Saviour Siblings – Is it a boon or a bane?

Artificial Reproductive Technology (ART) has been a boon for infertile couples, who have been able to overcome their childlessness through various advanced ART techniques. Besides helping infertile couples, ART combined with preimplantation genetic testing also helps in identifying and eliminating the risk of transmission of several genetic diseases from the affected or carrier parents to their offspring. Another important and evolving therapeutic application of IVF combined with preimplantation genetic diagnosis (PGD) technique is to  identify create “saviour embryos”, which will help in giving birth to babies commonly known as “saviour siblings”.

Saviour Sibling

The possibility of “saviour sibling” has existed at a global level for last three decades, but it came under limelight in India very recently with the birth of one of the first Indian saviour siblings in Ahmedabad, with the procedure performed at Nova IVI Fertility centre. (Read this news here –

So, what is a saviour baby or a saviour siblings? A saviour baby or asaviour sibling is “a child who is born to provide life-saving tissue to an existing childaffected with a fatal disease that can be best treated by tissue transplantation”. This has become possible by using IVF technique in conjunction with PGD to identify the embryo for implantation, which is HLA matched with the affected sibling. Therefore, the doctors are able to select an embryo for transfer which, if successfully implanted, will become a “saviour sibling” – a sibling capable of donating life-saving tissue to the affected child.

Patients with diseases like certain leukemias and anemias need bone marrow transplant (BMT) as part of their treatment. However, BMT requires a donor who is an immunological match to the receiving patient. In most of the cases, a biological sibling of the patient is the best possible donor, as the siblings would share the same gene pool. Typically, there are 4 possible combinations resulting from mix-and-match of genes coming from the two biological parents. Thus the siblings have a 1 in 4 chance of a HLA (human leucocyte antigen) match.

Though the practise of saviour siblings can be life saving for the affected children who would otherwise have died in absence of appropriate treatment, the practice is also debatable with several critics raising ethical concerns on the procedure ever since it first got reported.

The key concerns raised by the critics around the concept saviour siblings include :

  1. Intention of the parents – critics argue that only intention in the creation of saviour siblings is to save the life of an existing child thus it involves ‘instrumentelizing’ the child that is created by bringing it into existence as a means to the end of saving another child’s life. However one can also argue that ultimately the parents of the saviour siblings will love the child for its own sake.
  2. Psychological impact on the saviour sibling once she/he grows up – Any child born as a result of the need for a saviour sibling will grow up with the realization that they were conceived for the sake of making tissue for transplant; the circumstances of their conception may have psychological consequences. This will not be a concern if instead of creating saviour babies, we only consider creating “saviour embryos” where, if instrumentalization occurs, it occurs without any consequences for any particular person. Therefore in a certain way, creation of saviour embryos is arguably more ethical than the creation of saviour siblings.
  3. Creation of designer babies – Critics argue that this concept may be misused by willing parents to create designer babies, and this could mean a gross misuse of this technique. This concern can only be addressed by carefully drafted and strictly followed regulations.

It is, therefore, very important to recognize that while this is a potentially lifesaving technique, it is also carries significant potential of misuse for selfish gains and for significant psychological impact on these babies. Thus, it is imperative that this procedure is regulated with strong regulations in order to prevent it’s abuse for non-clinical purposes and to protect the rights of the saviour siblings. This will help in striking the bright balance between the need to save a life and to save the rights of the saviour.

Please contact me at, if you need to know more about saviours siblings and in what disease conditions they could be considered.

How should an international patient select an IVF services provider in India


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Ever since the second IVF child in the world was borne in Mumbai in year 1978, India has made rapid strides in the field of infertility care. Over these 40 years the no of registered ART service providers in India has grown to over 400 (as per ICMR Registry of ART centres). Several of these centres are equipped with the latest technological infrastructure, have highly experienced clinicians and deliver success rates at par with the best centre across the world. These facts also make India one of the most favoured destinations for international patients seeking infertility treatment.

However, the international patients coming to India for treatment need to be careful while selecting the fertility clinic and treating experts. As per estimates, there are over 2,000 active ART service providers in India and most of the renters located in cities with international air connectivity try to attract patients from abroad. The patients, therefore need to exercise some caution and do their homework well before making their choices. Here is a quick guide cum checklist which can help patients make educated choices for their infertility treatment in India.

  1. Ethical treatment
    1. Make sure to read, understand and sign an informed consent before starting treatment
    2. Ask for “Real time”, comprehensive & non – editable data capture, and for complete, comprehendible and timely information sharing
    3. Ensure the centre and the treating clinicians are following the law of the land with respect to treatment options like surrogacy
  2. Transparent pricing
    1. Know what is included and what is excluded in the packages
    2. Beware of “Buy one, get one free” schemes – you need the best care, nit a guarantee against failure!
    3. Understand the surrogacy and donor programs the centre is offering, as these typically come with surprises
  3. Credibility of the centre and treating doctors
    1. Ask for the academic credentials and experience of the treating doctors
    2. Check if the centre has clinical protocols based on scientific evidence in place
    3. Check for the experience of embryology team
  4. Clinical excellence
    1. Check the treatment success rate for both centre and the treating doctor
    2. Ask if there is some published data and literature for documented success
    3. Do look out for genuine patient testimonials
  5. Infrastructure and accreditation
    1. Ensure the centre has good laboratory infrastructure and has advanced treatment facilities
    2. Check if the centre has all valid licenses to offer treatment and has been accredited by the agencies like NABH/ ISAR/ FEQH
    3. Make sure the centre is easily accessible and the locality has a community to support international guests like you
  6. Patient centric treatment approach
    1. In-house counselling in a comforting environment
    2. Ensuring care and compassion during treatment
    3. Comprehensive services at every centre

I hope this information helps patients make better decisions. Please contact Dr Parul Katiyar at, if you have any questions regarding infertility treatment in India.

Five questions to ask while choosing an Infertility Clinic

We are living in an age of consumerism, and healthcare has also been affected by it. In India, several Infertility clinics and IVF centers have come up over last few years. While this has helped fill in the demand supply gap in this field bringing in much needed competition and has given more options to the patients, this has also prompted aggressive marketing by these clinics is in order to attract more patients, thereby confusing patients on how to go about choosing their doctor and treatment center. Healthcare is a very sensitive subject and we have to be able to filter the right information from all the noise in order to be able to make the best decisions for ourselves.

In my own clinical experience, I have had several couples who have consulted me for their inability to have a child, and who were confused due to information overload on the subject and vastly varying offers and claims from infertility clinics. Patients often ask me how should a patient decide which infertility clinic is best for them and what parameters should they consider when selecting an Infertility clinic for treatment. I suggest my patients to ask these five questions before selecting an infertility specialist doctor and an IVF clinic for treatment.

Question 1 – What is the real cost of IVF treatment at the center?

Nowadays there is a flurry of ads on radio, newspapers and digital platforms, several of which try to attract patients by advertising the lower cost of IVF – at times claiming to do an IVF cycle for as low as Rs 25,000 only, while at others offering one IVF cycle free with one paid cycle. The lower cost of treatment is always better for the patients. However, it is important that patients also understand the “conditions apply” clause and read in between the lines to understand the overall cost implication before making their choice on the basis of low cost alone, so that they are not taken for a ride!

It’s important to understand that a typical IVF cycle includes several steps, namely  investigations of the couple, hormone injections for 10-11 days in order to stimulate maturation of eggs, the procedure of egg retrieval and finally transfer of embryo into the lady’s uterus. Patients should understand and take into consideration the overall cost of treatment, as at times the advertised cost may not include cost of hormones and investigations which contribute significantly to the overall cost of a cycle.

Question 2 – What is the success rate of IVF at the clinic?

Another very important parameter to check is the success rate of the clinic and also understand how the claimed success rate was calculated. While the success rate for IVF do vary from one center to another, and the patients should certainly go for treatment at centers with superior pregnancy rate, it’s important to do an apple to apple comparison of success rates.

The pregnancy rates are generally much higher in younger women undergoing IVF. Similarly, success rate for IVF is much higher among infertile couples using donor eggs as compared to the ones using their own gametes. Therefore, the claimed success rates at clinics doing a lot of donor egg cycles can actually be higher than centers with a more balanced distribution of cases.

My simple advice on this point is – if a clinic offers donor egg option without any justification or declares the patient to be having poor quality of eggs based on an ultrasound report and without doing an IVF cycle, the patient should get alert and seek a second opinion before making a decision. As such there is no way to assess the egg quality based on ultrasound or blood reports, which, at best, can estimate the ovarian reserve. There is no way to evaluate the egg quality other than to take the eggs out and check them for quality in the lab.

Question 3 – What is the incidence of multiple pregnancies with IVF at the center?

The aim of any infertility treatment is to enable a couple have a healthy child. So, one should always ask what is the protocol for the maximum number of embryos transferred in a cycle at the clinic.

There is a tendency to transfer more than one embryos in a cycle, which is based on the assumption that the chances of pregnancy in a cycle increases by transferring multiple embryos. However, the best outcome of a cycle can be achieved by transferring 1 or maximum 2 properly selected embryos. Not only does multiple embryo transfer not increase the chances of pregnancy, it, in fact, increases the risk of multiple pregnancies, thereby increasing the risk to both mother and child. Multiple pregnancy is the biggest complication of IVF treatment and the risk of multiple pregnancy is directly proportional to the number of embryos transferred in a cycle.

Question 4 – How good is the IVF lab at the center?

This is an often ignored aspect while choosing an IVF center over the other. But, a well-equipped and maintained lab is a crucial factor differentiating a good IVF center from a not-so-good center. Patients should understand that a well-equipped lab with strong quality control and quality assurance program will always do more justice to their eggs, sperms and embryos and maximize their chances of pregnancy. A good IVF clinic needs to have a good embryo freezing program in order to properly manage the extra high quality embryos from an IVF cycle for possible use for the same patient in future. This helps in preserving the precious embryos and also reduces the cost of possible IVF interventions in future. Many centers claiming a low cost IVF often don’t have a good embryo freezing options for the patients.

Likewise, a properly trained and experienced embryologist also plays an important role in success of the IVF program. So, patients should inquire about the background and competence of the embryologist also while they do the background check on the treating clinician.

Question  5 – Does the center have patient support program?

This is another lesser investigated aspect while choosing an infertility clinic for one’s treatment.  In my view, availability of a good support team including fertility counselors is as important a factor as having a good infertility specialist doctor in improving the success of IVF treatment. Good counselors help the patients understand their issues holistically and helps them overcome the stress associated with infertility. This, combined with the skills and personalized attention of the treating doctor, plays an important role in improving the outcome of IVF treatment.

So, next time you see an enticing, “too good to be true” offer for IVF treatment at an infertility clinic, stop and ask yourself these five questions before falling for it. Always remember, choosing the right infertility expert and the right infertility clinic for your treatment will largely decide the outcome of your treatment!

Do write to me at if you have any questions about IVF.

Three strategies to minimize multiple pregnancies with IVF treatment

Having twin pregnancy has become almost synonymous with undergoing the IVF treatment. And, my patients often ask me if they can conceive only twins with IVF? Here I share what are the best practices to optimize the outcome of IVF treatment and minimize the incidence of twin pregnancies.

With rising incidence of infertility, IVF treatment becoming more commonly available and all the technological innovations with IVF procedure, there is an ever growing focus on minimizing the complications associated with IVF treatment. One of the common risks associated with IVF, which is also a major cause of distress among couples preparing to start IVF treatment, is the risk of multiple pregnancies. In fact, having twin pregnancy has become almost synonymous with undergoing the IVF treatment. And, my patients often ask me if they can conceive only twins with IVF? In reality about 1 in every 4-5 pregnancies resulting from ART are twins, a rate much greater than in the general population (1 in 80 pregnancies). The incidence of triplets and quadruplets is also higher among women undergoing ART. However, the majority of ART pregnancies (about 70%) are singletons.

The risk of multiple pregnancy in IVF cycle exists primarily because of the tendency to transfer more than one embryo inside the uterus to increase the chances of pregnancy. This is done as there are no tests or procedures which can assure us of pregnancy after IVF. The process of implantation of an embryo in the womb is a complicated one, and what  transpires between the embryo and the womb that results in positive or negative pregnancy outcome is not fully understood. Therefore, in order to increase the chances of transferring an appropriate embryo, more embryos are transferred at a time. But, this puts the woman at risk of multiple pregnancy. But this does not mean that in the pregnancy rates increase proportionately to the number of embryos transferred. In fact, rather that increasing the overall pregnancy rates, transferring more than one embryos in one cycle actually increases the risk of multiple pregnancies, as more than one embryo may implant at a time.

Having twins may actually even sound tempting to many patients who have struggled to have a baby for long, but it is not as good as it sounds. Multiple pregnancy is associated with a higher rate of maternal, fetal and neonatal complications and is now considered as the single biggest risk of fertility treatment. Good practice in IVF aims to reduce risk of multiples in an IVF, whilst maintaining the overall chances of becoming pregnant. This is achieved by proper patient selection and counselling. I follow these three simple strategies to achieve the best clinical outcome from IVF procedure –

  1. Young women who have the best chance of conception also have the highest chance of conceiving multiples, so I prefer to do single embryo transfer in these patients. The remaining embryos can be frozen and preserved for later use
  2. An extended culture of embryos up to the day 5, called as blastocyst culture, allows us to select the best embryo for transfer, thereby improving the chance of pregnancy with single embryo transfer.
  3. For carefully selected set of women, who have had multiple IVF failures and who are not fit or willing for blastocyst culture, I transfer two high quality embryos, which gives the best possible chance of pregnancy with minimum possible risk of multiple pregnancies.

To sum it up, we need to counsel all our patients that only success parameter in any IVF cycle is a healthy baby born to a healthy mother, and reducing the number of embryos transferred in a cycle is a significant step in achieving this objective. Patients should be counselled about the risks associated with transferring many embryos and also explained the option to freeze the spare embryos, if any. If needed, subsequent cycles with both fresh and frozen embryos would give them even better cumulative pregnancy outcome than putting in several embryos in one cycle itself.

Do write to me at if you have any questions about IVF.


Looking beyond Semen Analysis as a marker for Male Fertility

Its often difficult to pin down the real cause of male infertility as the assessment of the male partner remains restricted to semen analysis and a normal report is used to rule male factors out. Many of these incompletely evaluated men and couples can benefit from further investigation of the male partner, which not only helps start proper intervention for conception early on, but also saves lot of mental stress and stigma for the woman partner.

It’s a well-known fact that male factor contributes to a couple’s inability to conceive in up to 40% of all cases of infertility. In practice, however, the inability of a couple to conceive is still seen largely as a woman’s problem. In fact, one of the most common initial responses of the male partners that we come across when assessing them is that all “I am healthy and all my reports are good” and then the whole responsibility is shifted to the woman partner alone.

So, what does “my reports are all good” actually mean? This refers to normal semen parameters as noted on standard semen analysis. But then the real question is if a normal semen analysis report indeed rules out male factor infertility! Recently there has been a big debate on how good a good semen analysis report actually is and if it is an accurate indicator or predictor of a man’s fertility. Well, the simple answer is No, it is not!  And, even though semen analysis offers a good initial assessment of male partner, there is more to sperm health and function than what a standard semen analysis picks up. It is now 300 years since Leeuwenhook first identified sperms under the microscope, yet it seems that we have only just begun to intelligently evaluate the concept of male Infertility and till date semen analysis remains the cornerstone for evaluation of male fertility.

Sperm production in the testis is a lengthy and tedious process and any adverse influence during the sperm production or maturation process can lead to an adverse sperm health and/or quality. According to estimates, up to 10% of men having normal semen parameters can actually fail to conceive due to undetectable damage in the spermatozoa. These men can be infertile without actually being aware of it and are often classified as unexplained Infertility, unless they are further investigated properly. Therefore, it is very important that the evaluation of male partner is not limited to only semen analysis, and is combined with comprehensive history taking, clinical examination and relevant endocrine /genetic investigations.

The real shortcomings of semen analysis include its inability to predict the fertilization potential of the sperms and the overall functional health (DNA integrity) of the sperms. Thus there is an increasing awareness about the need of supplementary tests to evaluate male partner and look beyond only semen analysis to assess the male factor infertility.

The reasons for infertility in such men can be attributed to development of anti-sperm antibodies, which interfere with a sperm’s ability to fertilize the egg. These antibodies cannot be detected on routine semen analysis and we need specialized tests to detect them. Also, the tests to detect anti-sperm antibodies have been in existence for a long time but since there is no particular treatment for this condition, these tests have not gained a lot of acceptance in clinical evaluation of infertile men. However, since these men benefit from IVF or ICSI for conception, an early detection of anti-sperm antibodies helps in overall management of the couple.

Another very common, and often missed, cause of male factor infertility is damaged sperm DNA. As discussed in one of my earlier articles, DNA is the basic genetic material and any abnormality or alteration in the sperm DNA affects its fertility potential – not just for natural conception, but also for IUI and IVF treatment. Damage to sperm DNA can happen at any stage of its development, maturation or transport – starting from beginning of spermatogenesis till the time of ejaculation. A number of factors can cause high DNA fragmentation. These include lifestyle factors such as smoking, excessive drinking and drug abuse, advanced age, exposure to environmental toxins, varicocele and infections causing oxidative damage to DNA.

One more factor leading to male factor infertility is dysfunctional sperms, as a result of which the sperms  may not be able to fertilize the eggs naturally. All these causes of infertility may be present in men with normal semen parameters.

ICSI has helped numerous couples with male factor infertility with seemingly normal semen parameters conceive by injecting the sperm directly into the egg for fertilization. This technique helps bypass many of the shortcomings of the sperms, but also increases the risk of selecting defected sperms, which could then pass  onto the offspring.

There is a lot of research in the field of andrology to understand and improve the health of sperms. This can help in not just improving the diagnosis of infertility and reducing the burden of unexplained Infertility, but also devising directed therapies to improve outcome of fertility treatments.

I will write about what should be done for couples having unexplained infertility with the male partner having normal semen parameters on semen analysis.

For any questions, please write to me at

Seven frequently asked questions on “Poor Ovarian Reserve”

Poor ovarian reserve is a major cause of reduced fertility among women who delay planning a family. Many of these women remain unaware of this reality and dont know that there was means to preserve their eggs for a delayed child bearing.

Ovarian Reserve is one of the more frequently discussed topic in my infertility practice, especially as many working women plan to defer child bearing while they remain worried about their fertility potential in future. Besides this, I see a lot of women who are not able to conceive and have poor ovarian reserve. Here are seven most frequently asked questions related to “Ovarian Reserve” and my answers to these.

  1. What is ovarian reserve?

Ovarian reserve of a woman is defined as an estimated number of oocytes/ eggs a woman has in her ovaries at a given time. A female fetus has a maximum of 6 to 7 million eggs at 16 to 20 weeks of gestational age. Thereafter, this number keeps on declining and reaches an approximate count of 1 to 2 million eggs at the time of birth, and further falls to approximately  250,000 to 500,000 eggs at puberty. This count further declines to approximately 25,000 at around 37 years of age and to less than 1000 at menopause.

  1. How is ovarian reserve estimated?

There are various tests to assess ovarian reserve. The main tests include –

  1. Serum FSH/LH- done on the 2nd /3rd day of a woman’s menstrual cycle gives an indication of the woman’s egg reserves.
  2. Serum Anti mullerian hormone (AMH) – very sensitive test of testing a woman’s ovarian reserve. It can be done on any day of the menstrual cycle.
  3. Antral Follicle count-  Antral follicle are small follicles present in the ovary that are best seen during the early phases of the menstrual cycle. Transvaginal ultrasound (TVS) of the pelvis is used to count the number of antral follicles, which gives good estimate of the woman’s ovarian reserve.AFC

    3.  Why is testing for ovarian reserve important?

A woman’s ovarian reserve is an indicator of her fertility potential. Women facing difficulty in  conception or planning to delay child bearing should be assessed for their ovarian reserve for timely and appropriate fertility intervention.

  1. What is poor ovarian reserve?

If a woman has a premature decline in her egg quantity due to any reason which reduces her chances of having a mature egg, she is suspected to have “poor ovarian reserve”. It is natural for the number of eggs present in a lady to decline as she ages – both due to ovulation and a natural cell death process called “Apoptosis” – and normally the woman would exhaust her egg reserve by the time she reaches menopause. But, if the decline in egg count happens faster than that and the woman is depleted of her egg reserve before expected menopause, she should be suspected to have “poor ovarian reserve”.

  1. What causes poor ovarian reserve?

Poor ovarian reserve can be caused by a number of reasons-

  1. Genetic defects including chromosomal anomalies such as Turner’s syndrome and gene defects like Fragile X syndrome.
  2. Damage to the ovaries due to any injury, torsion, infection, surgery or due to radiation or chemotherapy.

However in most cases the exact cause of poor ovarian reserve remains unknown.

  1. Does poor ovarian reserve lead to reduced chances of pregnancy?

Poor ovarian reserve is associated with reduced chances of pregnancy both naturally and following fertility treatment. This is because the number of eggs is reduced which corresponds to reduced chances of pregnancy. The goal of ovarian reserve testing is to identify those individuals who are at risk of diminished ovarian reserve so that they can be encouraged to pursue more aggressive treatment to achieve pregnancy.

  1. Is there any treatment to improve the ovarian reserve?

There are no concrete remedies to improve Ovarian reserve however lately some medications have been developed  to improve the egg quality and number. The benefits of these medicines are not yet conclusively proven.

preventing failure

You can read more about management of Poor Ovarian Reserve at

Dr Parul Katiyar 

For more information on poor ovarian reserve and ways to address poor fertility resulting from this, please write to me at


IVF treatment and twins – role of multiple embryo transfer

One of my patients whom I was counselling for IVF treatment for her primary infertility recently asked me a very basic question about the procedure and its outcome. She asked me – “Doctor, can I conceive only twins with IVF?”. This again prompted me to think about this very important aspect of fertility treatment – the risk of multiple pregnancy resulting from multiple embryo transfers. Some big celebrities like Celine Dion, Julia Bradbury and Jennifer Aniston and our own Farah Khan have been in news for conceiving multiple babies with IVF and that somehow makes many women undergoing IVF treatment to think that IVF produces multiple pregnancy only.  In this post, I  will try to explain the reasons for multiple pregnancies resulting from IVF treatment and how can this be avoided.

According to global evidence, approximately 25% of total births resulting from ART treatment are twins, a rate much greater than in the general population (approximately one in 80 births). The incidence of triplets and quadruplets is also high among pregnancies resulting from IVF treatment. However, the majority (approx. 70%) of pregnancies resulting from IVF treatment are singletons. With an ever increasing focus on optimizing treatment outcome and reducing complications associated with IVF treatment, the risk of multiple pregnancies with IVF has become  one of the most important considerations while planning the IVF cycle.

The process of implantation of an embryo in the womb is a complicated one and we still do not know what transpires between the embryo and the uterus when they come in contact with each other, and therefore, we do not completely understand the reasons for a positive or negative pregnancy outcome also. Since there is no test or procedure that can assure pregnancy with IVF – an expensive treatment not generally covered by insurance policies – the physicians naturally want to enhance the probability of pregnancy and consider putting in more than one embryos. The risk of multiple pregnancy in IVF cycle derives from this tendency among treating physicians to transfer more than one embryos inside the uterus in order to increase the odds of pregnancy.

Pregnancy rates with IVF treatment appear to peak with transfer of three or four embryos. However, the risk of multiple pregnancy also increases at the same time. Multiple pregnancy is associated with   a higher rate of maternal, fetal and neonatal complications and is considered as the single biggest risk or complication of fertility treatment.

Good practice in IVF treatment aims to reduce the risk of multiple pregnancy whilst maximizing the overall chances of conception. This is achieved by proper patient selection and counselling.

  1. Young women who have the best chance of conception, also have the highest chance of conceiving multiples. Therefore, I always offer them a single embryo transfer at a time and freeze the rest of the good quality embryos for later use.
  2. An extended culture of embryos up to the day 5, called as blastocyst culture, helps in better embryo selection for transfer into the uterus. I advise blastocyst culture for patients with more than 3 good quality embryos and transfer a single blastocyst in such patients.

I also believe that treating physicians should counsel the patients that only success parameter in any IVF cycle is a healthy baby born to a healthy mother and reducing the number of embryos transferred in a cycle is a significant step to achieve that goal. Patients should be counselled about the risk associated with transferring many embryos and also explained that freezing the spare embryos and transferring them in subsequent cycles if needed  would give them even better cumulative pregnancy outcome than putting back many embryos in one embryos transfer.

Please contact me at for any queries related to IVF or any aspect related to infertility treatment.

Does infertility treatment put women at higher risk of cancers?

Many patients ask me if IVF treatment leads to a higher risk of cancers, especially in breasts and ovaries. As per the latest published scientific literature on this subject, there is no real evidence to link IVF with higher risk of cancers among these women.

As an infertility specialist, I am required to counsel mcancery patients about potential complications of fertility treatment. One of the most often asked question is if infertility treatments put the women at a higher risk of cancers.

Fertility drugs like clomiphene citrate and hormones used for ovarian stimulation & assisted reproductive technologies like IVF and ICSI have all been implicated to causes various cancers among women, including not only cancers of cervix, uterus, ovaries and breast, but also melanoma and cancers of the central nervous system.

A simple answer to this question is that as per the latest studies, there is no conclusive evidence to suggest a higher risk of invasive cancers in women receiving infertility treatment.

Why has infertility treatment been linked with higher risk of cancers?

There are multiple theories as to why fertility treatment may increases the risk of cancer in women.

  1. Hormonal treatment with Clomiphene and Gonadotropins causes cancers because elevated levels of estrogen and progesterone hormones can trigger carcinogenic activity in the ovarian , uterine and breast tissues
  2. Ovarian enlargement due to development of multiple follicles causes trauma to the ovaries, which may result in carcinogenesis.
  3. Injury to ovaries resulting from multiple needle punctures made during egg retrieval has also been suggested to cause cancers of ovaries.

However, at the same time, it has also been suggested that infertile and nulliparous women are inherently at an increased risk of certain cancers so actually infertility treatment may not be the cause of cancers in these women.

What does the scientific evidence tell us?

Extensive research has been conducted on this subject, but the results so far have been pretty inconclusive. We need to appreciate that it is indeed difficult to study direct relationship between cancers in women and infertility treatment because many of these cancers appear many years after the treatment/ causative injury. Therefore, large populations have to be studied over a long period of time in order to arrive at any meaningful conclusions regarding the relationship between fertility treatment and cancers.

Of all the cancers suspected to be associated with infertility treatment, cancers in ovaries are most often linked to the infertility treatment. The overall evidence in this regard is mixed. While some studies have found the risk of ovarian cancers to be higher in women with a history of fertility treatment, others have ruled any such association out.

A research group from Israel retrospectively studied possibility of such an association in over 106,000 women, who had delivered between 1998 and 2013.1 The researchers found that women with conceived with IVF treatment had a significantly increased risk of being diagnosed with ovarian and uterine cancers as compared to women who had conceived either naturally or using ovulation induction. However, another study of over 87,000 women from Israel only conducted around the same time did not find any significant relationship between IVF exposure and risks of breast, endometrial, or ovarian cancers.2

In a population based cohort study of 812,986 women from Norway, who had delivered between 1984 and 2010, the researchers tried to assess the overall risk of cancers and specifically of cancers of cervix, uterus, ovary, thyroid, the central nervous system and melanoma among the women who had conceived using ART. 3 They found that the overall risk of cancers was not higher among the women conceiving using ART and delivering at least one baby. Although there was a hint of higher incidence of some cancers among women undergoing IVF, this could not be statistically proven owing to the weak nature of this kind of population based study.

A Cochrane review of 25 studies (consisting of 11 case-control studies and 14 cohort studies) covering 182,972 women did not find any convincing evidence supporting an increased risk of invasive ovarian tumors with fertility drug treatment. However, the researchers concluded that there may be an increased risk of borderline ovarian tumors in subfertile women treated with IVF.4

Cancer of the breast is the second most commonly discussed cancer that is assumed to be linked with hormonal treatment for infertility. Large studies and meta-analyses have not found any significant correlation between treatment for infertility and breast cancer. 5,6 While some studies have suggested that the risk of breast cancer increases after exposure to ovulation inducing agents (especially clomiphene citrate)6, many other studies do not support such an association.5 Therefore, I don’t advocate long term administration of Clomiphene, as the risk of breast cancer is not fully ruled out with its long term use.


Overall we can say that on the basis of existing scientific evidence, there is no conclusive proof of a causal link between ovarian and breast cancers and fertility treatment. Therefore, treatment of infertility using hormones and ART is by and large safe. The cancers of ovary and breast detected among women with history of treatment for infertility are more likely to be related to their infertile status than to the effect of fertility drugs. However, we must keep in mind that majority of the available studies on this subject suffer from methodological limitations and therefore cannot be fully relied upon. Further research on this subject will certainly enlighten us more on the possibility of any such association.


1.       The risk of female malignancies after fertility treatments: a cohort study with 25-year follow-up. Kessous et al. J Cancer Res Clin Oncol. 2016 Jan;142(1):287-93.

2.       In vitro fertilization and risk of breast and gynecologic cancers: a retrospective cohort study within the Israeli Maccabi Healthcare Services. Brinton et al. Fertil Steril. 2013 Apr;99(5):1189-96.

3.       Cancer risk among parous women following assisted reproductive technology. Reigstad et al. Hum Reprod. 2015 Aug;30(8):1952-63.

4.       Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Rizzuto I, Behrens RF, Smith LA. Cochrane Database Syst Rev. 2013 Aug 13;8:CD008215.

5.       IVF and breast cancer: a systematic review and meta-analysis. Sergentanis et al. Hum Reprod Update. Sergentanis et al. 2014 Jan-Feb;20(1):106-23.

6.       Breast cancer incidence after hormonal treatments for infertility: systematic review and meta-analysis of population-based studies. Gennari et al. Breast Cancer Res Treat. 2015 Apr;150(2):405-13.

For further information or queries on this subject, please write to me at

Dr Parul Katiyar

IVF- Frequently Asked Questions – I

Some frequently asked questions about fertility treatment in general and IVF in particular.

In today’s post I am going to address some questions I get asked very often by my patients undergoing fertility treatments, including IVF. I am sure there are many people with similar queries and they will all benefit from this post.

Q 1. Will there be an increased risk of birth defects in my baby if I conceive with IVF?

A. No, there is no merit in such an argument. The risk of birth defects in babies conceived by IVF is the same as for babies conceived naturally. From a scientific perspective, birth defects or congenital anomalies mostly result from alterations in the genetic material (known as mutations) and the process of IVF doesn’t cause any mutations. In fact, the incidence of chromosomal abnormalities such as Down syndrome and Turner’s syndrome with fertility treatment is also same as for general population.

Q 2. Can fertility treatment including the IVF procedure damage ovaries? 

A. There is no real evidence to suggest that either pre-IVF diagnostic laparoscopy or ultrasound guided ovum pickup through vagina causes any major/ permanent physical trauma to the ovaries. These are well established procedures now and carry only as much risk as any other medical intervention/ procedure.

What is more important is the expertise and experience of the treating doctor and quality of equipment and support functions at the treatment facility. So, I encourage my patients to do proper research and due diligence to find out whats the best and most convenient place to seek such treatment.

Q 3. Since IVF can lead to twin pregnancy, should I get only one embryo transferred?

A. It is true that transfer of more than one embryos carries a real risk of twin pregnancy. In fact, as per the collective evidence, the chance of twin pregnancy with IVF is 1 in every 4-5 pregnancies, whereas it is 1 in 80 in naturally conceived pregnancies. The chances of conceiving triplets and quadruplets is also much higher with IVF than naturally. It is also a well known fact that the chance of multiple pregnancy in an IVF cycle goes up as the number of embryos transferred increases.

IVF being a very costly treatment, we need to weigh the risk of multiple pregnancies with the chance of success in a cycle. So, the real questions to ask are how many embryos should be transferred in an IVF cycle and if it is justified to transfer only one embryo during an IVF cycle? While there is no single definite answer to this question, I generally recommend transferring 2-3 embryos – of course, the final count depends upon the quality of the embryos, age of the woman and affordability of the couple seeking IVF.

If the woman treated with IVF actually gets twin pregnancies, I generally advice her to carry on with the same and accept that as God’s gift. However, in case of triplets and quadruplets  I suggest the woman should try selective reduction of implanted embryos in order to increase the chances of successful pregnancy.


Q 4. What precautions should we take after the embryo transfer?

A. As such there are no special precautions to be taken after embryo transfer. The woman can continue with routine diet and regular activities. However, the woman should avoid excessive physical exertion after the transfer. There is also no additional advantage of bed rest after the transfer. I am also often asked if the couple can have intercourse after embryo transfer. While there is no rule regarding this, I advise couples to abstain for two weeks after the transfer just to give some rest to the uterus. 

Q 5. Can we also attempt naturally while going for IVF?

A. Yes, you can because you never know when your prayers get answered! As such there is no medical reason to avoid intercourse while undergoing fertility treatment However, in order to maximize the chances of success with IVF, I recommend that the couple avoids intercourse for 48 hours preceding collection of semen sample to ensure that the semen sample collected for ART is of optimal quality. For the same reason, the male partner should also abstain from masturbating for at least 48 hours preceding sample collection/ egg retrieval.

There are some more frequently asked questions, which I will take up in my subsequent posts.