, it offers the best chance at becoming pregnant. Because IVF success rates vary in individual fertility treatment centers and since the treatments involve considerable cost, it is important to research your fertility treatment center’s statistics and treatment philosophy.

When is it Time to Test?
Depending on the fertility treatment center policy, embryo transfer usually occurs within five days after the egg(s) is fertilized. The embryo will implant in the uterine wall, if successful, and a pregnancy, or failure, will be detectable after two weeks. A pregnancy test will be administered at the fertility treatment center though many choose to also test using a home pregnancy test.

What are the Success Rates?
One of the biggest concerns for those in the IVF process, is whether or not it will be successful for them. Success is dependent on many factors, many of which the patient has little control. Factors such as age of the patient and causes of infertility as well as the level of expertise of the lab staff will all play a role. Success rates for individual fertility treatment centers can be found at the Center for Disease Control and Prevention (CDC) or the Society for Assisted Reproductive Technology (SART) websites. While the success rates are helpful in choosing a clinic and in weighing a decision in which treatments to pursue, they can not determine whether or not an individual patient will be successful in becoming pregnant.

A New Test on the Horizon
Recently, scientists in Dublin, Ireland have identified special biomarkers that can help predict whether IVF treatment will be successful for individual patients. The simple blood test indicate whether or not an embryo is likely to implant successfully and the body’s response to treatment. Currently, only basic medical information such as a patient’s age and the cause of infertility are used as baseline indicators. Since infertility is such an emotional and costly journey, the possibility of saving much grief and money is very  attractive to many.  Advocates feel such a test could give the patient an added tool, help patients decide whether or not IVF is for them, or whether or not to pursue additional IVF treatments. It is unknown when such a test will be available in US fertility treatment centers but many groups are already pushing for widespread usage.

Expected Side Effects
The in vitro fertilization process involves suppressing the normal menstrual cycle so the reproductive endocrinologist can induce ovulation when it is optimum to harvest the eggs. The treatment includes frequent blood tests and nasal spray or injection of hormonal drugs, and some bruising can be expected.  Since the menstrual cycle is suspended for a short time, a patient may experience some menopausal symptoms that include:

• Hot flashes
• Mood Swings
• Nausea
• Headaches

Most women experience only mild side effects but any severe headaches or vision disturbances should be discussed with your physician.

Side Effects of Stimulation
Most fertility treatment center protocols require the patient continue to take the suppression drugs while on the stimulation drugs, to prevent premature ovulation. The symptoms women experience from the stimulation drugs vary, and most experience them only minimally.

• Abdominal Bloating
• Fatigue
• Diarrhea
• Weight gain
• Nausea

It is important to discuss any concerns with your physician at the fertility treatment center.

Ovarian Hyper Stimulation Syndrome (OHSS)
OHSS is a potential complication from any fertility drug and is a condition in which the ovaries produce many follicles which become larger than usual. Most commonly, the condition is mild and improves without intervention. However, severe cases can lead to blood clots and kidney failure. Symptoms include:

• Bloating
• Abdominal pain
• Rapid weight gain (As much as 10 pounds within 3-5 days)
• Decreased urination
• Nausea
• Vomiting
• Shortness of breath

Severe OHSS has only been reported in 3-8% of IVF cycles. Fertility treatment centers closely monitor each patient for OHSS, and encourage patients to discuss any concerns with their physician. Fertility treatment centers also reduce the risk of severe OHSS by:

• Reducing the dosage of fertility drugs
• Withholding the human chorionic gonadotrpin (hCG)
• Proceed with egg retrieval but freeze embryos for a later cycle

Egg Retrieval and Embryo Transfer
During the process of egg retrieval, the physician uses a vaginal ultrasound to guide the insertion of a needle through the vagina into the ovary to retrieve eggs. The procedure is performed under sedation or anesthesia. The risks are minimal, but do include:

• Discomfort during or after the procedure
• Possible injury to organs near the ovaries such as the bladder, blood vessels and bowel.
• Bleeding from ovary or pelvic vessels
• Pelvic infection

During Embryo transfer, a patient may experience cramping, bleeding or spotting during the procedure. Infrequently, infections develop. Though the problems many be minimal, it is important to report them to your fertility treatment center and physician.

Is Ovarian Cancer a Risk?
Despite early reports of a possible connection between fertility treatments and ovarian cancer, recent studies fail to provide convincing evidence of any connection. However, fertility treatment centers understand the concern and encourage the patient to discuss their concerns.

In Vitro Fertilization, or IVF, is the most common of all assisted reproductive technology (ART). The techniques, which was first developed in the United Kingdom by Doctors Patrick Steptoe and Robert Edwards and resulted in the first pregnancy in 1978. Fertility treatment centers in the United States began to adopt the process which resulted in the first IVF pregnancy in the US in 1981, and over 45,000 since that time.

The IVF process involves removing the eggs, or ova, from a woman’s body and placing them in a lab dish with the sperm. After fertilization occurs, the eggs are transferred to the woman’s uterus where they continue to develop.

Before the IFV Process begins, the patient is evaluated by the reproductive endocrinologist to see if IFV is a possible solution to over come their infertility problems. Fertility specialists understand the patient’s desire to have a child but also balance that with the biologic understanding of the possibilities for each patient. Reputable fertility treatment centers will assure that the patient understands their choices and will help guide them to ones bet fit for situation.

Best candidates for IVF include:

• Those with blocked or damaged fallopian tubes
• Male factor infertility
• Those with Endometriosis
• Problems concerning the uterus
• Problems concerning the ovaries
• Unexplained infertility

The IFV Process is very involved and will include many visits to the fertility treatment center for  evaluation, treatments and monitoring. The process includes:

• Ovulation induction medication, such as Pergonal, are administered.
• Eggs are commonly retrieved using ultrasound guided needle which collects the follicular fluid which is placed in an incubator.
• Semen is collected and prepared.
• Sperm and egg are incubated together and fertilization should occur.
• Fertilized eggs are transferred to the woman’s body
• Woman returns to the fertility treatment center in two week for a pregnancy test
• If successful, she is monitored by the physician at the fertility treatment center for a short time then care is released to her regular OB/GYN. If unsuccessful, the woman will wait a month to recover, and then be reassessed for the next or further treatment.

IVF Concerns
The IVF process has involved some controversy over the years, and does evoke some serious considerations. The process has made headlines enabling women well beyond childbearing years to conceive and other to become pregnant with multiples well beyond what medicine deems safe. The medical standard is the placement of no more than two embryos into the womb at a time. Some consideration of IVF include:

• Cost
• How many children desired
• How many embryos remain after treatment
• What will be done with unused embryos

Not every fertility treatment center shares the same protocol, philosophies, or success rates. It is very important for any patient considering fertility treatments to check the physician’s standing with the board as well as the fertility treatment center’s results with the CDC.

For the patient experiencing fertility problems, the success rate of a treatment plays a major role when deciding on a course of treatment, as well as in the choice of fertility treatment centers. If fertility drugs have not been successful alone, many are faced with the option of IUI, intrauterine insemination, also known as AI or artificial insemination.

The Process Briefly Explained
The IUI treatment utilizes a catheter to insert washed sperm directly into the uterus. This increases the chances of sperm reaching the fallopian tubes, which increases the chance of fertilization.

The process may include medication to stimulate the ovaries and increase the production of eggs. The hormone hCG, or human Chorionic Gonadotropin, is then administered which stimulates the release of the eggs

The IUI fertility treatment is often a course of treatment considered by couples who have been unsuccessful  in conceiving after trying for a year or more. Most fertility treatment centers offer IUI as an option to treat conditions such as:

• sperm with decreased mobility
• low sperm count
• cervical conditions not conducive to sperm
• as the requirement of donor sperm
• sexual dysfunctions

Advantages of IUI
The advantages of this course of treatment include simplicity and comfort. Done by a specialist in the privacy of a fertility treatment center, the process is fast and involves little discomfort. The IUI process is also much more affordable than other ART technologies.

IUI Success Rates
The rates of success for IUI vary in studies, but in most are not very high and range from 4-20%. Women under the age of 35 experience more success than those over and for those for whom it is successful, it is so 10-20% of the time within one cycle. It is generally more successful in trying to overcome a problem with the cervical mucus than a problem with the quality of sperm. Many factors play a part in the rate of success of this treatment and include:

• age and health of woman
• health and mobility of sperm
• timing of insemination

Individual fertility treatment center’s success rates can be found at the Center for Disease Control and Prevention website and may be helpful in choosing a fertility treatment center to begin the reproductive journey. It is also helpful to discuss the success rates of IUI and all reproductive treatments with others who have experienced them and can share in their own IUI Success Stories.

The Downside of IUI
One of the main concerns of the IUI is, when cycles have been stimulated, there is an increased risk of developing Ovarian Hyperstimulation Syndrome, or OHSS. OHSS is developed when a woman’s body responds too well to the fertility drugs used to encourage ovulation, causing the ovaries to swell and leak fluid into the abdomen. Your physician will monitor for OHSS and the fertility treatment center may have a patient admitted to the hospital for a few days for observation as the ovaries come back to their normal state.