Luis HoyosReproductive Endocrinology & Infertility, IVF Florida
- IVF Florida
- United States of America
This is a very thorough committee opinion describing the state of the art in regards to ovarian reserve testing. However, I would like to play devil's advocate for a second about the following statement "markers of ovarian reserve should not be used to promote planned oocyte cryopreservation. Decisions regarding oocyte cryopreservation should be based on a woman's reproductive plans and age." While I agree with the substance of the statement, I do think that the decision should actually include ovarian reserve testing in addition to reproductive plans and age. In a hypothetical example of a 28 year woman with diminished ovarian reserve by antral follicle count (to avoid possible AMH assay technical difficulties), the decision to promote oocyte cryopreservation would be very different if she wanted to delay child-bearing until age 35-37 and her ideal family size was >1 child vs. if she wanted to conceive within the next two years or if her ideal family was just one child even if she decides to wait until age 35. Therefore, I do think that ovarian reserve testing definitely provides some valuable information to be used in conjunction with the woman's reproductive plans and age. If her ideal family size is >1 child and she is sure about delaying conception past age 35, she is at risk of a double whammy by adding decreased oocyte quality to the mix and therefore, not having done oocyte cryopreservation at an earlier age would be a missed opportunity.
Sounds like an interesting book full of great ideas for how to make the infertility journey less of a burden on our patients. Some of the mentioned advancements may be a sooner reality than others, particularly concerning frequent blood draws. The article, “Concordance of Fingerstick and Venipuncture Sampling for Fertility Hormones,” published in the Green Journal February 2019 showed that hormonal results for AMH, E2, FSH, LH, PRL, testosterone, TSH, and free T4 were concordant between venipuncture and fingerstick samples! While home sonography for follicle monitoring seems unbelievable, with the advances in automated, 3D follicular monitoring with SonoAVC, perhaps this really could become a reality in the future. A low-tech but welcome change I have noticed during the coronavirus pandemic is that it is encouraging clinics to very much reconsider whether each ultrasound, blood draw, or clinic visit is absolutely necessary, to minimize unnecessary risk to our patients.
Burke EE, Beqaj S, Douglas NC, Luo R. Concordance of Fingerstick and Venipuncture Sampling for Fertility Hormones. Obstet Gynecol. 2019 Feb;133(2):343-348. doi: 10.1097/AOG.0000000000003066. PMID: 30633131.
I completely agree. I think these changes are closer than we think and not not only will our patients benefit from them, but so will we. With all the terrible things we have gone through as a society due to the pandemic, we do have to acknowledge the opportunity that was given to us to change and improve several of our usual paradigms, the biggest being office visits for everything.
Congratulations to the authors for bringing this topic to our attention. I do think there may be a benefit from this approach which may not be biological but more from a psychological point of view as suggested in the article. There is such thing as treatment exhaustion which seems to be driving many of the differences among both groups. By having two retrievals close to each other, the number of gametes available increases in a short period of time which would increase the chances of success among poor responders. The question about whether this approach is superior to two retrievals farther apart is still unresolved, but if patients are dropping out and not having that other retrieval done, without taking into account potential decreases in ovarian reserve, that may be reason enough to offer DuoStim.
Thanks to Dr. Parra for participating in this conversation. He agrees with the fact that doctors, by virtue of their hyppocratic oath, have a responsability to society. Because of this, the Colombian association of fertility centers have recently released recommendations to guide centers on how to face the pandemic as well as care for patients during this time with responsability. They will be revising them almost daily to adapt them to the rapidly changing situation.
Thank you for providing us with this perspective. I do agree with the need to hold on any IVF for now and I think they key lies in the following statement "given the burden these measures put on patients and providers, any decision to hold IVF should be periodically and frequently revisited". The situation is very fluid and we should be reassessing it frequently, but for now we should all do our part as members of society.
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.
That's a great analysis Alex thank you for sharing! The way I see it, I was not that concerned about non-urgent cases since I was anticipating this to last a couple of weeks tops. However, those ethical dilemmas will become a real consideration if the recommendations persist for a prolonged period of time. If that were to be the case, another discussion would be warranted. At this point, the situation is very fluid and I am glad that our society said they would reassess the situation in the near future when I hope they take all those points into account.
Very strong statement -created/reviewed/approved in record time. I eagerly await the next update and hope that the Task Force has started to think about the criteria for "re-starting" infertility care.
I agree. The question in my mind is, if this is just the beginning and disease peak is anticipated to happen around July, as some experts have stated, what does that mean for us? No treatments until then?
We appreciate our society's invaluable guidance. We have implemented these recommendations and have halted non-urgent fertility treatment starts.