Insight & Opinion

Fertility - no one answer

Craig Canavan

The different methods of inducing ovulation in women experiencing problems in getting pregnant came under the spotlight last month at the 19th annual World Congress on Fertility and Sterility, with researchers and gynaecologists seemingly divided as to which therapy works best.

What all the speakers concluded, no matter which therapy they advocated, was that more research needed to be done in the fields of Assisted Reproductive Technologies (ART) and In-Vitro Fertilisation (IVF) before any definitive statements could be made about the benefits and detriments of different therapies.

In the first presentation, Dr Stratis Kolibianakis from Greece made a strong argument for the use of antagonists as opposed to agonists to stimulate ovulation during IVF. 

According to Dr Kolibianakis, who referred to both his own research in to the subject as well as the research of eminent others, antagonists are preferable to agonists mostly because they offer more flexibility during treatment.

"While the research does not indicate any significant difference in the stimulation of ovulation between agonists and antagonists," he explained, "nor in the probability of live birth, it did show that the use of antagonists resulted in fewer detrimental side-effects in the patient, in particular a significantly reduced rate of Ovarian Hyper-Stimulation Syndrome (OHSS).
"This tells us that the use of antagonists is safer by some degree, cutting down the possibility of hospital admission due to complications."

Judging by the response of his audience, most of Kolibianakis' colleagues seemed to agree with his findings, though some questioned the wisdom of promoting a treatment that would mean multiple injections for the patient (in the case of the more complex antagonist treatment) as opposed to just one injection (in the case of agonist treatment).

However, Kolibianakis did stress that the decision was one of personal preference that could easily change from patient to patient, and that doctors should use their own clinical expertise when determining which treatment would work best for a particular patient.

"There is no one right answer," he said. "What is clear is that the question of which treatment should be first choice in IVF needs to be re-examined."
And this was the mantra throughout the discussion, with both the other speakers, Professor Mohamed Aboulghar and Dr Jacob Farhi, claiming that previous and current research in to ART and IVF treatments was not exhaustive enough to make conclusive statements one way or the other.
Egypt's Professor Aboulghar, described as one of the founding fathers of the gynaecological profession, gave a critical evaluation on the use of luteinising hormone (LH), a pituitary hormone that triggers ovulation in the female and stimulates the corpus luteum to secrete the hormone progesterone.

He concluded that while no proof exists that LH could adversely affect ovarian stimulation, there was some proof that such therapy could improve the outcome in some women.

Again, however, he made it clear that more research needed to be done before any definitive answers could be arrived at.

The role of oestrogen hormonal support in ART was the topic tackled by Dr Farhi from Israel, with a particular emphasis on the use of estradiol, the most potent naturally occurring form of the hormone estrogen in humans.
In presenting his findings, Farhi claimed that there was some evidence that estradiol supplementation did have a positive effect on pregnancy rates but that there was little evidence that such therapy could prevent early pregnancy loss.

He also stressed that the decision to use estradiol support was a personal one for him because, in his experience, it had some positive effect with no negative side effects. But whether such therapy was worth it for the patient who would be paying for it is still up for conjecture.

With no clear answers scientists called for further research.

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