Does ICSI cause birth defects? Does ovarian stimulation cause breast cancer? Does embryo biopsy hurt the embryo? Will these injections make me crazy? Will I gain weight?
These are all very important questions that I spend a significant amount of time discussing every day. But while it’s very reasonable to carefully consider the risks of any potential treatment, at least as much consideration should be given to the benefits.
For example, while some studies have shown a higher risk of birth defects in children born after ICSI (and the increase is very small), most couples with severe male factor infertility would not have had the opportunity to experience pregnancy and have a child if not for ICSI. This makes it difficult (if not impossible) to isolate the effect of ICSI. How can we know what the risk of birth defects would have been without ICSI if these children would not have existed without ICSI? When there isn’t a good control group with which to compare it is impossible to attribute risk.
Now, admittedly, we often use ICSI even when the male factor is not so severe, such as when preimplantation genetic testing like comprehensive chromosome screening (CCS) is performed. ICSI is required in these cases to minimize the chance of genetic contamination. Can we extrapolate the potential (but not proven) association of ICSI and birth defects to a couple with relatively normal semen parameters who is using ICSI to facilitate CCS? Probably not. The data on ICSI use for PGD is very reassuring. And the benefits of CCS in reducing the risk of transferring a chromosomally abnormal (aneuploid) embryo are absolutely clear: reduced risk of miscarriage, ongoing aneuploid pregnancies (such as Trisomy 13 – Patau syndrome), and multiple pregnancies (when elective single embryo transfer is employed). If a couple chooses not to use IVF/ICSI and CCS, they should also consider the potential effects of delaying pregnancy, which has an emotional toll and may result in a lower chance of ultimately delivering a healthy child.
The situation with breast cancer is similar. There are studies showing a small increased risk of breast cancer in women who underwent IVF and studies showing no increased risk. Whether the proposed association, if there is one, is due to the stimulation medications is unclear. However, the evidence is very clear that women who ultimately have a pregnancy and delivery reduce their lifetime risk of breast cancer. Those who choose to breastfeed even further reduce that risk. Women who are considering not taking gonadotropin medications due to this theoretical risk should also factor in the real risks of not achieving a pregnancy and delivery (which reduce the risk of breast cancer).
Of course there’s a lot more to fertility treatment than a simple risk-benefit calculation. Many people have a strong desire to have a pregnancy and deliver a child and are even willing to take some risks to help make that happen. Throughout history women have taken on significant health risks to have children. Pregnancy and child birth have never been safer than they are now, so those risks are rarely considered by most couples. Treatments like IVF provide an effective, and sometimes necessary, means to help achieve the goal of pregnancy. Advances in assisted reproductive technologies have provided the ability to reliably prevent ovarian hyperstimulation (OHSS) and multiple gestation, making these technologies even safer. The future is now with improved pregnancy rates and safer deliveries with elective single embryo transfer. So try not to get so caught up in the potential risks that you lose sight of the benefits.
Blog post by Dr. Eric J. Forman, MD, FACOG
Reproductive Medicine Associates of New Jersey Morristown, NJ