Fertility Treatment: Long Term Risks?

​Hello. I'm Dr. Gil Wilshire of Missouri Fertility in Columbia, Missouri. Today, we are going to be discussing fertility treatment and its effect on long-term health. I get this question all the time. Women are concerned, "I was treated for fertility over these years. I had some IVF babies, and now I have these health issues coming up. Did my treatments affect my health?". These are very good questions, so let's discuss this issue. One aspect of fertility treatment is, we frequently give medications to produce more eggs. It's a common misperception that if we produce more eggs each month that we are running down, that we are "using up" the eggs in the "pool" that every woman has. The answer to this is "No".  When we give women medications such as injectable medications to make lots of eggs for in vitro fertilization, for example, we are not getting more eggs to grow, we are taking the eggs that are already waking up and getting ready to grow and we are promoting growth for all of them.  Kind of like "a rising tide raises all ships". We are not depleting the number of eggs, even though it seems like we may be doing that. So, are we bringing on early menopause with treatment?   Probably not. 
 
A second problem or difficulty with this whole field of inquiry is that it will be almost impossible to prove a connection between fertility treatments and adverse outcomes in the long term. Let me explain a little better. To prove something in medicine, you need to do something to one group and NOT do it to another group, then follow them over years and see what happens. You can see in practical terms, that will never happen with fertility treatments.  We are not going to give placebos or sham treatment to half of the patients who come to us. We are going to treat everybody. So, when you see in studies that maybe there is a link between a problem and a fertility treatment, what you are looking at is an association, part of a process called epidemiology, where you give some women a questionnaire, and you go back and see how often did the women experience this, or this, or eat this, or was treated with this, and you look for associations, or their increased risk of an outcome that  is  associated  with  a  particular  medication or a particular treatment. These may show small-percentage changes, but the problem with epidemiology is, unless you see a HUGE change in outcome—a three- or four-fold increase in something—then, the associations are weak and usually meaningless; this is what I call pseudoscience. There is no science that shows causality, and associations are NOT causality. One of my favorite examples of an association not showing causality is a fire. Say, your house is on fire. You go home, and you are going to see the fire department. You're going to see their trucks. You are going to see the firemen. So, you might say, "Aha! Firemen cause fires!" Well, they do not. They are associated with fires, but obviously, they are not causing them. So, that's the conflict you see between causality and association.
 
A third issue you need to understand is that chronic diseases and health conditions are associated  with  increased infertility or subfertility. Chronic diseases—such as autoimmune diseases, not just lupus but rheumatoid arthritis and psoriasis of the joints—these things can be associated with a lower fertility rate. Underweight, overweight, chronic pain, all kinds of chronic medical conditions will lower a woman's and a man's fertility potential. So, you can see that we are dealing with a pool of people who are more likely to have some chronic diseases, and this is the same pool of people who are more likely to have chronic diseases later on in life. Once again, it is an association, not a causality. One other thing—since I mentioned autoimmune diseases— some of these diseases actually get better in pregnancy. Pregnancy will make some of these conditions better, and some women with these conditions generally feel best when they are pregnant. Pregnancy does decrease the risk of some cancers and nursing, particularly longer than a year, may decrease the risk of breast cancer as well—so, there are benefits of pregnancy. It is very difficult to weigh risks and benefits and extrapolate them over the long term. Very difficult. So, if you are having health problems and you underwent fertility treatment, the natural question is, "Did my fertility treatment cause my problems?", and the answer is, "Probably not". Now, obviously, there may be some things going on that we don't understand yet. Future studies may show associations that actually do demonstrate causality, but at this point, there is NO evidence of long-term health damage due to fertility treatments. Fertility treatments—while you are doing them—can result in ovarian hyperstimulation and hormone issues and, obviously, treatment may have some risks, but as far as long-term health effects, there is no good evidence that fertility treatment affects future health or has any long-term damage to the body. So, I hope that answers your questions. This is Dr. Wilshire of Missouri Fertility.