- University of Oklahoma
- United States of America
Influencer Of
Joaquin Llacer
Spanish reproductive specialist. My field is ovarian stimulation in low responders. I am particularly interested in the emotional care of the couple.
Spanish reproductive specialist. My field is ovarian stimulation in low responders. I am particularly interested in the emotional care of the couple.
Recent Comments
A very well done and important paper by the authors. I’m interested to know if there were indications for DET such as intended parent age or multiple prior transfer failures?
This article was featured as one of the F & S #Tweetorials. Check it out!
https://twitter.com/FertStert/status/1363245477601370116
Thank you to the authors for an important addition to the literature regarding male infertility and COVID-19. Regarding the decreased semen analysis parameters in those with moderate symptoms, is there a follow up evaluation planned to see if the parameters improve after the typical spermatogenesis timeline has passed?
Although an approximately doubling in LBR, the p value = 0.07. I'm curious if this potential benefit is cost effective to have so many days away from work in a short duration vs spread out a few months? I suppose the patient’s employer could be a big factor there, and you could also make the argument that if ovarian reserve is already not ideal, time is of the essence even if the LBR is not significantly increased.
These clinical recommendations during the COVID-19 Pandemic are extremely useful, and ASRM should be applauded for issuing these so quickly.
The core problem at the moment is that the extent and the consequences of the pandemic cannot be reliably predicted. It is possible that the current precautions may be necessary for prolonged periods of time.
That produces very challenging ethical dilemmas in all areas of life, including the area of assisted reproduction.
In our societies, quests to increase survival and decrease morbity and mortality in the population have the unwanted effect of challenging people's economic livelihoods: many people will lose their jobs, many companies will go bankrupt, many restaurants, bars, theatres etc will not survive this crisis.
Likewise, the quest to decrease medical risk to our patients and reduce morbidity in our "real" (already existing) and unborn patients has unintended consequences. A large proportion of our patients is right at the edge of a virtual "reproductive cliff" where waiting even a few months will result in decreases in ovarian reserve that make autologous conception impossible. It is impossible to know how many couples will remain childless because of Corona precautions, but depending on the length of the precautions it will be a significant number.
This raises the question: who decides when one risk is weighed against another? Is it up to professional organizations such as ESHRE / ASRM? Up to the doctor? Or up to the patient?
When the patient is given the choice, they may prefer to proceed with treatment while taking recommended (handwashing / social distancing etc) precautions, accepting the risk of Corona exposure and its unknown effects on pregnancy, because the risk of irreversible ovarian insufficiency is perceived as a worse outcome.
Doctors may feel similarly, and may be faced with the dilemma of weighing ethical principles of patient autonomy and "do no harm" against each other.
So should it be taken out of the hands of patients and doctors, and decided by professional societies such as ASRM / ESHRE?
If that is the case, then should the same logic apply to other recommendations such as elective single embryo transfer? Transferring more than one embryo exposes patients to the risk of multiple pregnancy, with the associated potentially devastating public health consequences. However guidelines are just a "guide", and doctors and patients can have educated discussions on how to proceed.
At what point does a "guideline" become a rigid unshakeable mandatory decree that needs to be followed by all doctors and patients?
The next few days and weeks will tell. Until this unusual period of time, it seemed far-fetched that countries would implement laws to limit people's movement, impose curfews or enforce quarantines in exposed individuals.
All of us will be charged with the difficult task of weighing competing risks to our patients and make the best decisions for them. Staying informed and engaging in the ongoing discussion (for example on this "Dialog" site) forms the basis for evolving treatment recommendations and guidelines going forward.
Agree with all of these comments, great insight. Each day seems to unfold a new set of challenges for both providers and patients. Hopefully the coming weeks will give us all more guidance as this fluid situation changes, and I'm interested to see what everyone else is doing in the discussion here.
In a clinically important contribution to the existing literature, these data do not support gonadotropin use w/ IUI in unexplained infertility patients. Click here to see the Fertility and Sterility #Tweetorial.
The content in this manuscript is an important discussion I will frequently have with my patients when faced with the decision of moving from failed clomid/IUI cycles to IVF. Although the cost of IVF is a significant burden, especially in non-mandated states, the risks of multiples must be considered. The high cost of gonadotropins and elevated multiples risk outweighs the high success rates of IVF and ability to transfer a single embryo.
Thank you to the authors for a clinically useful study in an extremely common diagnosis that we see on a daily basis. The findings make me think more about how we should be utilizing metformin in our daily practice. As we know, the ASRM Practice Committee documents summarize that there is good evidence that metformin + CC improves ovulation and clinical pregnancy rates, fair evidence that pretreatment with metformin for at least 3 months followed by ovulation induction increases live-birth rate, and good evidence that metformin decreases the OHSS risk in PCOS patients. In addition to recommending metformin for the obese and insulin resistant PCOS patients, as was done in the study at hand, I'm inclined to recommend metformin to ALL PCOS patients prior to undergoing infertility treatment. I'm interested to hear what others think as well as the authors.
Thanks for the reply, Luis. In those with risk factors for impaired glucose tolerance (family Hx, overweight, hyperandrogenism phenotype, obviously acanthosis) I'll get the recommended 75 g OGTT, but otherwise not perform any insulin testing. My thought is that if I'm already obtaining at least a TSH in someone who has AUB-O and/or has hyperandrogenism as part of my PCOS work up, then that would at least eliminate one main aspect of hypothalamic dysfunction if I took a "meformin for all" approach. To answer your question on metformin in phenotypes, I typically think about prescribing in the obese (or of course IGT) or NIH phenotype, as you mentioned. If they aren't obese, had an AFC of 45 and ultimately went to IVF, my thought is that would it would be nice to already have metformin on board to reduce OHSS risk so I'm not backpedaling once we start stimulating. I appreciate the insight!
Thank you to the authors for a clinically useful study in an extremely common diagnosis that we see on a daily basis. The findings make me think more about how we should be utilizing metformin in our daily practice. As we know, the ASRM Practice Committee documents summarize that there is good evidence that metformin + CC improves ovulation and clinical pregnancy rates, fair evidence that pretreatment with metformin for at least 3 months followed by ovulation induction increases live-birth rate, and good evidence that metformin decreases the OHSS risk in PCOS patients. In addition to recommending metformin for the obese and insulin resistant PCOS patients, as was done in the study at hand, I'm inclined to recommend metformin to ALL PCOS patients prior to undergoing infertility treatment. I'm interested to hear what others think as well as the authors.