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Fertility Drugs for IVF: How safe are They and do They Cause Cancer?

by Dr. Geoffrey Sher on December 12, 2015

Are unsuspecting infertile women at increased risk through the drugs and treatment they administered with fertility treatment?

When it comes to fertility drugs (e.g. gonadotropins such as Follistim, Gonal F, Puregon, Bravelle, Menopur, Lupron, Superfact, Ganirelix, Cetrotide etc.,) used in IVF, claims that there are long term serious side effects have been grossly over stated. While it is indeed a fact indiscriminate overdosing of women who is inordinately sensitive to gonadotropins (“high responder”) does increase the incidence of multiple pregnancies and can precipitate the serious complications associated with Severe Ovarian Hyperstimulation Syndrome (OHSS), the risk of this happening can be minimized or even avoided through judicious and individualized approaches to the use.

Almost 3 decades ago, following the tragic diagnosis of ovarian cancer in the Saturday Night Live celebrity, Gilda Radner, who had received prior gonadotropin therapy many began to suggest the existence of a cause and effect relationship. A retrospective hastily performed study, reported in a highly prestigious journal, sounded an alarm, raising near panic throughout the field, prompting several other studies followed, mostly prospective,   almost, all of which refuted a connection. Recently, the results of a substantial , relatively 30-year study involving >12,000 women  showed that the use of conventional injectable fertility hormones for ovarian stimulation in the treatment of infertility does not increase the long-term risk of breast, uterine or ovarian cancer.  There was one possible exception that applied to women who took the oral fertility drug, clomiphene citrate for more than 12 cycles in a row, where the risk of breast cancer was slightly increased. But  the use of gonadotrophins such as Menopur, Bravelle, Follistim, Gonal-F, and Puregon, commonly used for ovarian stimulation in preparation for IVF was by and large not associated with any increased risk of reproductive cancers.

The fact is that infertility itself is associated with an overall increase in the risk of ovarian (and breast) cancer and childless women who have never used gonadotropins develop ovarian cancer with the same frequency as those that have. It should also be pointed out that ovarian cancer cells do not even have follicle stimulating hormone (FSH) surface receptors.  Thus the suggestion that such gonadotropins would promote the proliferation of ovarian cancer cells is ridiculous.

Lupron and other similar drugs on the other hand are among the safest short-term medications in the infertility arena. Though their prolonged usage can lead to osteoporosis (bone loss), this can be avoided through the concomitant administration of low dose estrogen.

This having been said, what should be considered is the fact that any intervention carries with it both an upside and a downside….whether it is driving a car, discharging a fire arm or taking medication. Obviously the level of such risk is directly proportionate to competency, skill and intent It follows that when it comes to fertility treatments, it is incumbent upon the doctor and patient to assess the cost-benefit ratio, and in so doing to base their judgment on fact rather than emotion.

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  • Rachel Greenleaf - February 25, 2017 reply

    Hi, I’m about to start medications for an egg donation cycle. The medications are a bit different this time around (this will be my 5th cycle over the course of about 5 years). I’m nervous about donating this time, having had a miscarriage two years ago, and I’m wondering if egg donations have negatively impacted my fertility. I’ve gone in to see female health specialists for ultrasounds on many separate occasions, and no one has reported finding anything unusual (like cysts). I’ve also kept up to date with pap smears and they’ve all turned out normal.

    Can you please tell me what you think about this medication protocol, and whether it is standard for egg donations?

    Estradiol .05mg twice a day, Follistim 150 IU once per day, and Menopur 75 IU once per day. I’m supposed to continue this medication schedule for 4 days, at which time they’ll review my blood work and ultrasounds to determine my future medication schedule.

    Would this put my own fertility or health at risk?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 25, 2017 reply

    Hi Rachel,

    If I understand correctly you are an egg donor, having donated 4 times before and since then you have miscarried one of your own pregnancies. You are now about to go into your 5th stimulation cycle and you are concerned as to whether the stimulations might have compromised your own reproduction.

    Obviously you could have an inherent but separate problem with your own reproduction, but this would in my opinion be almost certainly be independent of your previous egg donations. So as you decide whether/when to do the next donation, such a decision need in my opinion not be influenced by the possibility that in doing so you might harm your own reproductive potential.

    Good luck and G-d bless!

    Geoff Sher

    Rachel Greenleaf - February 25, 2017 reply

    Hi Doctor Sher,

    Thanks for responding. I’d like to know if the medication schedule is standard for IVF & egg donations (in your opinion)? I recently spoke with other egg donors and they thought my medication schedule was very unusual (since it contains estradiol). I also know that for my trigger shot, the clinic will have me do a combination of HCG and lupron.

    Thanks again,

    Rachel

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 25, 2017 reply

    I personally do not use a Lupron trigger (see below), but the approach to ovarian stimulation will differ from center to center.

    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
    • “Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
    • The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691
     800-780-7437

    Geoff Sher

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

  • Jo - May 2, 2016 reply

    Hello Dr Sher
    What are your thoughts on Lupron for endometriosis.? Would you think 36 months continuos could cause long term damage? Thank you

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 2, 2016 reply

    I do not advocate prolonged Lupron . AS soon as you stop, everything comes back again rapidly. I only use Lupron in the short term for ovarian stimulation in IVF.

    Geoff Sher

  • Susan Clark - April 30, 2016 reply

    Dr. Sher, your Lupron writings are pure AbbVie / TAP / Abbott propaganda and fly in the face of fact. Read the opinions of the FDA scientist who believes Lupron only harms, based on the original proprietary data, rather than misleading more patients to such gross harm. Lupron has already maimed millions for more than a quarter century and needs to stop. Now, what do you think caused Gilda Radner’s ovarian cancer? Same thing that caused my cervical cancer… those ignoble GnRH are nothing but a cash-cow for AbbVie and pure poison to women.

    Just one example… “Dr. Gueriguian alleges that that TAP intentionally suppressed knowledge about the risks associated with Lupron, including bone density loss (leading to permanent disability in some cases), generalized pain, headaches, fluid retention, depression and immune and nervous system problems, including spinal fracture, convulsions and paralysis.” -https://www.lawyersandsettlements.com/articles/drugs-medical/drug-side-effects-medical-device-companies-dangerous-2-13725.html

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 30, 2016 reply

    Susan,
    You are entitled to your opinion with which I vehemently disagree.

    There is to my knowledge no proven reports on an association between the use of Lupron and ovarian cancer. I am fully aware of the hype that surrounded Gilda Radner’s tragic death from Ovarian cancer and the original assertion that this was due to stimulation with gonadotropins. In fact I and others at the time provided written opinions that there was no cause and effect relationship at the time and I stand by that opinion to this day. The assertion that tis was linked to Lupron usage is new to me however.

    Any use of hormonal therapy for ovarian stimulation can (and will) in susceptible individuals evoke emotional side effects and the agonist, Lupron is not exempt from doing this. However , loss of bone density/immunologic dysfunction/spiinal fractures/permanent disability…are unheard of unless an agonist/antagonist is used continuously for months on end (i.e. for protracted periods of time). In such circumstances, since Lupron does inhibit ovarian estrogen production which is important for maintenance of bone integrity, it follows that if used over an extended period of time, loss of bone density can occur and then lead to problems. However I have NEVER advocated or prescribed long term agonist/antagonist therapy to any of my patients….. who rarely stay on Lupron for >2 weeks at a time.

    I stand by my expressed opinion that provided it is used for short periods of time d , Lupron is one of the safest pharmacologic products used with controlled ovarian stimulation. Infrequently emotional side effects effects and allergic responses is one of the best and safest drugs available and plays a vital role in optimizing response to ovarian stimulation. Removing it from the pharmacologic armamentarium would do serious disservice to women undergoing controlled ovarian stimulation (COS) for IVFand would in my opinion compromise results.

    AS a sided note, with >25 years of prescribing Lupron for ovarian stimulation, I have yet to encounter a single related physical problem that can be attributed to its short-term use in cycles of ovarian stimulation.

    Unfortunately, this forum does not lend itself to a lengthy debate on issue such as this and I simply cannot commit the time to do so . Accordingly I will refrain from engaging in an ongoing debate here. However, if you wish, you can call 800-780-7437 and set up a formal consultation with me to discuss this further.

    Good luck and G-d bless!

    Geoff Sher

    I wish you well!

    Geoff Sher

    Susan Clark - April 30, 2016 reply

    Dig a little deeper, Dr. Sher… ie: Klein vs. TAP / Abbott (2008): Dr. John L. Gueriguian, former FDA Medical Officer involved with the initial 1985 FDA NOC for Lupron for palliative treatment of prostate cancer: “Lupron causes irreversible side effects and permanent severely disabling health problems… TAP intentionally suppressed knowledge about the real dangers associated with the use of Lupron… Prescribers and patients were misled… Lupron causes irreversible damage to the human body and the development of chronic disabling diseases… TAP fails to warn about hazards associated with the use of Lupron… Lupron Depot is both ineffective and unsafe… Lupron appears to be more toxic than other GnRHa’s.”

    -excerpt: “LUPRON AND [PLAINTIFF’S] HEALTH PROBLEMS A THEMATIC REPORT, John L. Gueriguian, M.D.”

    Does a physician really need more than the previous article’s remarks or this new one above one to more than question the both the safety and efficacy of a drug? As a prescriber, you have been misled, Dr. Sher.

    B. A medical study of the original raw data that brought Lupron to market shows that the original data ”indicated definitive evidence of long-term damage to ovarian function.” The FDA has chosen not to act upon the information. Its author is a well-known endometriosis specialist.

    A specialist such as yourself ought lead the charge to demand that safety information be divulged, based on Dr. John L. Gueriguian’s remarks alone. Rather, you claim that “Lupron is one of the safest pharmacologic products used with controlled ovarian stimulation,” when that claim has no basis in science, but only in commerce.

    The fraudulent so-called clinical trials of the 1990s are already well known (Friedman) as is the manufacturer’s record of civil and criminal frauds around Lupron. It’s really not a stretch to question the drug’s legitimacy, all things considered. Please take a much closer look at the product and the brand that you are here advertising as safe. The lack of any legitimate safety information or authentic female trials should be a big red flag. The lack of adaptation to the realities of Lupron by the medical community only necessitates such as I and delays true remedy for those suffering.

    If you refuse to look at and acknowledge actual data is a choice, and not a scientific one. Do you require further evidence?

    Again… a hint, even, of where you saw such data as a 12,000 woman study, that you mentioned in your blog?

    I wish us all well, in wellness.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 30, 2016 reply

    Respectfully, we are talking “apples and oranges” here. I represented that Lupron used in the short term to launch and enhance ovarian stimulation is safe, a valuable adjunct and virtually risk-fee. I have never suggested long term administration. That is another matter altogether. All the studies you quote, reference long term use of agonist and this is really not relevant to my position. My use of Lupron for use in ovarian stimulation is confined to daily 5-10U injections for a period of up to 14 days….. and I NEVER ever even advocate the use of long acting Depot Lupron for ovarian stimulation. So let me say one more time…..when appropriately prescribed in the IVF setting, Lupron is virtually free of significant/serious risk………

    And that is my last contribution to this argument!

    Geoff Sher

    Susan Clark - May 1, 2016

    show me a single medical study that supports your safety claim, Dr. Sher… along with a link to that now-mythic 12,000 woman study… science would be a fitting last word. There is no “appropriately prescribed” Lupron for women – that is mere manufacturer’s propaganda to support their sales agenda, and contrary to the proprietary data in their possession. Please do not further their sales agenda, but look deeper into the science behind the claims, for the sake of your patients. Lupron for women is far from risk-free in any quantity, regardless of fabricated safety claims from the manufacturer… a company already convicted of civil and criminal frauds regarding this drug. How do you not miss a beat over the FDA scientist’s claims (quoted and referenced above). Your patients deserve to know.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 1, 2016

    As I said Kim…there will be no further dialogue from me on this matter .You have my opinion and I stand by it!.

    Separately…here (below) is the information you asked for (and more) regarding controlled population

    Geoff Sher

    ADDENDUM:

    Here are several of many articles that show no cause and effect relationship between ovarian stimulation and the risk of ovarian cancer. The largest of these studies ever reported on was by Mosgaard et al in 1998. (#1 below) I have added an abstract on that study separately below:

    1. Mosgaard BJ, Lidegaard O, Kjaer SK, Schou G, Andersen AN. Infertility, fertility drugs, and invasive ovarian cancer: a case-control study. Fertil Steril. 1997;67(6):1005–1012. doi: 10.1016/S0015-0282(97)81431-8.
    2. Ness RB, Cramer DW, Goodman MT, Kjaer SK, Mallin K, Mosgaard BJ, Purdie DM, Risch HA, Vergona R, Wu AH. Infertility, fertility drugs, and ovarian cancer: a pooled analysis of case-control studies. Am J Epidemiol. 2002;155(3):217–224. doi: 10.1093/aje/155.3.217
    3. Klip H, Burger CW, Van Leeuwen FE. The Omega Project Group. Risk of hormone-related cancers after ovarian stimulation for in-vitro fertilization in a cohort of 25,152 women. Enschede
    4. Dor J, Lerner-Geva L, Rabinovici J, Chetrit A, Levran D, Lunenfeld B, Mashiach S, Modan B. Cancer incidence in a cohort of infertile women who underwent in vitro fertilization. Fertil Steril. 2002;77(2):324–327. doi: 10.1016/S0015-0282(01)02986-7.
    5. Venn A, Watson L, Bruinsma F, Giles G, Healy D. Risk of cancer after use of fertility drugs with in-vitro fertilisation. Lancet. 1999;354(9190):1586–1590. doi: 10.1016/S0140-6736(99)05203-4.
    6. Lerner-Geva L, Geva E, Lessing JB, Chetrit A, Modan B, Amit A. The possible association between in vitro fertilization treatments and cancer development. Int J Gynecol Cancer. 2003;13(1):23–27. doi: 10.1046/j.1525-1438.2003.13041.
    7. Siristatidis C, Sergentanis TN, Kanavidis P, Trivella M, Sotiraki M, Mavromatis I, Psaltopoulou T, Skalkidou A, Petridou ET. Controlled ovarian hyperstimulation for IVF: impact on ovarian, endometrial and cervical cancer–a systematic review and meta-analysis. Hum Reprod Update.
    8. Lerner-Geva L, Rabinovici J, Olmer L, Blumstein T, Mashiach S, Lunenfeld B. Are infertility treatments a potential risk factor for cancer development? Perspective of 30 years of follow-up. Gynecol Endocrinol. 2012;28(10):809–814. doi: 10.3109/09513590.2012.671391
    9. Silva Idos S, Wark PA, McCormack VA, Mayer D, Overton C, Little V, Nieto J, Hardiman P, Davies M, MacLean AB. Ovulation-stimulation drugs and cancer risks: a long-term follow-up of a British cohort. Br J Cancer. 2009;100(11):1824–1831. doi: 10.1038/sj.bjc.6605086.
    ______________________________________________________________________

    ADDENDUM:Mosgaard BJ1, Lidegaard O, Kjaer SK, Schou G, Andersen AN.
    Abstract
    OBJECTIVE:
    To assess the risk of borderline ovarian cancer among infertile women treated with fertility drugs.
    DESIGN:
    Case-control study.
    SETTING:
    Nationwide data obtained from public registers and postal questionnaires.
    PATIENT(S):
    All Danish women <60 years old with borderline ovarian cancer during the period 1989-1994 and randomly selected population controls. The analysis included 231 cases and 1,721 controls.
    INTERVENTION(S):
    None.
    MAIN OUTCOME MEASURE(S):
    Influence of parity, infertility, and fertility drugs on the risk of borderline ovarian cancer after multivariate confounder control.
    RESULT(S):
    The odds ratio (OR) for borderline ovarian cancer among infertile untreated nulliparous women compared with fertile nulliparous women was 1.9. The OR for borderline ovarian cancer among treated nulliparous women compared with untreated infertile nulliparous women was 1.5, and the OR among treated parous women compared with untreated infertile parous women was 1.5.
    CONCLUSION(S):
    Among fertile women, the difference in the risk of borderline ovarian cancer between nulliparous women and parous women was not statistically significant. Nulliparous women who were infertile and who did not receive medical treatment had a twofold higher risk of borderline ovarian cancer than fertile nulliparous women. There was no statistically significant increase in the risk of borderline ovarian cancer among nulliparous women who were treated with fertility drugs compared with nulliparous untreated infertile women or among parous women who were treated with fertility drugs compared with parous untreated infertile women.

    Susan Clark - May 2, 2016

    “Dr. Gueriguian alleges that that TAP intentionally suppressed knowledge about the risks associated with Lupron, including bone density loss (leading to permanent disability in some cases), generalized pain, headaches, fluid retention, depression and immune and nervous system problems, including spinal fracture, convulsions and paralysis.

    Drugs whose risks outweigh their benefits should be pulled from the market, the report concludes.

    Lupron, manufactured originally by TAP and now by Abbott, resulted from a joint venture between Takeda Pharmaceuticals and Abbott. The companies subsequently split in 2008, leaving Abbott with the rights to Lupron.” [And, now they are AbbVie.]
    https://www.lawyersandsettlements.com/articles/drugs-medical/drug-side-effects-medical-device-companies-dangerous-2-13725.html

    How that does not motivate you to reconsider your use of Lupron on patients, is beyond understanding.

    Do you give your patients printed safety information about Lupron prior to acquiring what would then be informed consent for receiving Lupron, which is a palliative prostate cancer chemo… ?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 2, 2016

    Sorry Susan…no further comment on this issue!

    Geoff Sher

  • Jessica Dockins - March 5, 2016 reply

    Can you please provide a link to the 30 year 12,000 women study?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - March 5, 2016 reply

    Sorry cannot do offhand. But if I come across it again I will post.

    Geoff Sher

    Susan Clark - April 30, 2016 reply

    Really like to see that 12,000 woman study you can’t seem to find, yet you quote.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 30, 2016 reply

    I understand.

    Geoff Sher

    Kim Bernhardt - May 1, 2016

    I would love to have a copy of this study as well, Dr. Sher. Thank you in advance.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - May 1, 2016

    Separately…here (below) is the information you asked for (and more) regarding controlled population

    Geoff Sher

    ADDENDUM:

    Here are several of many articles that show no cause and effect relationship between ovarian stimulation and the risk of ovarian cancer. The largest of these studies ever reported on was by Mosgaard et al in 1998. (#1 below) I have added an abstract on that study separately below:

    1. Mosgaard BJ, Lidegaard O, Kjaer SK, Schou G, Andersen AN. Infertility, fertility drugs, and invasive ovarian cancer: a case-control study. Fertil Steril. 1997;67(6):1005–1012. doi: 10.1016/S0015-0282(97)81431-8.
    2. Ness RB, Cramer DW, Goodman MT, Kjaer SK, Mallin K, Mosgaard BJ, Purdie DM, Risch HA, Vergona R, Wu AH. Infertility, fertility drugs, and ovarian cancer: a pooled analysis of case-control studies. Am J Epidemiol. 2002;155(3):217–224. doi: 10.1093/aje/155.3.217
    3. Klip H, Burger CW, Van Leeuwen FE. The Omega Project Group. Risk of hormone-related cancers after ovarian stimulation for in-vitro fertilization in a cohort of 25,152 women. Enschede
    4. Dor J, Lerner-Geva L, Rabinovici J, Chetrit A, Levran D, Lunenfeld B, Mashiach S, Modan B. Cancer incidence in a cohort of infertile women who underwent in vitro fertilization. Fertil Steril. 2002;77(2):324–327. doi: 10.1016/S0015-0282(01)02986-7.
    5. Venn A, Watson L, Bruinsma F, Giles G, Healy D. Risk of cancer after use of fertility drugs with in-vitro fertilisation. Lancet. 1999;354(9190):1586–1590. doi: 10.1016/S0140-6736(99)05203-4.
    6. Lerner-Geva L, Geva E, Lessing JB, Chetrit A, Modan B, Amit A. The possible association between in vitro fertilization treatments and cancer development. Int J Gynecol Cancer. 2003;13(1):23–27. doi: 10.1046/j.1525-1438.2003.13041.
    7. Siristatidis C, Sergentanis TN, Kanavidis P, Trivella M, Sotiraki M, Mavromatis I, Psaltopoulou T, Skalkidou A, Petridou ET. Controlled ovarian hyperstimulation for IVF: impact on ovarian, endometrial and cervical cancer–a systematic review and meta-analysis. Hum Reprod Update.
    8. Lerner-Geva L, Rabinovici J, Olmer L, Blumstein T, Mashiach S, Lunenfeld B. Are infertility treatments a potential risk factor for cancer development? Perspective of 30 years of follow-up. Gynecol Endocrinol. 2012;28(10):809–814. doi: 10.3109/09513590.2012.671391
    9. Silva Idos S, Wark PA, McCormack VA, Mayer D, Overton C, Little V, Nieto J, Hardiman P, Davies M, MacLean AB. Ovulation-stimulation drugs and cancer risks: a long-term follow-up of a British cohort. Br J Cancer. 2009;100(11):1824–1831. doi: 10.1038/sj.bjc.6605086.
    ______________________________________________________________________

    ADDENDUM:Mosgaard BJ1, Lidegaard O, Kjaer SK, Schou G, Andersen AN.
    Abstract
    OBJECTIVE:
    To assess the risk of borderline ovarian cancer among infertile women treated with fertility drugs.
    DESIGN:
    Case-control study.
    SETTING:
    Nationwide data obtained from public registers and postal questionnaires.
    PATIENT(S):
    All Danish women <60 years old with borderline ovarian cancer during the period 1989-1994 and randomly selected population controls. The analysis included 231 cases and 1,721 controls.
    INTERVENTION(S):
    None.
    MAIN OUTCOME MEASURE(S):
    Influence of parity, infertility, and fertility drugs on the risk of borderline ovarian cancer after multivariate confounder control.
    RESULT(S):
    The odds ratio (OR) for borderline ovarian cancer among infertile untreated nulliparous women compared with fertile nulliparous women was 1.9. The OR for borderline ovarian cancer among treated nulliparous women compared with untreated infertile nulliparous women was 1.5, and the OR among treated parous women compared with untreated infertile parous women was 1.5.
    CONCLUSION(S):
    Among fertile women, the difference in the risk of borderline ovarian cancer between nulliparous women and parous women was not statistically significant. Nulliparous women who were infertile and who did not receive medical treatment had a twofold higher risk of borderline ovarian cancer than fertile nulliparous women. There was no statistically significant increase in the risk of borderline ovarian cancer among nulliparous women who were treated with fertility drugs compared with nulliparous untreated infertile women or among parous women who were treated with fertility drugs compared with parous untreated infertile women.

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