Expert opinion on treatment add-ons

If you’ve been unsure who to believe about fertility proline_level_measurement_in_eurasian_national_universitytreatment add-ons, you may be interested in some impartial and expert advice in two new scientific opinion papers published by the Royal College of Obstetricians and Gynaecologists (RCOG). They call for more high quality research into the role of natural killer cells in fertility and the effect of endometrial scratching on pregnancy outcomes.

Scientific Impact Papers (SIP), are up-to-date reviews of emerging or controversial scientific issues. The first paper looks at the role of uterine natural killer (uNK) cells, how they are measured, the role of testing and the evidence behind any links to improving implantation rates and early placental development. The paper clarifies that uNK cells are completely different from peripheral blood natural killer cells (which you would be testing in the blood tests some fertility clinics currently offer).

The paper makes it clear that there is no evidence to offer routine tests for NK cells as part of fertility treatment or testing, and that there is uncertainty about how NK cells are measured and reported. The paper says that treatment for raised levels with intravenous immunoglobulin (IVIg)  is not supported by the current evidence and, since it may have serious adverse effects, should not be used..

The second opinion paper explores the effect of endometrial scratch on pregnancy outcomes in women who have experienced recurrent miscarriage and recurrent implantation failure.

Endometrial scratch is a procedure which is hypothesised to help embryos implant more successfully after IVF/ICSI and involves scratching the lining of the womb.

Several studies have examined the impact of endometrial scratch in the cycle preceding an IVF treatment cycle in women with recurrent implantation failure, which appear to provide convincing evidence of benefit of superficial endometrial scratch in improving the implantation rate in this group of women. However, the effect of this treatment on pregnancy outcomes in women who have experienced recurrent miscarriage or those undergoing their first IVF cycle is uncertain.

Professor Adam Balen, Chair of the British Fertility Society (BFS) and spokesperson for the RCOG, said: “These two papers look at the current available evidence which exists and give much-needed guidance to both healthcare professionals and the public on these two topics. It is important that patients receive full information about treatments, the current evidence for benefit and whether there are any side effects or risks associated with it.”

Mr Mostafa Metwally, Vice Chair of the RCOG’s Scientific Advisory Committee added: “There is currently no convincing evidence that uterine natural killer cells are the cause of reproductive failure. Despite this, a number of women are requesting and being offered analysis of either peripheral blood or uterine killer cells and the value of these measurements remains controversial. Current evidence suggests that endometrial scratch may benefit women with recurrent implantation failure and therefore defining the optimal number of previously failed embryo transfer cycles needs to be evaluated in large cohort randomised prospective clinical trials.We still do not understand the mechanism by which endometrial trauma may lead to improvements in IVF outcomes in women and further studies are needed looking specifically at its success among women undergoing their first IVF cycle.”

The papers are available here:

The Role of Natural Killer Cells in Human Fertility

Local Endometrial Trauma (Endometrial Scratch): A Treatment Strategy to Improve Implantation Rates

Left confused about intralipids?

lipidemulsionIf you watched Panorama yesterday and were left worried or confused about intralipids, there are sources of accurate and sensible information.

Looking at some of the comments from fertility patients after the programme, it seems that many people were actually surprisingly unconcerned by the lack of evidence for many of the treatments discussed because they felt if there was any chance at all of something making a difference, they would still be happy to try it.

What the programme didn’t make clear was that there are some potential health risks from using intralipids. These are clearly explained on the current HFEA website which has excellent information on reproductive immunology and covers intralipids. There is also a basic information sheet on add-ons from the British Fertility Society.

Should you pay for add-ons when having IVF?

proline_level_measurement_in_eurasian_national_universityWhether you are at the point of considering IVF or have already had some treatment, you will be aware of the wide range of additional treatments which some fertility clinics offer on top of the standard treatment cycle. The idea is that these will improve your chances of success, and as people inevitably want to do all they can to boost the likelihood of a positive outcome, it can be very tempting to pay for at least some of these.

It is clear that they will certainly add to the cost of your treatment, but whether they will add any benefits in terms of outcomes is still very much up for debate. Few of these add-ons have a reliable base of scientific evidence to prove that they are likely to work, yet patients are often paying for them believing that without them there is a lower chance of a successful cycle.

Yacoub Khalaf who is Director of the Assisted Conception Unit a Guy’s and St Thomas’ in London, spoke on the subject at The Fertility Show at the weekend. If you missed it, you may be interested in his article on the Huffington Post about this.

Treatment add-ons

ivf_science-300x168If you are currently having fertility treatment, you are likely to be aware of the many different additions that are offered on top of the standard IVF from immunology treatments to time-lapse imaging. Yesterday’s Independent contained three articles on the subject;  a news story, details of some of the treatments which may not be evidence-based and an editorial suggesting that clinics should not be offering unproven treatments. It is worth reading if you are thinking of having treatment.

It is to be welcomed that the Independent are exploring this issue – it is something which has been a concern to many of those supporting patients for some time as more and more additional treatments are offered in fertility clinics, just a few of which are listed in the paper. Patients are often worried that if they don’t pay for extras they will be reducing their chances of success, when there isn’t a strong evidence base to support this as the leading experts quoted in the articles explain.

I’m not entirely sure I agree with the editorial though, which seems to put some of the blame for this back at the door of fertility patients with the suggestion that  “We also live in an age in which people do not like to take no for an answer. Some couples may be reluctant to face the fact that there may be no simple answer to their fertility issues. If one treatment does not work, the temptation is to demand another.”.  Patients are not likely to demand different treatments if clinics don’t offer them, and it seems to me unfair to be blame patients for the fact that clinics are offering unproven treatments. In fact, the editorial does go on to say that “the onus lies on the clinics – not the patients – to be the voice of realism“. It also claims that only a quarter of women who have IVF conceive – this may be true of an individual cycle of treatment but cumulative outcomes are far higher – many of those who conceive after IVF treatment did not get pregnant in the first cycle.

If you are having fertility treatment and are being given the opportunity to pay for additional extras, it is really important to make sure that you are clear about the evidence. The best kind of evidence comes from a randomised controlled trial (an RCT) and it is always a good idea to ask whoever is treating you to point you in the direction of evidence in the form of an RCT to suggest that paying for an extra treatment is a good idea.

Reproductive immunology

Natural_killer_cellIf you look on fertility websites, you’ll often find people discussing reproductive immunology or their NK cell tests and results. What’s often not clear from the discussions is the fact that the reason many fertility specialists don’t offer this kind of treatment is because they don’t believe there is any scientific evidence to back up the theories.

This picture above is apparently an NK cell – I can’t imagine they are quite that purple in colour, but it gives them just the kind of slightly sinister look that the name conjures up. In fact, as Dr Norman Shreeve from Cambridge University explains in the latest edition of the BioNews online newsletter, the name is misleading as the cells play a key role in early pregnancy,

If you’re thinking of looking into having your NK cells tested, or taking some of the treatments currently offered in this field, you should first read the information on the HFEA website and a scientific impact paper on the subject from the Royal College of Obstetricians and Gynaecologists which is more complex but also concludes that there is little evidence to support the use of these treatments and that their use should be restricted to research trials.

What the experts have to say on reproductive immunology

If you are considering having immune tests or treatments along with your fertility treatment, it is important to have looked into this properly. You will find vast amounts of information about this online, some of it written by people who currently offer the treatment. More and more patients consider having NK cell testing along with other assessments, but not all are aware of the views of leading professionals in the field.

The things it is really worth reading about this are first, a Scientific Impact Paper from the Royal College of Obstetricians and Gynaecologists, which is the professional body for gynaecologists, including fertility specialists, in the UK. The other is the Human Fertilisation and Embryology Authority’s information for patients about reproductive immunology. These give an evidence-based view from professional experts and will give a good basis on which to make any decision about immune tests and treatments.