1. What are their indications?
DHEA is a hormonal supplement which has been given different properties according to what we use it for. It is an androgen which is being produced in both males and females by the adrenals. Its level in the blood circulation can be measured but the available assays are not sensitive enough and even when the tested blood level is within the normal reference range there may be a benefit from its use.

It has been shown that its long term use may increase the antral follicle count and the ovarian reserve, as proven by increased Anti-Mullerian Hormone; there is some evidence from small case control studies that the quality of oocytes can be improved. Its use can diminish FSH and LH levels, so it can help ameliorate the woman’s cycle in cases of irregular periods due to ovarian dysfunction.

2. Are they necessary?
DHEA is not necessary but it is an aid in cases of low/poor ovarian reserve, low oocyte quality, or irregular cycles. Its regular dosage is 25mg three times daily irrespectively of meal intake. If there will be any side-effects these are consequences of the androgen intake, such as oily skin and acne.

On the other hand, there may be many cases that there will be no benefit of its use. Some physicians have raised questions regarding potential side-effects and although there are not any significant ones reported, patients and doctors should be aware of these possibilities and should be prompt to discontinue DHEA if such case arises.

Preeclampsia and egg donation

1. What is preeclampsia?

Preeclampsia is diagnosed by persistent high blood pressure that develops during pregnancy or during the postpartum period that is associated with a lot of protein in the urine or the new development of decreased blood platelets, trouble with the kidney or liver, fluid in the lungs, or signs of brain trouble such as seizures and/or visual disturbances.

It happens more frequently in women in their first pregnancy, with advanced maternal age, with antiphospholipid syndrome and in pregnancies with donor gametes.

It increases maternal morbidity and even mortality in severe cases and also causes iatrogenic prematurity as when preeclampsia happens the decision for a preterm delivery is quite frequent.


2. How preeclampsia is being related with egg donation and woman’s age?

Pregnancies derived from donor oocytes may be at a higher risk for hypertensive disorders of pregnancy. Initially this was thought to be due to the usual older age of women embarking in egg donation, which could be combined with increased blood pressure. But as pregnancies achieved by egg donation possibly involve a stronger immunological reaction, being a foreign material for the mother, this can explain the theory behind the above.

As placentation is with allogenic material there is a strong theory that pathophysiology behind this process is similar to graft rejection. There have been several studies that matched the mother’s age and parity between pregnancies with donor and homologous oocytes which found that the risk of preeclampsia rises from 1,5-2% to 12-15%.

So egg donation by itself is a risk factor for preeclampsia and this needs to be discussed with the woman prior to pregnancy, in order for her to be aware and be proactive with her diet, weight, and early signs of the disease. Knowledge is the key to prevention, as there will not be many women that will not embark to a pregnancy only with the possibility of preeclampsia development.

Endometrial problems

1. Is there a cutoff in endometrium thickness that no pregnancy occurs?
There is no absolute cutoff in endometrium thickness that we consider incompatible with implantation, although research suggests that endometrial thickness less than 7 mm is associated with reduced chance of pregnancy.

2. What happens if I get a maximum endometrial thickness of less than 7mm?
Usually it is suggested that the cycle is cancelled, and instructions are given with regards to the following cycle. If in a subsequent cycle, and despite the different medication protocol, the maximum endometrial thickness remains less than 7mm, one has to consider a diagnostic hysteroscopy to rule out endometrial pathology.

3. What is the role of diagnostic hysteroscopy in endometrial assessment?
Diagnostic hysteroscopy serves as a very accurate means to diagnose endometrial pathology, such as endometrial adhesions, endometrial atrophy, as well as endometrial hyperplasia and endometrial polyps. Once diagnosed, endometrial pathologies can be managed with hysteroscopic surgery with a view to restore the cavity back to normal morphology.

Hysterosalpingogram before IVF and egg donation

1. What is a hysterosalpingography (HSG)?
A: It is an X-ray test used to check whether the fallopian tubes are open, and at the same time it gives useful information about the size and shape of the uterine cavity.

2. I have had a laparoscopy recently. Do I also need to have an HSG examination?
No, a laparoscopy is a surgical procedure that gives all relevant information provided by an HSG, regarding tubal status and the presence of inflammation.

3. Is HSG necessary before IVF treatment?
Assessment of fallopian tubes is one of the essential investigations carried out prior to IVF treatment. Even though the tubes are bypassed during IVF, an HSG can provide very important information on the possibility of tubal inflammation, which can have a negative impact on IVF treatment outcome. In case of tubal obstruction, this will have to be dealt with prior to IVF treatment in order to achieve maximum treatment results.

4. Should I get tested with a HSG before egg donation?
Likewise, an HSG can rule out the possibility of tubal infection that can have a negative impact on IVF treatment with egg donation too. Any case of obstructed tube will need to be operated on first, then IVF treatment with egg donation may follow, with excellent results.

Polycystic Ovarian Syndrome (PCOS)

1. Does the diagnosis of PCOS mean i will need to undergo IVF in order to get pregnant?
No. A lot of women are diagnosed with PCOS but most of them do get pregnant spontaneously. Having a regular cycle- albeit sometimes long, maintaining a normal body weight and exercising regularly will help them avoid unnecessary interventions while they are trying for a pregnancy.
Women that more often require assistance are the ones with anovulation, i.e the ones who do not see a period unless taken medication. Even within this population weight loss and exercise may promote fertility. In any case if a couple tries for a year without success then they need to seek expert advice as there may be other issues involved.

2. What are the side effects /complications I might expect, if I have PCOS?
A woman with PCOS when undergoes IVF treatment may encounter ovarian hyperstimulation syndrome (OHSS). It has different degrees of severity, starting from mild bloating and small amount of fluid in the abdomen- very usual and sometimes necessary in an IVF setting, to -very rare- severe reaction dangerous for the patient that requires hospital stay.
Nowadays the different medications that we use and the evolution on cryopreservation techniques give us the opportunity to avoid completely severe complications by freezing all embryos and postponing embryo transfer, thus allowing us to have OHSS-free clinics.

3.What is the effect of PCOS in IVF?
When PCOS leeds to infertility it can be due to anovulation, which can easily be solved with ovarian stimulation, but it can also imply other problems, such as immature oocytes.
Oocyte maturity cannot be measured with some test prior to IVF nor does it mean that all patients with PCOS will have such an issue. It remains to be seen at the time of the egg retrieval. This maturation process may affect most but not all of their oocytes, so, through the stimulation protocols and drugs that we use in IVF, we try to change the maturity rate and get as many mature oocytes as possible for fertilisation, in order to increase their success rate.

Use of clomifene citrate in IVF treatment.

1. Can clomifene citrate be used along with conventional gonadotropin injections during treatment for IVF?
Clomifene citrate is one of the oldest drugs used in fertility treatment and in particular for ovulation induction purposes. Its mode of action is different than this of gonadotropins, and for this reason some physicians may use it along with gonadotropins to get the maximum of response to treatment during ovarian stimulation.

2. Is it likely to experience more side-effects due to the use of clomifene citrate at the same time with gonadotropin injections?
Clomifene citrate is a drug with a relatively low risk of side-effects and is usually very well tolerated. Its parallel use with gonadotropins is unlikely to cause more side-effects.

3. How effective is a combined stimulation protocol with clomifene citrate compared with conventional ovarian stimulation with gonadotropins only?
Combined stimulation protocols using clomifene citrate have been used especially in the treatment of poor responders, with results varying from improved response to no difference at all. It is a alternative way of stimulating the ovaries and is worth considering when other conventional stimulation protocols have proved unsuccessful.