| (It is helpful to remember that though you may have CF, it may not cause you a problem with your fertility or that there may be other factors affecting your fertility besides CF. Do not rule out other issues, just because you also have CF. If you have been diligent in following the Four-Month Plan referred to on "Improving Fertility" as prescribed in Natural Solutions to Infertility by Marilyn Glenville, Ph.D. and tried to concieve for the suggested six months following the establishment of a healthy lifestyle without success, or the woman in your relationship is over 35, look for other possible causes of your infertility than CF and find the appropriate section on this page to read about your options. The decision to override nature is of greater concern with regard to maternal fertility, since it is her body that must nurture and birth this life. It is a very personal decision and the process can be frought with stress. It is important to have a good support system and even counselling in place for both of you--ed.) Recommendations from IVF Australia We recommend to all couples considering ART that they should: 1. Endeavour to maintain a healthy lifestyle - we know that alcohol and caffeine in excess adversely affect the outcome and smoking, or using any other recreational drugs, also decreases the chance of success. 2. Aim for a sensible weight for their height and build. It is harmful to be excessively over or under weight and this is reflected in much lower success. 3. Take a multivitamin containing folic acid (0.5 mg per day) as this has been shown to decrease the incidence of neural tube defects (eg spina bifida) in babies. 4. Stop taking herbal medicines as these may interfere with how the body deals with medications we provide as part of the treatment. Click www.ivf.com.au/htmlpages/ivf_introduction.html to view the article in entirety. (It may be helpful to contact your chosen ART clinic to find out what of your herbal therapies need to be stopped and in what time frame--ed.) CAUSE, INVESTIGATION and TREATMENT OPTIONS C: Failure of Ovulation I: Hormone Assessments T:Fertility drugs (tablets or injections) or Rarely ovum donation C: Blocked or damaged Fallopian tubes I: Laparoscopy or Hysterosalpingogram (HSG) T: Tubal microsurgery or IVF C: Endometriosis I: Laparoscopy T: Surgical/laser treatment or Drug therapy or IVF C: Fibroids I: Laparoscopy or Hysteroscopy or Ultrasound Scan T: May not need treatment but if necessary, can be removed surgically, often laparoscopically. C: Hostile cervical mucus I: Post-coital test (PCT) or Confirm ovulation or Antisperm antibody test T: IUI or IVF C: Failure of sperm production I: Initial semen analysis or Hormone assessments or Testicular biopsy T: Surgical sperm collection (SSC) or Donor sperm C: Blocked/absent vas deferens I: Scrotal examination or Screen for cystic fibrosis T: Unblock microsurgically or SSC with IVF/ICSI C: Low sperm numbers and / or poor sperm movement I: Semen analysis ("sperm count") T: IUI or IVF or ICSI C: High numbers of abnormal forms I: Semen analysis T: IVF or ICSI C: Antisperm antibodies I: Antisperm antibody screen T: Steroids now rarely used or Sperm preparation for IUI, IVF or ICSI Click www.ivf.com.au/htmlpages/treatment.html to view the table in entirety. Drugs for Male Infertility Most men with CF have sperm production that is completely normal but the sperm simply can't get out. However, if whether you have CF or not, there are a number of drug treatments that can be offered if problems are found with the quantity or quality of your sperm. FSH (Follicle Stimulating Hormone) FSH is vital for the production of healthy sperm. Click www.fertility.com/international/treatment/Female_Treatments/Second_Step/Follicle_stimulating_ Hormone.jsp for more about FSH hCG (Human Chorionic Gonadotropin) and hMG (Human Menopausal Gonadotropin) For LH and FSH deficiencies or a lack of GnRH. hCG and hMG can be used separately or in conjuction with one another to promote sperm production. If the problem is a lack GnRH, these drugs may help or you may benefit from pulsating GnRH therapy as described below. There is reason to believe that there may be a connection between lack of GnRH and too-low levels of zinc. See below description for possible side effects of hCG and hMG. Click www.ferringusa.com/fertility_products/insert_novarel.htm to read pharmeceutical information in hCG Click www.fertility.com/international/treatment/Female_Treatments/Second_Step/Human_ Menopausal_Gonadotropin.jsp for more about hMG Testosterone For low sperm count. Sperm require massive amounts of testosterone to develop properly and taking that amount orally would have very negative effects on the liver. It is often given where no hormone imbalance exists. Giving testosterone can actually create other problems with sperm production by decreasing naturally produced levels of FSH and LH. Therefore the use of testosterone where there is no hormone imbalance is of questionable value. Click www.nlm.nih.gov/medlineplus/druginfo/uspdi/500525.html for more about Testosterone Clomiphene or tamioxifen For low sperm count. It may be prescribed to men whose fertility problems are due to a hormonal imbalance. Unfortunately, these drugs have been given to men with no hormone imbalance, but to try to increase sperm count. The effectiveness of anti-estrogen treatment for men is unproven. Click www.pregnancy-info.net/infertility_clomiphene.html for more about Clomiphene Click www.jr2.ox.ac.uk/bandolier/band33/b33-6.html for more about Clomiphene and Tamoxifen Drugs for Female Infertility This is usually the first line of treatment if it is discovered that you are not ovulating but your fallopian tubes and your partner's sperm are normal. These drugs do not actually make you more fertile: they only work during the month they are being taken. Clomiphene Citrate and Letrozole Clomiphene citrate (Clomid and Serophene) and Letrozole (Femara) stimulate ovulation if you are not ovulating and it is also used if you have infrequent periods or long cycles. It is taken for five days early on in the cycle. This drug should not be used for more than six cycles. Although the drug is easy to administer, since it is taken by mouth, physicians recommend that it should only be prescribed when ultrasound monitoring can be done at the same time. Monitoring means that the dose can be altered, depending on your response to the drug. Letrozole is less likely to adversely affect uterine lining and cervical mucus. Risks and side effects can include: increased risk of ovarian cancer with 12 or more cycles of this drug, multiple births, bowel upsets, bloating, headache, dizziness, breast discomfort, blurred vision, hot flashes and depression, as well as increased rate of miscarriage. Click www.ivf.com/clom.html for more on Clomiphene and Letrozole hCG (Human Chorionic Gonadotropin) hCG is a sterile human hormone. This hormone should be produced naturally during the early stages of pregnancy. It (Profasi or Pregnyl) has been safely in use for over 30 years. It is given by subcutaneous injection 36 - 38 hours before your egg collection and is used to mature the follicles and to trigger ovulation. It (or progesterone) is also often given in lower doses after the embryo transfer to support the lining of the uterus to allow implantation. It is usually only necessary in hormone (clomiphene) stimulated cycles. Reported Side Effects: i. Breast enlargement ii. Ovarian tenderness iii. Abdominal distension - bloating iv. Nausea and constipation v. Pain at the injection site vi. O.H.S.S. (more information) Click www.ferringusa.com/fertility_products/insert_novarel.htm to read pharmeceutical information in hCG hMG (Human Menopausal Gonadotropin) This is one of the most potent ovulation drugs in use. It combines both FSH and LH and is given by injection.This drug is often used for women who have not had any success with clomiphene or have amenorrhea (no periods). Careful monitoring is needed to avoid hyperstimulation, where the ovaries can become enlarged and cause abdominal pain. Doctors will abandon the cycle if there are too many follicles present or if your estrogen level is too high. Risks and side effects can include: increased risk of multiple births, higher miscarriage rate, premature labour, mood swings, depression, and breast tenderness. Click www.fertility.com/international/treatment/Female_Treatments/Second_Step/Human_ Menopausal_Gonadotropin.jsp for more about hMG FSH (Follicle Stimulating Hormone) Like hMG this hormone is given as an injection. Because the demand for if has been so high, there is also a genetically engineered form of FSH called recombinant human FSH (Gonal-F or Puergon). This is a synthetic hormone which is exactly like a natural hormone but, being synthetic, it cannot carry any infectious agents. It is used to promote the growth of ovarian follicles and is administered as a subcutaneous (just under the skin) injection. This medication contains no LH and can therefore only be used by women who have adequate amounts of of their own LH. It can be useful for women with plycystic ovarian syndrome (PCOS). It is possible to obtain a kit with this drug so that you can self-inject. Reported Side Effects: i. Headaches, tiredness and lethargy ii. Irritability and tearfulness iii. Breast tenderness iv. Nausea v. Enlarged tender ovaries vi. Abdominal distension and discomfort vii. Fluid retention viii. O.H.S.S. (more information) Click www.fertility.com/international/treatment/Female_Treatments/Second_Step/Follicle_ stimulating_Hormone.jsp for more about FSH Bromocriptine This drug is used if a woman secretes too much prolactin. Prolactin is the same hormone that stimulates breast milk and can stop ovulation and periods because it inhibits the release of FSH and LH. Excess prolactin can also be caused by a benign tumor within the pituitary gland so cases of high prolactin (where the woman is not breastfeeding) should be investigated fully. This drug is given in tablet form. Risks and side effects can include: nausea, headache, dizziness, fainting and decreased blood pressure. Cabergoline is a newer drug for treating high levels of prolactin and it has fewer side effects than bromocriptine. Click www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682079.html for more about Bromocriptine Click www.nlm.nih.gov/medlineplus/druginfo/uspdi/203584.html for more about Cabergoline GnRH (Gonadotropin Releasing Hormone) GnRH is released naturally from the hypothalamus in small amounts every 90 minutes. This pulsing effect releases effect releases both FSH and LH from the pituitary gland. When the secretion of GnRH decreases it stops ovulation and causes infertility. Because GnRH works in a pulsing rhythm it has to be given in the same way to mimic the natural cycle. This means wearing an automatic pump 24 hours a day; at intervals of 90 minutes the pump releases the GnRH which goes to a needle inserted under the skin. Risks and side effects can include: slight risk of multiple pregnancy, headaches and nausea. GnRH Analogues - Synarel (Nafarelin) and Lucrin (Leuprolide) Synarel and Lucrin are synthetic drugs which are analogues (variants) of a naturally occurring brain substance. Synarel is given by nasal spray morning and night and Lucrin by a daily subcutaneous (just under the skin) injection. They both act the same way and the one chosen usually depends on the women's preference. They are long acting, at first stimulating the pituitary gland at the base of the brain (we call this a flare) but then paradoxically causing a sustained suppression (called down-regulation) allowing us better control over the hormone stimulation. They work for 10 - 18 days after the last dose so they may alter the next cycle in some way, e.g. longer or shorter cycle, lighter or heavier loss. Reported Side Effects: i. Headaches ii. Local irritation inside the nose or at the injection site iii. Occasional hot flushes and breast tenderness iv. Muscle weakness and pains, and double vision v. 1 in 500 women have a slight allergic reaction - shortness of breath, chest pains and rashes. If you have a reaction, stop the medication and call us so we can arrange alternative treatment. Click www.infertilityphysician.com/ovulation/GnRH.html for more about GnRH GnRH Antagonists Cetrotide (Cetrorelix) and Ganirelix (Orgalutron). These two drugs, known as GnRH antagonists, specifically and only stop the normal dramatic mid cycle rise of LH, which is the hormone that normally triggers ovulation. By suppressing the LH we can control the day of ovulation to allow more follicular growth. We only use these drugs for a short time around expected ovulation and they eliminate the necessity for �down regulation� using Synarel or Lucrin. They are not used as often because they are more costly and the pregnancy rate is not improved, except in some particular circumstances. They are relatively free of side effects. They come in a 3mg single dose or 0.25 mg multi-dose preparations. Click www.ivf.com.au/htmlpages/ivf_drugs.html to view a list from IVF Australia Click www.infertilityphysician.com/ovulation/GnRH.html for more about GnRH Antagonists Assisted Reproductive Technologies Unless there is a medical reason not to, Marilyn Glenville suggests you embark on assisted conception by trying the low tech treatments first. (If you are a man with CF and you have been found to have CBAVD, you can look either at the ICSI combination method if your sperm is normal and healthy or you can look at IUI with donated sperm if you do not produce sperm or it is abnormal and unhealthy--ed.) IUI (Intra-uterine Insemination) In this treatment we stimulate and monitor ovulation by a combination of drugs, blood and urine tests, and then, having determined the most fertile time for the woman we concentrate a fresh sample of the male�s sperm in our laboratory and painlessly inject it through the cervix up into the uterus (womb) using a very fine disposable catheter. This procedure is carried out for a number of reasons but when suggested for sperm problems it is only of use in the minor disorders. Click www.ivf.com.au/htmlpages/treatment.html to view the table in entirety. (It bypasses the woman's cervix and is effective for women whose mucus is too thick or inhospitable to her husband's sperm. If you are a woman age 35 or under and there is no structural reason for infertility in either you or your partner this should be the first ART offered --ed.) IUI can be used if you have a problem with ovulation because stimulatory drugs can be given at the same time. Stimulatory drugs are often given anyway to encourage two or three eggs to mature and to increase the chance of the technique working. IUI can be used with donor sperm if your partner is infertile. However, donor insemination is an emotional issue. There may be religious concerns and you should be counselled if donor insemination is required to enable you to conceive. Using a friend or family member as a donor is not usually advised. IUI has a good success rate--around 15 percent before the age of 35. Too many couples go straight to IVF without trying IUI or other options first. IUI costs only one-tenth of the amount of IVF. IVF (In-vitro Fertilization) With this method eggs are collected and put with sperm in vitro (although this means 'in glass' we actually use plastic). IVF is often chosen if the woman has damaged fallopian tubes or other specific problems which mean that normal fertilization cannot take place. IVF is also an option for women over age 35. Embryos that result from this are placed (we say �transferred�) into the uterus between 2 and 5 days later. They can, if suitable, also be frozen (cryopreserved) for later use. Click www.ivf.com.au/htmlpages/ivf_introduction.html to view the article in entirety. (IVF has a lower success rate for women after the age of 40, and so may be offered in conjunction with another procedure to raise chances of success. There are also issues with freezing embryos. Beyond the moral, ethical, religious issues of cryopreservation are issues of the viability of embryos after thawing. Many do not survive cryopreservation and still more do not survive being thawed out--ed.) ICSI (Intra Cytoplasmic Sperm Injection) This is a more sophisticated method of achieving fertilisation in vitro, (i.e. a more complicated form of IVF involving the scientists putting the sperm directly into the egg), and is used for those with severe male factor problems, (e.g. very few sperm, or very poor quality). It requires very expensive equipment, is labour intensive and is only used when conventional I.V.F. does not, or is not expected to, result in fertilisation. Click www.ivf.com.au/htmlpages/ivf_introduction.html to view the article in entirety. Combination Method for Men with CF The result combines three procedures. The first is MESA (micro- surgical epididymal sperm aspiration), the second is ICSI (intracytoplasmic sperm injection), and the third is transfer of the fertilized egg into the womb. MESA is used to retrieve sperm. A small incision is made in the scrotum, and the epididymis (sperm duct) is exposed. A tiny incision is made with microscissors in the part of the duct near the testis. A micropipette is then used to aspirate sperm cells from the duct. This procedure takes about 20 minutes and is done under local anesthesia. These sperm usually would not be able to fertilize an egg, because they have missed their trip down the sperm duct and so are not completely mature. The solution to this problem is ICSI. "We pick up a single sperm at a time and inject one sperm into each egg. This makes up for the fact that these sperm do not have the strength to fertilize the eggs themselves. Once they are put into the egg, they work fine," Dr. Silber said. Before the sperm are taken, the woman is given 10 to 14 days of hormone injections, which cause the ovaries to prepare several eggs at a time for fertilization. Dr. Silber puts a needle in through the vagina and aspirates the fluid and egg from each of the "ready" follicles in the ovary. "Once all the eggs are fertilized," Dr. Silber continued, "they are put into an incubator for two days. Then they are checked to see that they are developing properly We then pick three or four of the best embryos to transfer into the woman's womb. The chance of any single fertilized egg becoming a baby is about 15%. Dr. Silber has used the ICSI method in about 400 women, including about 150 who have CF "The pregnancy rate depends on the woman's age," he said. "If the woman is under 30, the pregnancy rate is over 50% per treatment. If the woman is between 30 and 36, the pregnancy rate goes down to about 35% (Table 1). Most couples should have a successful pregnancy within three tries if the woman is 30 years old or younger." He generally does not recommend in vitro fertilization for women over the age of 40, because of the low success rate. "No matter how advanced the CF is, we can always get live sperm from a man. Whether he wants to conceive a child is thus more a matter of social and psychological concerns. This method costs about $10,000 per treatment cycle at Dr. Silber's clinic. Insurance coverage is a patchwork and largely depends on whether your state insurance commission requires companies to cover infertility treatment. "ICSI Method Helps Men With CF Become Dads" by Janis Kelly, editor of CF Life Click www.infertile.com/inthenew/lay/cflife.htm to view the article in entirety. Possible Risks and Concerns of Drug Therapy or ART Ovarian Hyperstimulation Syndrome (o.h.s.s.) Despite close monitoring, approximately 5% of women will over-respond to the hormone stimulation, i.e. too many follicles develop so that the ovaries become very enlarged. If a woman shows unusual susceptibility during stimulation, she may be 'coasted' ( which means the treatment is stopped or reduced to allow the hormones to settle down) or the treatment cycle may be cancelled and the ovaries allowed to return to normal size. Future treatment then requires modification. Embryo Transfer Transferring the embryo(s) to the uterus may cause mild discomfort and carries a very small risk of infection (carried up from the cervix) and sometimes causes minor bleeding. Ultrasound Egg Collection Ultrasound guided egg retrieval may cause discomfort during or after the procedure and can cause: i. Internal bleeding ii. Puncture of abdominal organs iii. infection - especially if there are endometriomata iv. scarring in and around the ovaries Miscarriage Light bleeding (or spotting) occurs in up to 55% of A.R.T. pregnancies and should not cause undue concern unless it becomes heavy or is associated with increasing abdominal pain. Occasionally an ultrasound scan and further blood tests will also be required. Miscarriages still occur in up to 25% of all pregnancies (whether natural or by A.R.T.). Ectopic Pregnancy An ectopic pregnancy is one that implants outside the uterus, usually in the Fallopian tube. It occurs in approximately 1-2% of A.R.T. pregnancies, usually only when there is pre-existing Fallopian tube damage. Multiple Pregnancy National figures show twins occur in up to 30%, and triplets in up to 1%, of 'successful' A.R.T. cycles. This will be influenced by a number of factors (especially age) but is the result of transferring more than one embryo. Congenital Abnormality The congenital abnormality rate in A.R.T. babies is no different from that of the general population. Cancer The variety of medical and surgical treatments, including the drugs used in A.R.T., may have unknown long term effects. From the Australian cancer registers there has not been any increase in breast or ovarian cancer since the start of I.V.F. treatments. Click www.ivf.com.au/htmlpages/ivf_risks.html to view the article in entirety. Reading and Resources Natural Procreative Technology http://naprotechnology.com (Naprotechnology, pioneered over 35 years ago by Dr. Hilgers of Omaha, Nebraska, offers specialized procedures to restore fertility, uses only natural hormones, and has offered health and hope to many women that conventional fertility specialists/reproductive endocrinologists were unable to help. In accordance with Catholic beliefs on the sanctity of life and sacred act of co-creation with God, physicians who practice NaProTechnology do not offer AI, IVF, or IUI--ed.) |
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| Excerpts from various sources on the available and applicaple drugs and procedures to achieve pregnancy for men and women with CF |
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| Then God remembered Rachel, and God listened to her and opened her womb. Genesis 30:22 |