AMH - Why every woman should know her AMH level

A simple blood test measuring a hormone called Anti- Mullerian Hormone (AMH) is the best test currently available to estimate ovarian reserve. What this means is that this blood test can estimate your age at menopause (ie when your eggs have run out) and give you a reasonable idea of your reproductive time remaining. So if you have an AMH test performed in your 20s and it is an average result and sits on the 50th centile, then this means that your menopause will be at around 51 and your reproductive window is likely to close at about 41. How useful is that to know? You can know plan to freeze eggs if you knew that your reproductive lifespan was limited. Also super informative for women who may have had cancer treatment or ovarian surgery and are wondering how this may have impacted on their eggs.

The AMH blood test can be done at any time in the menstrual cycle, during pregnancy or on the pill. In New Zealand the test is not funded and Fertility Associates charge $75 in Auckland and slightly more outside of Auckland because of courier fees.

AMH is also useful in other scenarios. It allows IVF doctors to predict the right dose of drugs in an IVF cycle and therefore make IVF safer by reducing the chances of ovarian hyperstimulation syndrome. AMH levels are also higher in women with polycystic ovary syndrome (PCOS) and in the future may be used to diagnose PCOS.

AMH may also reflect egg quality. Our own data at Fertility Associates based on more than 2500 cycles, show that if your AMH is low (less than 3 pmol/l) then your take home baby rate on our IVF programme is significantly reduced compared to women with an AMH of 7 or more.
So really why would you not have an AMH test?

You can find out more from the PDF on our website http://www.fertilityassociates.co.nz/Downloads/0313-AMH-info-card-A5_LR.aspx 

Please choose one embryo at a time

At Fertility Associates we are thinking about becoming the first IVF unit in the world to only replace 1 embryo at a time no matter how old the patient nor how much treatment they have had previously. We perform over 3000 embryo transfers a year across our four clinics and about 20% of these cycles involve a double embryo transfer. Whilst twin rates have fallen from over 20% a few years ago to now about 8% of all of our pregnancies, we would like to see that rate fall further.

This is an ideal time to make this recommendation as freezing of embryos has become a very robust process, which means that one embryo at a  time gives the same overall chance of a baby as having two embryos at once.

Twin pregnancies have a higher rate of stillbirth, cerebral palsy and any degree of handicap in the babies. Twin pregnancies are also associated with increased maternal complications as well as relationship break ups.

Even when two embryos are replaced and  a singleton pregnancy results, the outcome from that pregnancy is not as good as when a singleton embryo transfer occurs.

I would like all of our patients to think about the risks to themselves and their children and to choose to replace 1 embryo at a time.

Information on Twin or Multiple pregnancies and the risks associated with it, can be found on our website in the Avoiding Twins PDF under Fertility Facts. http://www.fertilityassociates.co.nz/Resources/Fertility-Facts.aspx 

male varicoceles

Varicoceles are a collection of varicose veins around the testes much more commonly on the left and are present in between 4 and 22% of all men. However if men with primary infertility are examined then between 21 and 41% have varicoceles and men with secondary infertility have an even higher incidence. Varicoceles may run in families and may  worsen with time.
The association between varicocele and male infertility has been hotly debated for the last 50 years. Recently the world of science has  changed its view and is now saying that repair of a varicocele which is of moderate to large size is a useful exercise in men with fertility issues.The choice of repair either surgical or radiological is also up for debate.
Varicoceles are thought to impact on sperm health by increasing the temperature of the testes. The increased pressure in the veins may cause reflux of toxic adrenal and renal metabolites into the testes along with  chronic vasoconstriction of arterioles. This  leads to  under perfusion, stasis and hypoxia, and subsequent dysfunction of the spermatic epithelium . There is also evidence that DNA damage to the sperm is higher in men with varicoceles and that this reduces after ligation.
So what does this all mean? Men should be examined for the presence of varicoceles particularly when their semen analysis is abnormal or their DNA fragmentation level is raised.

Selecting Great Sperm

We are excited to be getting a technology called IMSI up and running in the next few weeks. IMSI stands for Intracytoplasmic Morphologicall Selected Sperm Injection. In an normal ICSI cycle the embryologist selects the sperm for injection at a magnification of 400x however IMSI is where sophisticated optics allows a magnification of 7000 to 8000x therefore enabling a much better look inside the sperm to select sperm without vacuoles within the nucleus. A recent meta analysis suggested that both implantation and pregnancy rates may be improved over conventional ICSI by 2 to 3 times with reduced miscarriage rates.
As yet it is not clear who may benefit from this technique possibly men with 2 previous failed ICSI cycles, poor embryo quality or poor sperm morphology or high levels of DNA fragmentation. The technique is time consumptive for the lab staff and will add about another $750 of cost.
We expect to offer IMSI by mid July and will announce its introduction on our website. It will be available initially through our Auckland Clinic only.

What to eat during an IVF cycle

I had always assumed that women knew what was a healthy diet and that they followed the general principles when going through an IVF cycle because they knew this would increase their chances of conceiving and also that their child would have improved lifelong health outcomes. However recent work has shown that women often eat poorly during their IVF treatment with many not having enough folic acid, iodine, carbohydrate or protein in their diet, with many still consuming caffeine and alcohol along with too much fat, salt and convenience foodc.
So this is a blog about what women should be eating when doing IVF treatment. Firstly, adequate folic acid supplementation which means 0.8mg daily and if a woman has a BMI above 30 then she should be taking 5 mg folic acid. The folic acid story is really confusing as many of the pregnancy supplements don't have the correct dose. The next absolute is to remove caffeine and alcohol from the diet, caffeine can be difficult as is present in a number of beverages not just coffee, such as tea, green tea, chocolate. coke and energy drinks. The NZ Ministry of Health Guidelines suggest women who are pregnant should be eating 6 serves of fruit and vegetables, two servings of lean protein, six servings of bread and cereals (preferably wholegrain), three servings of dairy (low fat yoghurt, trim milk), drink plenty of fluids, choose and prepare foods low in fat, salt and sugar. Here are the  Ministry of Health Guidelines . So eat well!

Birth Defects and IVF

There has just been an article published in the New England Journal of Medicine concerning this issue which is why I thought the subject deserved a blog. This paper showed an association between babies born from assisted reproductive technologies having a slightly increased risk of birth defects. What was important about this study is that it also looked at couples who had fertility issues but who managed to conceive spontaneously. This is valuable as we all want to know is this observed association due to the drugs and the lab processes involved in an IVF programme or is it due to the possibly suboptimal sperm and eggs which are causing a couple's infertility. This new study showed a similar increase in birth defects in couples with infertility who then conceived without treatment. This is a new finding.
They also found that the increase in birth defects was in children born after ICSI but not IVF. Children born from frozen and then thawed embryos showed no increase in birth defects even when they were from ICSI cycles. Possible explanations for this include a reduced chance of a suboptimal embryo surviving the thawing process or the absence of ovarian stimulating drugs.
It is really important that all people going through fertility treatments are aware of these findings and can make real informed decisions about their options going forward.