ivf Archives - Fertility Fact Checker

7 must knows for an IVF first timer

You’ve chosen your fertility clinic, got a grasp on the type of cycle you’re doing and you’ve got an action plan for administering those needles.

There is just a few more things you need to know…

1. It all takes so much longer than what you anticipate.

I don’t mean to start all negative here, but it really does and you are either going to develop your patience skills to equal that of Mr Miyagi in the Karate Kid, or go a little cray-cray. I’m sure it will be the first of those two options, but if it’s the second, take a breath and remember you’ve got this. And if you haven’t got this, seek counseling or see a doctor that knows you well. You definitely won’t be the first.

But back to the waiting. Whether its waiting to get into a specialist for an initial appointment, waiting for day 1, waiting to get the money together to buy your medications, waiting to get bloods done in the morning, waiting for the afternoon results to come in, waiting for your what-went-wrong appointment (otherwise knows as the WTF appointment) after an unsuccessful cycle or even waiting during the dreaded two week wait for that pregnancy result there is waiting behind every twist and turn.

And while I hope you are one of the lucky ones that get pregnant and get that take home baby on the first go, unfortunately, statistics indicate that most women will need to have more than one cycle.

Hoping for the best but preparing for the worst has never been more appropriate than when starting out the IVF journey.

2. You need to be kind to yourself.

And protect yourself. There may be days when you just can’t go to another baby shower. When the thought of going to your best friends babies first birthday is just that step too far. That’s ok. A good friend will understand and one that doesn’t perhaps wasn’t really a good friend to begin with.

Sometimes you know when you need to have a break and hold onto those emotional reserves for when you really need it.

3. Most of it – out of your control.

There are very few things that you can control in this whole crazy process. People who do everything absolutely ‘right’ may fail a cycle and those that do everything ‘wrong’ have success first go. Kind of put that in the ‘ignore bucket’ like hearing about unwanted teenage pregnancies… it really doesn’t help to try and find the fairness in the situation and it doesn’t make sense.

Similarly, ‘bad’ blood tests one day may quickly turn into ‘good’ news the next day at the ultrasound. It really is a rollercoaster and you can be thinking you are ‘kicking fertility goals’ one goals one day and ready to throw in the towel the next.

The quicker you learn that so much of it is out of your control, the easier it is.

4. Get fertility fit.

Not forgetting that you really can’t control a lot of what happens during an IVF cycle, there are just a few things you can control. This includes what you eat, drink and to an extent other toxins that your body comes into contact with.

I know now, before your first cycle your thinking all you really need is a few drugs to get you ovulating or a bit of ICSI to get the sperm to meet the egg and bam! The magic is all going to happen. And hopefully it will! But if it doesn’t, chances are in a cycle or two you are going to look for alternative ways to try and improve the success of your cycle and you’ll quickly read that there are some real changes YOU can make to try and improve the egg quality, lining and implantation rates BUT ideally you’ll be starting these changes three months before your cycle for them to have full impact.

I know many women have read the well-known book about increasing egg quality . This is a great book chock full of research and ideas. But for some women, this can also be a bit intense. An alternative read is ‘Eat Think Grow’ it also has research but in a lighter format as well as practical strategies (including 4 week eating plan and mindfulness strategies) on how to implement it and get going .

5. Be your best advocate.

I’ve said it before, but no one really cares as much as you if you get this take home baby or not. Except maybe your partner that is. Doctor’s are people too and you are paying them a lot of money to help you bring this little baby into existence. If you have a question about a medication, or aren’t sure why you are doing the same protocol for the 5^th cycle in a row, ask! This is happening to your body, so make sure you understand (more or less!) why you are injecting those drugs!

Similarly, if you have done several cycles and don’t feel you are getting anywhere, or that your concerns aren’t being heard or if it is just your gut instinct, it can’t hurt to get a second opinion. Well, it might hurt the back pocket, but nowhere as near as much as extra IVF cycles does. Sometimes just putting a fresh set of eyes on your situation can come up with a new (and more successful!) plan.

6. Quality over quantity.

Like every day of the week. Try not to get down when your fertility friend has 18 eggs harvested come collection day and you are feeling like a dried up hen with your two. Although, your friends eggs might be all the highest quality, chances are they may not be. Personally, I’d take a low number of eggs with a higher quality than a large number of maybe immature and lower quality eggs any day of the week.

7. Think about what you will do with any left over embryos – if you should be so lucky.

Ok, so not really a ‘must know’ but definitely something to think about…You don’t need to set the decision in stone and situations and feelings on the issue can change in a heartbeat (literally!). But being mindful of what you might want to happen with ‘left over’ embryos now might make it a little easier in the future if you are one of the lucky ones who manage to complete their family with embryos to spare.

Good luck as you go about your first IVF cycle. Hopefully doing everything you can now to prepare your body for it and setting your mindset to roll with the punches (and the victories!) will make the rollercoaster just that little bit smoother

Possible benefits of mindfulness when doing IVF (including increased DHEA and melatonin)

When I learnt at a seminar I attended this week that mindfulness can increase DHEA and melatonin levels in our blood, I was intrigued.

As you may remember from the free book, ’19 ways you can contribute to increasing your chances of IVF success’, optimized melatonin levels can be associated with higher numbers and quality of eggs come IVF egg pick up day (1).

Similarly DHEA, or dehydroepiandrosterone, is a bit of a controversial IVF supplement which is believed to increase egg quality, especially for those with diminished ovarian reserve or who have been poor responders to IVF treatment. There needs to be more larger studies supporting and evaluating its use but from the preliminary evidence there is, it seems like DHEA could be beneficial to increasing the live birth rates for some women doing IVF.

For example, in a very small study with only 33 patients (2) they found that the live birth rates for women who had DHEA supplementation were 23% where as those women who did not take the supplementation had live birth rates of around 4% (remember, it was only a very small study and although an increased birth rate of 19% for taking a tablet seems great, it is ‘only’ an extra 5 births… but it is certainly a start and a step in the right direction). You absolutely need to check with your treating fertility specialist to check that DHEA would be suitable in your situation (so no off-grid, unapproved supplementation) but maybe if we can support levels naturally through mindfulness that can only be a good thing?

What about mindfulness

At the seminar, led by mindfulness expert and international best selling author, David Michie, a study which found that when people meditate for five years or more the DHEA in their blood stream is the equivalent to someone twelve years younger was discussed. DHEA depletes as we age and if we can have the DHEA of someone twelve years younger, could that lead us to the path of having eggs twelve years younger? It seems unlikely that such a direct correlation exists, but while looking for evidence to support this theory, I found other remarkable statistics linking DHEA to mindfulness. For example, did you know people who meditate have upto 44% more DHEA than those who don’t? (3)

Whilst looking for the ‘smoking gun’ linking DHEA, mindfulness and IVF, I found that the studies linking mindfulness to increasing DHEA were sometimes just only looking at male populations, sometimes it only looked as far as it impacted cardiovascular health… unfortunately I could not find any evidence that examined directly, or even indirectly, of how mindfulness impacts DHEA in women, women with fertility problems or women doing IVF.

Mindfulness Benefits for IVF

This then lead me to think, that if you want to increase your DHEA or melatonin levels, by all means giving mindfulness a go is definitely worth it for this reason alone. But ultimately, to achieve the results that you want in the quickest time possible (forget yesterday, who doesn’t want that baby, like, 3 years ago?!) with a more evidence based approach, you are best speaking to your fertility specialist to see if supplementation might be right for you.

But mindfulness has so much more to offer than just its influence on hormone levels.

For many women doing IVF, the process can become EVERYTHING. Everything you eat, everything you touch, everything you do, the plans you make, the plans you don’t make, it all becomes linked as to how it’s going to possibly increase or decrease your chances of a take home baby this cycle. It’s mentally exhausting. Practicing mindfulness gives you the opportunity to have that weight taken off your shoulders even for the shortest time while you are doing it.

We focus so much on eating right and taking the medications at the exact time in the exact way that we forget to take care of our mental health. But as David Michie highlights, when we look at our physical health, the absence of disease does not equate to health. We can be incredibly unhealthy physically, not at all ‘fit’ and still not have an actual disease process going on. Similarly, we may not have a mental health condition, such as anxiety, depression or otherwise, but that still is not to say we are actually mentally healthy either. Mindfulness is what helps you achieve a better state of mental wellbeing as exercise helps you achieve a better state of physical wellbeing.

Other benefits of mindfulness

When we are in our one thought IVF tracked mind it is hard to open up to other things and experiences. It is, understandably, easy to get resentful with the world – especially the 25 year old you share an office with who ‘boom!’ accidentally got pregnant. Giving yourself the head space to get out of that mindset even if it is just for a short period of time at first lets you feel less stressed, develop better coping strategies, become more accepting, innovative, creative and taking one more step towards living your most vivid life.

How to practice mindfulness

I’ve written about the benefits of mindfulness to IVF success rates in previous posts and also given some practical exercises for you to get started on. Although you can get benefits from day one, overall for the best results you need to practice mindfulness on a daily basis. As David Michie points out, you don’t go to the gym just the one time and then wonder why you haven’t got abs of steel. Similarly, don’t just practice mindfulness the one time before deciding it’s not for you. Like going to the gym, it seems there is direct correlation between the hours you put in and the impact it has.

But if you want a time frame to aim for, David Michie guarantees if you practice mindfulness five times a week for six weeks you’ll definitely see these rewards.

I write a lot about mindfulness in Eat Think Grow. In fact, there are mindfulness or mindset suggestions for every day of your cycle and it is specifically tailored for women doing IVF. It focuses on helping you through every step of your IVF cycle and is written from the perspective of someone who has been there and knows how you might be feeling.

There are also other mindfulness resources around, including apps such as ‘Insight Timer’ and ‘Smiling Mind’ and books such as ‘Why Mindfulness is Better than Chocolate’.

Like so many practices that will ultimately influence your quality of eggs and overall health, the key is just to start. If you are not ready to take the plunge into a more detailed mindfulness program, such as Eat Think Grow, for now just start the day taking three deep breaths. Breathing in for about 3 seconds and out for around six, focus on nothing but these breaths. Pay attention to the temperature of the air, the sound your breath makes, the rise of you abdomen as you breathe in and lowering as you breathe out. Let your thoughts only focus on these three breaths… It will certainly be a start in clearing away some of the unwanted and often negative thoughts that may be swirling around your mind.

To sum it up

Although it seems that there is still so much that is unknown about the mind-body connection, there is still so much information that supports that the way we think and feel can have a direct relation to our physical health. Already they have linked serotonin, cortisol and other steroids (which all potentially impact our IVF health) and here we have mentioned DHEA and melatonin.

While it is likely that by practicing mindfulness you will see an improvement in these hormone levels in a natural way (which is theoretically a great thing for egg health during IVF) the other benefits of mindfulness on your ability to cope and get through what for many women may be some of the most challenging times of their life, is equally, if not more so, important.

PS If you have any worrying thoughts that turn towards harming yourself, those around you, or you feel have gone on just a bit too long, make sure you speak to a health professional that knows you. There are many treatments out there – and some of which will be suitable for women doing IVF or, hopefully, about to be, pregnant.

Reference

Fernando, S. & Rombauts, L. (2014) Melatonin: shedding light on infertility? – a review of the recent literature. Journal of Ovarian Research 7 98
Wiser, A., Gonen, O., Ghetler, Y., Shavit, T., Berkovitz, A and Shulman, A. (2010). Addition of dehydroepiandrosterone (DHEA) for poor-responder patients before and during IVF treatment improves the pregnancy rate: A randomized prospective study. Human Reproduction, 25 (10) 2496–2500
https://eocinstitute.org/meditation/immune-brain-chemicals-how-meditation-boosts-dhea-melatonin-gh/)

Is IUI the best choice for women with unexplained infertility?

Up to 25% of women with fertility difficulties are ‘unexplained’. So there are certainly a few ladies who will be interested to know that a comprehensive literature review evaluating the success of intra-uterine insemination (IUI) for women with unexplained fertility has confirmed its findings (1).

In an attempt to determine if IUI (both with and without medication) is more successful at achieving higher birth rates than timed intercourse or ‘expectant management’, the findings from 14 studies including 1867 women were combined and analysed. ‘Expectant management’ by the way is letting nature run its course with no intervention. I find the term quite ironic in the fertility setting because that is the whole point – fertility patients are not ‘expectant!’

Remember, this review was completed to examine the impact of IUI for women with unexplained infertility. Not women with PCOS, not women who has a partner with low sperm count, just unexplained.

Interestingly, the authors included studies that examined women with mild endometriosis. Mild endometriosis was presumably not considered troublesome enough of a diagnosis to be the cause of preventing a woman getting pregnant. Women who had a diagnosis of moderate endometriosis however, were not included in the study. It seems that having moderate endometriosis was a reason for being unable to conceive and hence these women were not categorised as ‘unexplained’. You with me? Whilst we can appreciate why this distinction was made, I wonder if in years to come, as more research is completed if this distinction will change. From what I understand, how the reproductive system works – both in isolation and when interacting with our other systems such as the endocrine and immune system – it is in such a delicate balance. Perhaps one day even mild endometriosis will be found to have, for example, a very subtle immunological response that means it is widely recognised as a cause for fertility problems. Ultimately this may change the diagnosis and label of ‘unexplained’. But for now and the purposes of this review, I digress.

Using IUI

In some instances of unexplained infertility IUI is considered the first port of call. It is financially less expensive and places less physical stress on the woman trying to conceive than IVF. Though if you ask me, and anyone else who has had a two week wait after an IUI, psychologically it is just as hard. IUI can be completed either with ovarian hyperstimulation or without. Ovarian hyperstimulation is when medications are administered to stimulate the ovaries to produce and release an egg. When there is no ovarian hyperstimulation, this is also referred to as a ‘natural cycle’.

Benefits of IUI with ovarian hyperstimulation

IUI with ovarian hyperstimulation is thought to have a few added benefits when compared to IUI without ovarian hyperstimulation. One of these is that with the hCG trigger shot (such as pregnyl or ovidrel) doctors theoretically can more accurately pin point the time of ovulation (1). This means that you can be more sure that when the sperm is inseminated, it is at the right time to fertilise the egg and hopefully get that BFP.

Another reported benefit is that IUI with ovarian hyperstimulation enables some subtle abnormalities with follicle and endometrial lining growth to be ironed out (1). I kind of see this as your reproductive system getting ‘hijacked’ and being coerced into do the ‘right thing’ through the administration of medications.

Costs of doing IUI with ovarian hyperstimulation (and not the financial kind)

From what I read, the main negative is that there is a risk of ovarian hyperstimulation syndrome (OHSS). Presumably though this would be much less of a risk than women undergoing IVF as the quantities of medication being taken and the amount of follicles and eggs that are being grown are in much smaller quantities.

Another negative is the risk of a woman falling pregnant with multiple children. If during ovarian hyperstimulation a woman has three follicles growing there is a chance that all three follicles contain eggs and could fertilise (If you have more then two follicles growing in an IUI cycle sometimes your clinic will cancel your cycle for this reason). This risk would have been a little better controlled in IVF as most often only one or two embryos are actually transferred. It is also because of the risk of multiples that NICE fertility guidelines states that ‘ovarian hyperstimulation should not be offered to women with unexplained infertility.’

Regardless of the NICE guidelines though and the very real risk of complications to yourself and your future children, I am willing to bet that most women experiencing infertility would certainly take take their chances if it meant that an IUI with ovarian hyperstimulation would mean higher success rates…am I right?

Well, does IUI in unexplained infertility have good success rates?

Remember this is only the results from this literature review (1). There may be very real reasons why your odds are better (or worse) for a particular treatment and only a conversation with your doctor about all the alternatives can clarify that.

What this literature review did was compare a number of the different protocols of IUI against each other. These were:

IUI versus timed intercourse where both were done in a natural cycle – that is without ovarian hyperstimulation
IUI versus timed intercourse, both using ovarian stimulation
IUI in a natural cycle versus IUI in a stimulated cycle
IUI in a stimulated cycle versus timed intercourse in a natural cycle (similar to expectant management)
IUI in a natural cycle versus timed intercourse in a stimulated cycle.

The findings were:

1. IUI without stimulation when compared with timed intercourse, also without stimulation was found to have no evidence of a difference in cumulative live births between the two groups. The evidence suggested that if the chance of a live birth with timed intercourse was assumed to be 16%, that of IUI would be between 15% and 34% (remember the results are reporting cumulative birth rates, not birth rates per cycle).

2. IUI versus timed intercourse, both in a stimulated cycle – again the study reported that there was no evidence of a difference between the two treatment groups with the evidence suggesting that if the chance of achieving a live birth in timed intercourse was assumed to be 26%, the chance of a live birth with IUI would be between 23% and 50% (though I can see what you are thinking, it looks like the IUI was still better, though remember that this is cumulative birth rates and the difference may not have been statistically significant)

3. IUI in a natural cycle versus IUI in a stimulated cycle – there WAS an increase in live birth rates for women who were treated with IUI in a stimulated cycle compared with those who underwent IUI in natural cycle (without stimulation). The evidence suggested that if the chance of a live birth in IUI in a stimulated cycle was assumed to be 25%, the chance of a live birth in IUI in a natural cycle would be between 9% and 21%.

4. IUI in a stimulated cycle versus timed intercourse in a natural cycle– there was no evidence of a difference in live birth rate between the two groups The evidence suggested that if the chance of a live birth in timed intercourse or expectant management in a natural cycle was assumed to be 24%, the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%.

I find this one particularly interesting as surely an IUI in a stimulated cycle would be better than just letting nature do run it’s course? What it does say though, is that in the context of this particular study, for women who are experiencing unexplained infertility, there is still just as much of a chance that a pregnancy may still occur by trying through the ‘old fashioned way’ than by having a full blown IUI!

5. IUI in a natural cycle versus timed intercourse in a stimulated cycle – There was evidence of an increase in live births for IUI. The evidence suggested that if the chance of a live birth in timed intercourse in a stimulated cycle was assumed to be 13%, the chance of a live birth in IUI in a natural cycle would be between 14% and 34%

In Summary

Personally, I find it is difficult to see any rhyme or reason as to the above results. In some cases it is the IUI itself that seems to improve success rates but sometimes it doesn’t. Other times medication might be key to success but then this is not continued. And then in another scenario a stimulated IUI had no statistically significant improvement over ‘expectant management’! It did appear though that if you had decided that you needed to take action and see if an IUI was going to work for you, IUI with medication was the way to go.

The author of the study came to the conclusion that:

There was no conclusive evidence of a difference between most treatment groups in cumulative live birth rates (i.e. rates at conclusion of a course of treatment)… for couples with unexplained subfertility undergoing IUI when compared with timed intercourse, both with and without ovarian hyperstimulation

Before you ask your fertility specialist why you are doing one set of protocol over another, remember the following:

As always in fertility research more evidence is required. In this instance more studies examining each of the different situations would have led to stronger quality of evidence.
Your past medical history or individual set of circumstances may have led your fertility specialist to recommend one intervention of another which may seemingly contradict these findings.
The above findings are for cumulative birth rates – which in this instance means that when this treatment has stopped for one reason or another, then that is the outcome. It should not be confused with the success rates for each cycle ie each monthly treatment.
There is obviously a wide discrepancy in success rates across the studies which again reflects individual circumstance as well as highlighting a need for larger more precise studies.
The mean or median age (depending on the study reporting) was 30 – 33 and the findings shouldn’t necessarily be extrapolated out of this age range
Donor insemination was excluded from the study and it only included men with an average sperm sample.

Finally

As said previously, although this was a comprehensive review of the literature done to date these results are not necessarily the be all and end all and there is definitely room for the results to change in the future with more research.

At the moment it may appear that IUI for couples with unexplained infertility IUI isn’t necessarily the best evidence based approach to take, but does that necessarily mean that IVF is? IUI is cheaper and often physically easier for many women. For those reasons it still may be a very worth while first port of call when entering the world of fertility treatments.

Reference

Veltman-Verhulst SM, Hughes E, Ayeleke RO, Cohlen BJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD001838. DOI: 10.1002/14651858.CD001838.pub5.

Acupuncture and IVF: Does it help?

***For a 2018 update click here…

Acupuncture. Its one of those things that you feel you should do when having fertility treatments, but you’re not really sure why, when in the cycle you should have it or if it does actually work. I took the time to sift through all the research to see if it is actually worth our while. By the way, this is a long post packed full of evidence and information. If you are limited for time skip towards the end for a quick summary.

I remember my trip to an acupuncturist. And yes, I use the word ‘trip’, as in singular. Having decided to try and leave no stone unturned in the pursuit of a BFP I duly attended the acupuncturist which was attached to a nearby nutritionist (using the theory that if she was attached to other holistic type health people then surely I was on to a winner!). Despite looking up her qualifications, experience and interests (there was ‘women’s fertility’ listed with about 10 other ‘specialty’ areas) I was disappointed about her lack of insight into the fertility world and I definitely got the sense that she considered me to be ‘jumping on the bandwagon’ by pursuing IVF. Sitting down to discuss the treatment I told her my diagnosis, which included PCOS and she didn’t seem to think that there was a problem with the fact that ovulation was few and very far between, along with all the hormonal difficulties women with PCOS can have, and said that pregnancy was just a matter of time. When I asked about the mechanisms behind acupuncture I was told it was just about improving blood flow to the uterus and pointed at a diagram on the wall that was meant to be the explanation. I perhaps wasn’t the best acupuncturist patient and was a little anxious about the whole thing and the sensation of the needles going in was not a pleasurable one (for me anyway). But I think relaxing and discussing problems with a patient is as much part of the therapy as the therapy itself. Well, kind of. But I think the real kicker came when I was left to ‘relax’ for 20 minutes, which incidentally turned into 50 minutes, without music but with the soundtrack of the man next door discussing his bowel habits with the nutritionist! Anyway, convinced that she had forgotten about me and shouting out to attract her attention, she eventually came back and I eventually left– it was all quite bizarre. You hear a lot that the main benefit to acupuncture is taking the time to relax and distress and that’s the main way that it helps you, if that is the case it certainly didn’t help me. For those that are wondering it was a BFN that cycle by the way.

But that’s just me. I know a lot of people who have had acupuncture and rave about it. A lot of people find it relaxing and its stress relieving properties, like I said, seems to be one of its main perceived benefits in fertility treatments. Along with its ability to ‘improve bloodflow’ that is.

So how does acupuncture work?

In its most basic form, acupuncture involves inserting a number of needles into the body at certain points, or acupoints, along meridians in the body. There are around 400 acupoints running along 20 meridians – 12 primary ones which are generally associated with internal organs, and 8 extradordinary ones. Accupuncuretoday goes on to describe that ‘qi’ flows along the meridians. Qi is described as kind of like an energy or a vibration that carries the effects of the acupuncture from one acupoint to another. When the qi flows the body is able to work properly. There are certain acupoints that must be stimulated on various meridians to treat different ailments. For example, the acupoints for treating fertility will be different to those for treating back pain. For a full list of acupoints, have a look here.

But HOW does it work for FERTILITY?

In an overview of the use of acupuncture in gynecology, Napadow et al stated that in her view, recent basic and clinical research has demonstrated that acupuncture regulates uterine and ovarian blood flow, and that the effect is most likely mediated as a reflex response via the ovarian sympathetic nerves, and that the response is controlled via the supraspinal pathways

So it seems as if my acupuncturist was correct in that acupuncture assists with blood flow. AND there seems to be some sort of medical explanation for it. Because of the increased blood flow to the uterus, it also produces a healthier uterine lining and helps with implantation (1)

Besides in just assisting with blood flow, there are a number of other ways in which it can possible help IVF and pregnancy outcomes:

Acupuncture is well utilised for the management of pain. This is due to an increase in a type of endorphin when acupuncture is performed. When endorphin is altered it has a knock on effect of affecting hypothalamic function which is responsible for gonadotropin-releasing hormone which in turn impacts Follicle Stimulating Hormone and Luteinising Hormone and the overall functioning of the menstrual cycle (1). As we know these are all very important hormones in the IVF process (and the ones that are monitored closely when you go for regular bloods) so regulating these with help from acupuncture, should impact positively.
Acupuncture can encourage the production of naturally occurring opioids which are generally pain killers but is part of a chain of events that can also manage stress(1). Which brings us back to that chestnut of ‘relaxing’. Obviously if you are in my situation and find the acupuncture stressful, whether that be due to the process itself, the financial costs or the time it takes, then these benefits are probably not going to be felt and acupuncture may not be your thing.
Another study found that if acupuncture is done in the follicular phase, that is before egg collection, then it may affect the stem cell factor in the follicular fluid that surrounds the eggs causing better quality eggs and hence a better quality embryo (Chen et al as cited in 3)
And finally, acupuncture may also assist in hormonal balance during the implantation stage, again regulating hormones in this way and helping the embryo to implant (3).

So… Does It Work?

There have been quite a number of studies done on acupuncture trying to determine its use and benefit. It seems that each study seems to say a different thing. This is event the case for meta-anaylsis studies (where a researcher looks at all the relevant experiments that have been completed and combines it into one big summary so to speak). One article will state that acupuncture is helpful in increasing pregnancy rates whilst another will say that it does not increase live birth rates.

The most recent Cochrane Review stated that there was no significant difference of acupuncture on fertility treatments. This was regardless of whether acupuncture was done around the day of egg retrieval or around the day of embryo transfer (4).

Interestingly though the Cochrane Review evaluated acupuncture against different types of controls. That is, they compared the effectiveness of acupuncture against having no acupuncture and also examined studies where the effectiveness of acupuncture was compared against sham acupuncture. Sham acupuncture is where needles are used that retract back into themselves after hitting the skin and hence doesn’t penetrate the skin like a normal acupuncture needle – though the feeling is still the same and women receiving this treatment would have definitely have thought they were having acupuncture done. What they found was that when having acupuncture was compared against this sham acupuncture there was no significant differences in the live birth rate; however, when acupuncture was compared against having no treatment at all there was a significant difference in the live birth rate! This perhaps suggests that it is not the actual acupuncture and its effect on qi and manipulation of acupoints but that perhaps some placebo effect is having effect and the act of participating in the treatment is more beneficial then the actual treatment itself.

Saying all that though, there was another study done that looked at when in their cycle women had acupuncture done and if this had any impact on pregnancy. They looked at women who had it done during follicle phase (when eggs are still developing before pick up), on the day of egg pickup, before and/or after embryo transfer and during implantation stage. What they found was that there was ‘no statistically significant difference in … treatment (that was) performed only around the time of embryo transfer, follicle phase or implantation phase’ (3). They did indicate though ‘that acupuncture increased pregnancy rates when performed at follicle phase and 25 min before and after embryo transfer or 30 min after embryo transfer and after the implantation phase in the IVF process’ (3)What this seems to be saying is that acupuncture does seem to have a roll but just going at egg pick up or transfer isn’t going to be enough. It needs to be done consistently throughout the follicular phase, that is when you are being stimulated and taking medications, AS WELL AS before and after embryo transfer and even perhaps during implantation phase.

At exactly what times in these phases isn’t exactly known. Some studies had women having acupuncture at day 1 or 7 or 9 …or more! It varies a lot and seems to be at the whim of whoever designed the experiment. Perphas if you think that acupuncture might be worth trying, and you have the time and the money to give it ago, that should be something that you can discuss with your experienced acupuncturist.

You haven’t really given me an answer here…

No, to reply to my own comment, I haven’t. Although from what I have read, most articles seem to support the theory that acupuncture is not of any significant assistance in fertility treatments there is none the less still wide ranging views.

There are a number of reason why there is so much disparity:

Having acupuncture can come in many different forms. As we have noted, some women go for just a ‘one off’, some may go for the duration of their cycle, some just before egg pickup and some just before and/ or after embryo transfer. There are many different timeframes as to which you can receive acupuncture and to date studies seem to be evaluating the effectiveness of acupuncture (in no consistent format) to no acupuncture, rather than evaluating the effectiveness of the different formats…This makes it more difficult to compare apples with apples, so to speak.
It seems that the skill of the practitioner can and does, impact on success of the acupuncture. When these studies have been completed there are some instances of inadequately trained practitioners performing the acupuncture. If it is not an experienced and knowledgeable practitioner inserting those needles it may as well be as useful as having sham acupuncture (though as we previously noted this has been found to be just as useful! Confusing much?!)
The location of the acupuncturist and the effort it takes to attend such appointments also needs to be taken into account. There was one trial in which acupuncture was found to lower the rate of pregnancy. One theory for the reason for this result was that the study required patients to drive to an acupuncturist before and after embryo transfer rather than have acupuncture ‘on site’ where the transfer was being completed. It is thought that driving to this extra appoinment timed just before and just after the transfer, added stress in an already stressful day and this extra stress helped explain this difference (2). Don’t get scared off though, this (from what I have read) is the only study to have had this ‘negative’ result, it should also be noted that the group NOT receiving acupuncture had a freakishly high success rate – nearly double of what it should be. This in turn would make anything in comparison look bad.
None of the studies seem to break down what the medical conditions are of the women receiving the treatment and the reason they are receiving IVF. That is a woman who is having IVF due to male factor infertility will likely to have different hormone levels then a women with severe PCOS and hence the impact of acupuncture may be different. If further research was completed it may, or may not, help to identify, or rule out, which groups of women are likely to benefit from acupuncture.

So in summary…

Evidence is varied whether or not acupuncture in fertility works and as in many of the topics surrounding fertility more research is needed. Some say it does and some say it doesn’t have any impact on pregnancy rates and increasing the chances of you getting your ‘take home baby’. If you do happen to have the time and the money there does not appear to be any harm done so is perhaps worth a try – even if it is just to get some ‘stress relief’ or benefit from a placebo effect.

If you do decide to that acupuncture is for you, remember that some of the evidence suggests that there is only benefit if done throughout the cycle and not just as a one off, tick the box kind of activity. Unfortunately, there is no set regime for these what days to get acupuncture and you would need to find a reputable acupuncturist specialising in fertility to help you form a treatment plan. Put the effort into finding an acupuncturist who understands the unique challenges that fertility patients face, the various medical conditions that cause fertility and is willing to take the time to tailor your treatment for you.

References

1. Cochrane, S., Smith, C., Possamai-Inesedy, A. & Bensoussan, A. 2014. Acupuncture and women’s health: an overview of the role of acupuncture and its clinical management in women’s reproductive health. International Journal of Women’s Health 6: 313 – 325

2. Stener-Victorin, E. & Manheimer, E. 2011. Commentary on the Cochrane Review of acupuncture and assisted conception. Explore (NY). 2011 ; 7(2): 120–123. doi:10.1016/j.explore.2010.12.01

3. Shen, C., Wu, M., Shu, D., Zhao X. & Gao, Y. 2015. The Role of Acupuncture in in vitro Fertilization: A Systematic Review and Meta-Analysis. Gynaelogical and Obstetetric Investigation 79:1–12 DOI: 10.1159/000362231

4. Cheong YC, Dix S, Hung Yu Ng E, Ledger WL & Farquhar C.2013. Acupuncture and assisted reproductive technology (Review). The Cochrane Library, (http://www.thecochranelibrary.com) issue 7

Does bed rest help after an embryo transfer?

As if there isn’t enough to worry about after an embryo transfer, worrying that you are ruining any chance of a BFP as you have to get up and go straight after an embryo transfer is up there. This is especially so for women who need to go straight back to work after taking all that time off for blood tests and monitoring, the egg collection and the transfer itself.

Everyone has an opinion on how much bed rest you need and it ranges from none at all, to 10 minutes straight after the transfer to up to three days (who has time for that?). Saying that though, who amongst us wouldn’t lie flat on our backs for three weeks if it was proven to increase the probability of a successful embryo transfer?

When I searched ‘bed rest embryo transfer’ in a medical search engine I found less than 10 articles directly related to this topic in the last 10 years. Needless to say more research would be useful. Or would it? I only say this for I couldn’t find one piece of evidence that indicates that bed rest is beneficial – has this conclusion already been drawn?

The JURY IS IN

If it were to be summed all up in one sentence, Abou-Setta et al in their 2014 Cochrane Review (1) report

there is insufficient evidence to support any specific length of time for women to remain recumbent, if at all, following embryo transfer

So it seems as if there is no evidence to support the need to rest after a transfer. To reach this conclusion they did a thorough search for all trials that had been conducted and found two studies that they thought were appropriate, consisting of 594 patients. When we think of how many embryo transfers get done every day and the amount of money that changes hands, I think that this indicates a disproportionately small number of research articles being produced. But hey.

Abou-Setta et al (1) also highlight that the research done is of low quality and recognises that more research is definitely needed in this area which may help to change future thinking.

Well at least it doesn’t do any harm…?

Gaikwad et al (2) report that even 10 minutes of bed rest following embryo transfer can be detrimental. They report on one study where there were two groups of women – one who had been told to rest following transfer and one who didn’t rest. Ultimately this study had to be abandoned for ethical reasons because it became evident early on that the women who rested following a transfer had a lower chance of a successful outcome then those who did not. Gaikwad speculates on other investigators thoughts as to whether or not the seemingly detrimental effect of bed rest is due to the position of the uterus when lying down as well as speculating that continuing on with every day living helps manage our coping strategies and anxiety levels which has previously been researched to have an impact on success rates.

The amount of time women are recommended to rest in bed also varies. This has also been researched and regardless of whether the bed rest is for 10 minutes (2), 30 minutes (3), one hour (4) or one day (5) it seems that the less time that is spent in bed post embryo transfer the better the chances of pregnancy and ultimately a take home baby. It should be noted that there is some conflicting evidence and not all researchers say that bed rest is detrimental (though they do all seem to concur that it is at the very least not beneficial).

Why is bed rest recommended?

Whilst I am sure that they exist (surely?!) I have been unable to find any articles, proper research articles or internet articles that support the need for bed rest, despite the chat rooms and forums being full of women who report that their specialist advised them to do so. Whilst these articles are also not saying to go run a marathon (who would with ovaries the sizes of oranges) why are a lot of women undergoing embryo transfers still be advised to do so? Remember though if your specialist has recommended a period of rest for you, query it with them, there could be something in your particular medical history that makes it a worthwhile pursuit… maybe…

Other reasons why bed rest is not required

Placement of embryo

Personally, despite the fact that whilst I try and linger horizontally in the ‘transfer room’ as long as possible after a transfer, the rational side of me believes that rest is not required and the embryo isn’t going to ‘fall out’ as soon as you stand up. When you look at the thousands of years of natural conceptions that happened prior to IVF, I am pretty sure that not one of those fertile women even thought to have a lie down on day 3 or 5. Especially for those ladies who do the day 5 transfers the location in your uterus where your Specialist places the embryo during the transfer is pretty much exactly where it would be by day 5 in nature, ie typically towards the top of uterine cavity after traveling through the fallopian tube. And for those ladies who don’t do day 5 transfers, embryos can move and fertilise at any point in the fallopian tube or uterus so again, no stress required! Those ladies who really do think about things a lot, yes transferred embryos can move around, but they are pretty well supported once they are in they are in there (its not as if there is just a totally empty space) and the incidence of ectopic pregnancy in IVF gestations is around 1.3% (Australian Doctor, 27th March 2015) which when you think about the overall success rates is relatively low and putting yourself on bed rest because you think the embryo is going to move around doesn’t really outweigh the reasons for NOT going on bed rest.

Circulation and blood flow

Additionally, when we are moving around the circulation through out body is improved, this includes circulation to the uterus. The longer that we are immobile or resting in bed, our circulation system slows meaning that less blood is being pumped around the body and to the uterus. One of the reasons some of us take low dose aspirin or visit the acupuncturist is to try and increase blood flow to the uterus so why would we want to do anything that inhibits this. By increasing blood flow some believe that this can increase the quality of the lining which ultimately supports implantation. When you look at it from this point of view, we really should be making sure that we are doing light exercise and improving circulation throughout the cycle.

Over thinking time

When we are on bed rest it gives us too much time to think. Whilst for a short time we may be secretly quite happy to finish off the Orange is the New Black boxset our mind will pretty soon start turning back to the little ball of cells that has been placed inside of you. One thing that fertility patients tend to do very well is think, which inevitably leads into a dangerous cycle of self blaming, stress and anxiety. No thank you. And this theory is also supported by Küçük (7) and by Gaikwad (2) as briefly mentioned above. More on the impact of stress and anxiety in future posts.

I am sure there are many other reasons why bed rest could be detrimental to embryo transfer success, but these are just to name a few.

But please tell me if have you been instructed to rest after embryo transfer and for what reasons?

And as always, the above is just for information purposes, please discuss with your treating specialist to decide what is best for your individual situation.

References

1. Abou-Setta, AM, Peters LR, D’Angelo A, Sallam HN, Hart RJ, Al-Inany HG. Post-embryo transfer interventions for assisted reproduction technology cycles (Review). Cochrane Database of Systematic Reviews 2014. Issue 8

2. Gaikwad, S., Garrido, N., Cobo, A., Pellicer, A. & Remohi, J. (2013) Bed rest after embryo transfer negatively affects in vitro fertilization: a randomized controlled clinical trial. Fertility and Sterility Vol 100 (3) 730- 735

3. Purcell, K., Schembri, M., Telles, T., Fujimoto, V. & Cedars, M. (2007) Bed rest after embryo transfer: a randomized controlled trial. Fertility and Sterility Vol 87 (6) 1322 – 1326

4. Bar-Hava I, Kerner R, Yoeli R, Ashkenazi J, Shalev Y, Orvieto R. (2005) Immediate ambulation after embryo transfer: a prospective study. Fertility and Sterility 83 (3) 594–597.

5. Amarin, Z. & Obeidat, B. (2004) Bed rest versus free mobilisation following embryo transfer: a prospective randomised study. BJOG: An International Journal of Obstetrics and Gynaecology Vol 111(11) 1273-6.

6. Australian Doctor

7. Küçük, M. (2013) Review Bed rest after embryo transfer: is it harmful? European Journal of Obstetrics & Gynecology andReproductive Biology Vo (167) 123–126