Breastfeeding Through Fertility Treatments (IVF and FET)

So, I’ve made an important decision.  I didn’t make it lightly or quickly.  It involved information that was, frankly, very hard to find.  I want to include my research here so someone else might be able to find it in the future. I’ll talk about my decision at the end.

The topic: Doctors require you de riguer to wean your baby before attempting a subsequent IVF or FET cycle.  This might seem like a black and white issue to some – why not wean if you doctor says so?  You want to have another baby right?  But, for infertile women it is a very loaded question.  I have journeyed through hell to get my baby and I want to give her ALL that I can.  At the same time I want more children and want to bring my embryos a chance at life.  Sadly, this isn’t researched/discussed at all and most (in the US nearly ALL) doctors won’t even discuss it with you.

I don’t want to hurt Aellyn with drugs.  I dont’ want to hurt our breastfeeding relationship by reducing my supply drastically or weaning.  I don’t want my Frozen Embryo Transfer not to work.  I don’t want to wait (as I get older and older) to attempt to have more children.  If we have to build our family in another way (foster, adopt, etc.) time is ticking.  So, I wanted the facts.  I didn’t want to just take at face value “thou shalt wean.”

Here is what I’ve found:

The absolute best resource I could find was from a talk by Jeany Elliot of the Australian Breastfeeding Association – Hot Milk Podcast on Breastfeeding Through IVF Treatment.  She had 2 children via IVF and FET while breastfeeding.  Here are my notes from her podcast or you can listen yourself at the link.

Knee jerk on the part of doctors reaction to wean a child before treatment.  Prolactin inhibits ovulation and development of the lining.  Prolactin levels decrease over time.  Many women resume ovulation while continuing to breastfeed.  “You must wean” fails to recognize the wide diversity of patients and not given true choice.

Are the drugs dangerous to the baby? Determined by age of child, frequency of nursing, and types of drugs.

1. BCP (birth control pills) – no harm to baby.  some reduction in milk supply (however, pregnancy will also reduce supply so that isn’t a good reason to wean).
2. Gonadotropin releasing hormone (Lupron – injection, Synarel – spray) –   drugs for suppression.  Broken down by baby’s digestive system[1. She talks about this with several of the drugs.  The point being that they aren’t give to women orally specifically because they break down in digestion and not enough reaches the blood supply to work.  Even if some reaches the mothers breastmilk and then the baby gets it the drug must be digested by the baby.  The resulting bioavailability is exceedingly low].  Given once or twice a day so you can breastfeed immediately before dosing to reduce exposure (note: she isn’t saying this is necessary but just an additional way to reduce risk if it bothers you).
3. Clomid – superovulation, daily oral dose.  once per day so time breastfeeding.  May cause reduction in milk supply (see caveat above #1)
4. Stimulation drugs (Gonal-F, FSH, LH) – normal hormones in menstruating women with no harm to baby.  Once daily so time breastfeeding. 4-6 hour half-life common.  If it passes through it is unlikely to be absorbed by baby’s digestive system into the bloodstream.
5. HCG (ovidrel) – triggers ovulation.  injection.  normal hormone of pregnant women.  no known harm to babies.  Once daily so time breastfeeding.
6. *Progesterone – (injectible PIO or suppositories) normal hormones in women.  no known harm to babies.
7. (she did not talk about this but I added it because it is used in my FET protocol) *Estrogen (estrace) – normal hormone.

Who NEEDS to wean:

1. menstrual cycle not returned during lactation
2. women who do not ovulate without drugs – prolactin would interfere so weaning would be better

Who MAY NOT need to wean (ideal candidate for not weaning):

1. resumed regular menstrual cycles with adequate luteal phase and known ovulation – no benefit of weaning
2. frozen embryos don’t need to superovulate.  all they need is timing – no benefit of weaning
3. male factor is reason for infertility
4. Fallopian tube blockage is reason for infertility
5. b/f child over 1 year
6. not breastfeeding more than 3 or 4 times a day

Psychological issues – 2 mindsets

1. Will you regret not doing “everything” to make it successful?
2. Nothing is guaranteed in infertility treatments.  I’m not going to compromise the b/f relationship with the child I have for a pregnancy that might not happen.

She didn’t tell the doctors! 🙂

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Other resources:

Dr. Hale’s thread on fertility drugs during lactation.  I also checked LactMed.  For FET protocol (at my clinic they do not use Lupron just estrace and then progesterone.  medrol and tetracycline on transfer day) all of the drugs are generally recognized as safe during breastfeeding by LactMed and the AAP.

Transition to Full Fertility at Kelly Mom

Trying to Conceive while Breastfeeding at Kelly Mom

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I’ve lost much sleep worrying about this and then I decided to just do what I do best – research.  Now I feel comfortable with my decision.  I’m going to do my FET while breastfeeding and I’m not going to tell my doctors.

How did I choose this?

1. I’ve had clockwork menstrual cycles since Aellyn was 8 months old.
2. I know (via Natural Family Planning methods) that I’m ovulating
3. Aellyn will be 18 months this summer
4. She currently nurses 3-4 times a day
5. We have male factor infertility
6. I’m doing a Frozen embryo not fresh cycle (thus I don’t need to superovulate)
7. I’m lying because a) I believe, through my research, that it is not life threatening to me or my child (I wouldn’t lie about something germane to our health) and therefore b) I’m not going to argue my case with my doctor about what comes down to a judgment call when her judgment might not (and probably doesn’t) include the value I place on breastfeeding and c) I know my FET has about a 30-40% chance of success and I won’t blame breastfeeding on a failure but I would blame myself for prematurely weaning Aellyn.

I hope they don’t read my blog!

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Edited to Add: Based on Deb’s comment I’m going to post some things I find about prolactin and implantation.
The Role of Prolactin in Implantation and Luteal Maintenance in the Ferret
BRUCE D. MURPHY

“It is concluded that PRL can sustain luteal progesterone production during the first half of pregnancy in hypophysectomized ferrets. Further, PRL can qualitatively maintain the CL of pregnancy as evidenced by its ability to induce embryo implantation in hypophysectomized ferrets.”

Paracrine control of uterine differentiation and implantation
HN Jabbour, HOD Critchley & O Gubbay

Prolactin is secreted by the decidualised endometrium at the time of predicted conception and in the event of pregnancy local expression/secretion of prolactin persists until term.  PRLR deficiency results in implantation failure[4. Paracrine refers to hormones that are secreted locally into adjacent cells as opposed to hormones released into the bloodstream]

http://www.biology-online.org/articles/control-human-trophoblast-function/decidualization.html

Decidualization

In order for implantation to occur, endometrium has to be changed into decidua. This process consists in modifying endometrial stromal cells, uterine glands and vessels, as well as the population of uterine immune cells. In humans, unlike other species [1], decidualization is independent of the blastocyst’s presence in the uterine cavity and begins in the late secretory phase of the menstrual cycle. It is evoked by progesterone

Implantation and Decidualization Defects in Prolactin Receptor (PRLR)-Deficient Mice Are Mediated by Ovarian But Not Uterine PRLR

Together, these results show that luteal P₄ production via ovarianPRLR signaling is required for implantation and early pregnancy.The function of uterine PRLR remains unclear. However, the eventualloss of pregnancy in P₄-treated PRLR^-/- mice suggests that uterine PRLRmay be essential for the support of late gestation

Control of luteal function and implantation in the mink by prolactin – I read the following passage and it sounded bad because it uses the word termination.  I had to find out what embryonic diapause was.  It is a dormancy state of an embryo that some mammals use when ecological conditions are not right for having offspring.  This allows the embryo to suspend its development until conditions are right when it then implants.  so “termination of embryonic diapause” is the embryo coming out of dormancy and implanting.

Mink (Mustela vison) were treated during the period of embryonic diapause with prolactin or ergocryptine (CB-154). Prolactin advanced implantation time and hastened onset of luteal phase progesterone secretion. Duration of gestation in prolactin-treated adult mink was shorter than that of control mink. Ergocryptine had the opposite effects, prolonging gestation and inhibiting onset of luteal phase progesterone secretion. Prolactin is suggested to be the luteotrophin necessary for termination of embryonic diapause in mink.

Hormonal requirement for ovum implantation – This article isn’t about humans but I took it to read that either progesterone alone or progesterone and estrogen are needed for implantation.

examination of effects on hormone levels and the receptivity of target tissues of drugs which interfere with implantation. The reported results indicate that both progesterone and estrogen are needed for implantation in rats, mice, and Mongolian gerbils; in other species of animals progesterone alone may be sufficient to induce implantation, although synergistic effect of estrogen appears to be seen in some species such as in the rabbit. It remains to be determined whether the blastocysts of those animals that need only progesterone for implantation have greater ability to produce estrogen than the blastocysts of the animals that need both progesterone and estrogen. Control mechanism of secretion of progesterone and estrogen for inducing implantation may be different in various species. It has been suggested that both leutropin and follicle stimulating hormone are needed for pre-implantation estrogen secretion in the rat, whereas only follicle stimulating hormone is needed in the mouse. In the species where the obligatory delay in implantation is observed, neuroendocrine mechanisms are reported to be involved in controlling the pituitary-ovarian function that causes a delay in implantation.

Prolactin and Delay of Implantation in Lactating Adrenalectomized Rats – adrenalectomized means “had the adrenal gland removed”

Adrenalectomy before pregnancy in rats caused the persistence of high blood levels of prolactin (PRL) throughout the ensuing postpartum lactation. The persistence of hyperprolactinaemia was without effect on the (delayed) timing of blastocyst implantation during lactation. The findings indicate that ovarian cycles and pregnancy may continue normally despite the absence of adrenal hormones. They reveal that the enhanced release of pituitary PRL in response to suckling is not dependent on the removal of the adrenals during early lactation. The normal delay of blastocyst implantation through suckling, in the presence of abnormally high concentrations of PRL in blood, throws doubt on the supposed critical role of PRL in determining the length of the period of delay of implantation during lactation.

Serum prolactin and TSH in an in vitro fertilization population: is there a link between fertilization and thyroid function? and Assessment of endocrine status in patients undergoing in-vitro fertilization treatment. Is it necessary? seem to show that THS but not prolactin are a big deal in success of tubal or male factor patients.

Neither TSH nor prolactin levels correlated with overall IVF outcome

Just more reading for everyone interested!

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