The Embryo Dilemma

Recent news reports brought up again the ongoing questions surrounding embryo creation via IVF. Actually, the questions aren't so much about the creation side of things as they are about disposition of extra embryos.

As reproductive medicine specialists, we have focused mostly on the best ways to help individuals and couples conceive biological children. Success is very often a matter of numbers: the more eggs a woman ovulates, the more sperm a man has available, the more embryos created... the greater their chances at getting pregnant.

For years now, we specialists have been boiling down the science and finely tuning the techniques toward the ultimate goal: how best to unite only as many eggs and sperm necessary to create only as many embryos needed to make one healthy baby.

Single embryo transfer is a true possibility for some patients, but almost a pointless, expensive protocol for others.

At this point, it remains common for IVF patients to wind up with at least some "extra" embryos -- that is, too many embryos to transfer within the same treatment cycle -- so the question of what to do with the surplus continues to be answered.

In the study recently published in Fertility & Sterility, more than 1,000 infertility patients were surveyed about the choices they've pondered and made to address their own embryo surpluses.

Among other things, the survey results reveal a broad consensus of disappointment -- with the options offered at various clinics and with the level of pre-IVF information made available to them.

Fertility treatment centers are like any medical practice: filled with professionals who are people first. Different practices have varying policies based on many factors, including the personal beliefs of the professionals. Another component that steers clinic policies is the availability of resources.

Patients and professionals need not have all their beliefs in common, but there are sometimes "bottom lines" that patients use to make their choices about which fertility practice to turn to for assistance with getting pregnant and about which treatments to use. In the past, some practices were so results-driven, so focused on success rates, that even crucial issues like the disposition of surplus embryos were side-stepped or, at least, addressed with as much brevity as possible. The dilemma of extra embryos is very real and can no longer be seen as ancillary.

I'll discuss specific related options for patients of Houston Infertility Clinic in a follow-up blogpost.

Finding Gratitude

With understanding of your struggles to achieve one of life's simplest joys, my Thanksgiving wish for all of you is to find treasure in the smallest things. Some of my staff and I will be hopefully helping a few patients do just that as we transfer some embryos to hopeful mothers on Thanksgiving morning.

I am grateful for the opportunities to play a role in the creation of families.

Our Presentation at ASRM: More Pieces of the Pregnancy Puzzle

We were pleased to have our poster presentation accepted into this year's meeting of the American Society for Reproductive Medicine. The title -- Differential Relationship Between the Total Number of Oocytes Retrieved and the Implantation Rate in IVF and ICSI Patients -- may sound dry, but our results were positive news for patients who need IVF to have a baby.

The Houston Infertility Clinic staff, in conjunction with the Department of OB/Gyn at the University of Sydney in Australia, examined 351 IVF cycles. In each case, patients were using their own eggs and non-frozen embryos. We looked at:

the number of eggs retrieved
number of embryos transferred
results of clinical pregnancy tests

Next we compared those cycles that included ICSI and those that used "conventional" IVF for insemination. These two groups were then split up into three sub-groups, based on the number of eggs that were retrieved (either 1-10 eggs, 11-20 eggs, or 21-40 eggs.)

It might seem a simple question of statistical odds that the more eggs you produce, the better your chances, but...

Here's the good news: We concluded that, at least in our hands, patients using ICSI who were in the 11-20 egg group had the highest implantation rate. Patients using "conventional" IVF w/o ICSI had higher implantation rates when they were in the subgroup producing the most eggs (21-40 eggs).

It's important to note that quality of eggs -- rather than quantity -- is the more important measure. Patients shouldn't be discouraged if their bodies aren't producing a high number of eggs. As our study indicates, the use of ICSI seems to make a noticeable difference in outcome.

On a related note -- in some cases, women's ovaries will produce far fewer eggs than everyone hoped for in an IVF cycle. Different clinics have different policies; many are, frankly, guided by heavy concern about success rate statistics.

Our policy is that if a patient wants to move forward and retrieve the one follicle that her ovary brought forth, we will respect her wishes and do our best to render highest quality care toward the best possible outcome.

We want every patient to have a fighting chance at getting pregnant.

Write About Your Experience: Infertility Haiku Contest

The new business called My Fertility Plan has started something unique - a poetry contest about infertility.

They're inviting everyone to submit haiku poetry until November 24, 2008. Entries will be judged by a panel of people in the infertility treatment business and some who blog about it. Your haiku can fall into either a serious or humorous category, but must be in the proper format, syllable-length-wise. For details, see their related webpage. 

My Fertility Plan Blog: Your Conception Action Plan

Article in Houston B.A.B.Y. Magazine

[Edited 11/26/08: We now have a copy of the article in PDF format on our BabyLater.com site. Read it here...]

I'm featured in an article for Houston B.A.B.Y. Magazine, a publication of Houston Family Magazine. The October issue is available in digital format here (click on the cute baby face cover), and you can find print issues at Krogers, and in OB/Gyn and pediatrician offices.

The article is called "From Cancer to Parenthood: Reproductive Expert Helps Survivors Create New Life" and includes a pretty interesting photo of Dr. Stoddart in the lab.

I'm glad the feature highlights my efforts at bridging the gaps between oncologists and reproductive specialists. Patients are the prospective losers if the facts about fertility preservation aren't immediately available at that very first discussion about cancer treatment. Making those physician-to-physician connections well in advance of patient need will be the key to enabling more survivors to become parents later.

Please feel free to share this article with your physicians and friends.

For easy sharing by email and for printing, I recommend this: find the article on page 16, click on the article title words "From Cancer to Parenthood" to display the article in easy-print format. From there, you also have options to post the article on your Facebook, MySpace, and other favorites. (Technology is great, but tricky at times...)

More Local News Coverage of Egg Freezing for Fertility Preservation

I received a last-minute request earlier this week from Elizabeth Lee, reporter for 39 News. Since I had two surgeries and an IVF to perform that afternoon, she and her video team made their way to the lab in central Houston for some interesting cryo shots after catching me at our Sugar Land office.

We talked about egg freezing and using the technique to preserve future fertility for women diagnosed with cancer, as well as for young healthy women who are worried they may not find "Mr. Right" before their egg cells age.

You can see the video on the 39 News website.

You Asked For It: Losing Hope, Considering a New Treatment Plan

A question from Robin, in response to "Are Simple Fertility Treatments Pointless?"

I've had three IUI's. Two after clomid and the last after injections of follistim (very expensive - my insurance doesn't cover). Is my only other option now IVF? It is not an affordable option for me. I'll be 38 Monday.
I'm losing hope.

My response:

First -- I hear your feeling of hopelessness, and my hope is that I can help you feel otherwise.

It would be unwise for me to advise you specifically, since I don't know your medical history or current patient information. The treatments you've been through already -- intrauterine insemination (IUI), clomiphene citrate (Clomid), and injectable FSH (Follistim) -- are prescribed for a number of different infertility causes. Since I don't know your diagnosis, I can't comment on the efficacy of these treatments for your individual case.

Obviously, though, you are wise to start considering new treatment plans to resolve your infertility, get pregnant, and have a baby.

Truthfully, IVF is not easy to afford for most patients. Not many of us start out trying to get pregnant with enough money in the bank to cover infertility treatment. There are ways to make the treatment process more affordable.

That said, it may not necessarily be time to talk IVF. There may be other pieces to the conception puzzle that are still missing. If you'd like to schedule a consultation with me, my staff will be happy to take your call.

Another Great Day Houston

Following last July's show, I was asked to visit Great Day Houston again to talk more about fertility-sparing treatments for women who wish to delay conception.

Tune in to Great Day Houston with Deborah Duncan - Tuesday, October 21
at 9 AM Central on KHOU-Channel 11. Or watch online by clicking the Live Video link from http://www.greatdayhouston.com/ during airtime.

The techniques to retrieve and freeze egg cells for future conception are primarily offered to women who have just been diagnosed with cancer. We're working on collaborative relationships with cancer specialists and other professionals who can quickly refer patients for fertility preservation before they undergo sterility-causing cancer treatment.

As long as patients are willing to educate themselves and be fully aware of the process involved, women without cancer can also utilize fertility preservation technology to have a baby later.

Learn more about fertility preservation (for women and men) at http://babylater.com.

[Edited 10-31-08 to add link to view video here...]

Spreading the Word About Fertility Preservation

Last week, I had the pleasure of meeting with and speaking to the Educational Committee of the local Susan G. Komen Foundation group.

What a thriving organization! Just a few days after their annual Race for the Cure®, with participants this year numbering over 26 thousand, the women who lead Komen's educational charge gathered again in an office crowded with boxes of materials and mementos.

Lorianne Classen, a Health Education Specialist with M.D. Anderson Cancer Center and Komen volunteer, remarked that the meeting was particularly well-attended that evening, likely because of interest in our topic: fertility preservation.

Judging from the many raised hands with questions, including several from survivors and their loved ones, I'd say that interest in the concepts of preserving fertility for use after surviving cancer was indeed very high. Good questions. Poignant situations.

I left feeling very positive about sharing the realities of how women and men can take action to preserve their fertility before engaging in life-saving cancer treatment. I also came away seeing the need for education *now* is possibly greater than I thought.

As I emphasized to the Komen Education Committee, timing is crucial in this matter. I'll be continuing my pursuit of pre-need connections among oncology specialists and their patients -- through http://babylater.com -- so that the information about real hope for having a family isn't only wistful hindsight for cancer survivors.

For more information, visit the Houston affiliate of the Susan G. Komen for the Cure.

Are Simple Fertility Treatments Pointless?

A few weeks back, the news was all about a UK study that pronounced simplistically that Clomid with IUI is ineffective for treating infertility. Of course, we know there's more to it than that.

Part of the problem is the media's often too quick with inaccurate, alarmist headlines. They may need to squeeze too much info into too small a space. It also may be that a lot of reporters just don't understand the complexities of infertility treatment.

If such a thing as a "magic pill" to promote pregnancy existed, the whole world would be entirely different. The truth is that clomiphene citrate (Clomid is only one of the drug's brand names) works for some, but not for most. The same might be said of intrauterine insemination (IUI).

A number of large studies, both single-center and collaborations of different fertility clinics, have demonstrated the limits of clomiphene citrate (CC), with and without IUI.

Should patients completely bypass this treatment option?

Contrary to what headlines would imply, there's simply no one answer for everyone. A thorough diagnostic process is a must, even in cases that -- once the results are in -- will call for very minimal medical assistance.

For each and every fertility patient, time is valuable. All should keep in mind that infertility treatment does not get easier or less expensive as the woman ages. I strongly advise against spinning your wheels (and spending your money) on too many cycles of CC/IUI.

Technorati Tags: infertility treatment,infertility research,clomid,iui,studies,effective medicine

Hurricane Ike Not a Problem For Patients' Fertility Needs

 

Hurricane Ike may have paid a visit to Houston, but I'm happy to report that Houston Infertility Clinic did not lose power. That means our staff is available. We were able to perform a scheduled egg retrieval on Monday, just two days after Ike roared through the Gulf Coast.

Additionally, our cryopreservation units never ceased functioning.

Ironically, though Hurricane Rita in 2005 didn't result in as much widespread damage to Houston, Houston Infertility Clinic was without power for a week after that storm. We prepared in advance (just as we did last week for Ike) by conducting embryo transfers earlier than scheduled to allow patients to evacuate.

This time, patients who were in mid-cycle were still able to stay on track.

Thank you to my staff for the dedicated extra efforts toward ensuring the safety of our patients' treatment cycles and the embryos they create.

Might be interesting to see if any babies named "Ike" are born in mid-2009!

Technorati Tags: hurricane ike,infertility clinic,cryopreservation,frozen embryos,hurricane rita,texas,weather

A Key to Ovulation Found In Brain

According to this Reuters article at Revolution Health, intriguing research being published in the Journal of Neuroscience points to a protein molecule in the brain as being essential to kick-starting ovulation.

Explaining the origins of infertility to patients isn't always easy. Often by the time I see someone in my office, they're frustrated, sad, and sometimes angry about all they've tried unsuccessfully to have a baby. They come to me wanting relatively simple answers to "why?" and "how?" Unfortunately, I can't always give those simple answers.

Keeping up with research in medical fields on the outer edges of reproductive endocrinology can sometimes increase my reference list, so to speak, to help patients grasp all the possibilities that may apply to their situation.

This latest research finding is one of many that are building to a more complete understanding of how the tiniest parts of the brain can have very big consequences in a person's life.

Technorati Tags: infertility,ovulation,brain research,kisspeptin,journal of neuroscience,medical studies

Fertility Patients' Rights To Be Treated & Keep Their Jobs

In an encouraging step forward, a Federal appeals court in Illinois has ruled that women undergoing IVF should have their employment protected in the same way as pregnant women, through the Pregnancy Discrimination Act.

I’m an involved mom -- besides my busy practice, my family keeps me running. I have the utmost respect for women who are trying to manage work and family with the added stress of infertility treatment. Our office has always maintained very early hours for the primary purpose of facilitating pre-work appointments for patients. I opened my Sugar Land office when I realized how many southwest area patients were squeezing ultrasounds and exams at our central Houston office into their schedules.

The court’s ruling is a first. It’s still quite possible that employers could be less than understanding about patients needing to come in late or leave in the middle of the day so they can follow their physician’s prescribed treatment. But at least a precedent has been set, and it’s one that can be cited if a patient encounters challenges at work.

Wall Street Journal article: Women Battling Infertility Find a Friend in the Court

Technorati Tags: pregnancy discrimination,federal legislation,infertility treatment,patient rights,ivf

Spread The Word: Great Day Houston

On Tuesday, July 29, Houston Infertility Clinic will be featured on Great Day Houston with Debra Duncan.

The show will include interviews with patients Karen and Cliff Nickel (and their two adorable daughters), as well as new patients Reece and Tracy Klepacz who kindly share with the audience their infertility struggle of many years. Plus, the Klepacz' allowed Great Day Houston crew to film their recent egg retrieval here at Houston Infertility Clinic.

Also included will be interviews with an egg donor from Prime Genetics and Chris Axelrad, Clinic Director of The Axelrad Clinic for Natural Fertility Enhancement & Women's Health. They'll be joining me to talk about the many varied solutions to all types of infertility conditions.

Tune in on Tuesday, July 29th at 9 AM on KHOU Channel 11 for Great Day Houston. If you miss the show, you can watch online on their homepage.

[Edited 8-15-08: You'll find full video online here.]

Technorati Tags: infertility treatment,tv show,interviews,patients,doctors,egg retrieval,medical

You Asked For It: Treating PCOS

In an earlier post, Christy asked about PCOS and its treatment. Polycystic Ovarian Syndrome is a complex diagnosis that is relatively easy to treat.

Here are my responses to Christy's questions:

How do you treat [PCOS]?

PCOS is sometimes referred to now as "metabolic syndrome" because the term more accurately reflects the entire condition. For example, not all women with PCOS have ovaries with many cysts.

The goal of treatment is ovulation. Treatment usually consists of oral medication (clomiphene citrate, more commonly referred to by one of its brand names, Clomid).

In the past, another drug, Metformin, was frequently administered in conjunction with Clomid. A couple of years ago, a large study found no advantages to using Metformin strictly for the purpose of getting pregnant. (I wrote about that finding in my November 2006 newsletter.)

How effective is Clomid? Does it work every month?

Clomid is generally effective within the first three cycles of use. Depending on several factors, I may prescribe the medication be used in conjunction with intrauterine insemination (IUI) or timed intercourse.

If a patient is Clomid resistant, what is the next protocol?

If a patient's ovaries are resistant to Clomid, the next step is often gonadotropins, which are administered by injection. Patients who also have abnormal glucose/insulin levels will be prescribed Metformin.

As a side note, it's important that women with PCOS are made aware of the links between that and more serious health conditions like heart disease and diabetes. I encourage all of my patients to make healthy lifestyle changes as needed, not only to increase their chances for pregnancy, but to promote overall better functioning of their total body.

Technorati Tags: pcos,polycystic,metformin,clomid,womens health,getting pregnant,fertility treatment

You Asked For It: Predicting Ov with PCOS

One of my readers asked me to discuss PCOS, in conjunction with my earlier comments on using ovulation predictor kits at home.

It's true that PCOS and several other ovulatory disorders can make home ovulation prediction a very inaccurate process. If you're determined to use at-home testing kits, try to look at the results as information that is helpful but that may not be giving you the full picture of your ovulatory function.

A very important point here: regular menses does not necessarily mean you are ovulating during every cycle. Women with PCOS come with a range of cycles -- from amenorrhea (completely absent periods) to wildly irregular cycles to fairly consistent menstrual periods.

In short, when a woman has PCOS or other ovulatory disorders, menstruation and ovulation may be different, seemingly unrelated events. You can't always use "Aunt Flo" as an indicator of how well your ovaries are working.

Advances in fertility science spawn new issues - Houston Business Journal:

I was interviewed by the Houston Business Journal's Nicole Bradford at our Sugar Land office for this article on egg freezing. It's in their July 4th issue's special section on Health Care. [Edited 8-15-08: The full article is now online and readable by non-subscribers.]

Advances in fertility science spawn new issues - Houston Business Journal:

This photo of a metaphase II oocyte was taken by our Lab Director, Dr. Neil Stoddart, and used on the front page of the July 4 issue of Houston Business Journal.

Technorati Tags: egg freezing,houston business journal,interview,media,dr sonja kristiansen interview,infertility clinic

My Opinion: On DIY Fertility Testing

There was a lot of news attention a few weeks back about a new at-home fertility test. I'm frequently asked for my opinion on such tests by both patients and the media.

While it's certainly understandable in this age of the Internet that empowered, educated patients want to take their health and wellness into their own hands, the distributors and manufacturers of DIY tests often fail to accurately inform consumers about their products' limitations. So I'm glad when people come forward to find out about the bigger picture.

In this case, the test claims to be "a breakthrough test for ovarian reserve" when in actuality, it's a collection of analyses that clinicians have used for many years now. I suppose the "breakthrough" aspect is that folks can use it at home. But should they?

Consumers need to weigh the cost-benefit ratio -- yes, even for health care. I know that I consider numerous aspects before making a substantial purchase, and I'm positive that my patients do, too.

Like other home tests, The Plan Ahead test claims to address two issues common to the topic of getting pregnant: privacy and cost.

It's true that performing a test "at home" is more private than a consultation in my office and a blood draw in the exam room. But in the case of this particular test, the consumer is still required to have their blood drawn by a participating physician. The cost benefit -- in this case, just under $400 -- of such a test is debatable.

There are so many more variables that add up to successful conception and pregnancy that home tests do not and cannot address. Ovarian reserve - a term that refers to a woman's egg supply -- is but one of numerous components that make someone fertile. Likewise, patients sometimes are unable to get pregnant or maintain a pregnancy because of underlying health conditions that will not be detected by home testing.

So the cost of doing-it-yourself in this case could mean that you miss an important diagnosis of an undetected condition. DIY fertility diagnosis can also cost patients crucial time in their journey toward getting pregnant.

While I may sound biased, I think it just makes common sense to go ahead, make sure your bases are covered, and have a consultation with a specialist from the start.

Technorati Tags: infertility testing,ovarian reserve,fertility,plan ahead,diy,health care,at-home tests

POF: Future Help On the Horizon?

In my experience as a fertility specialist - and as a mother - by far one of the most traumatic diagnoses to render to a patient is one of POF, premature ovarian failure.

A POF diagnosis can ring with emotionally painful finality in a patient's mind. It means, in effect, premature menopause, sometimes as early as the woman's 20's. However, I am grateful to have alternatives to present in many cases. For many women with POF, the use of donor eggs with IVF can result in successful pregnancy.

Today there is even better news, even if only of the long-range type. Scientists have found more evidence of genetic connections to the incidence of POF. What this means is that the future may possibly hold a test that can tell very young women of their chance for having POF.

Presumably if a young woman with healthy eggs tests positive for the gene mutation, she could have her healthy existing egg cells retrieved and cryopreserved for later use.

I look forward to every additional opportunity I'm given for presenting a fulfilled future to women with POF.

Oocyte-specific gene mutations cause premature ovarian failure - Baylor College of Medicine

Technorati Tags: premature ovarian failure,pof,infertility treatment,premature menopause,egg freezing

In the End, Treatment Not For Everyone

We are lucky to live in a time when assisted reproductive technology can assist so many with making their dreams come true. Still, some people do indeed arrive at the conclusion that they've pursued treatment to a different end.

This article on Canada.com (Choices that will bear fruit) provides a well-balanced illustration of two different end-of-treatment options. In both cases, numerous attempts with fertility treatment did not result in pregnancy. One couple chose to build their family through adoption. The other is remaining child-free.

When pursuing a goal as heartfelt as having a baby, it's difficult for anyone to look at the 'what-if's' -- some may even call it defeatist thinking. In fact, there comes a time for some fertility patients when all options must be at least put on the table for viewing, if not actively chosen at that time.

What this article does not have the time or space to detail are the no-doubt lengthy journeys through complex emotions that these couples went through toward their decisions. Hopefully and most likely, they had the emotional and informational support of their fertility treatment team in the process. After all, while we reproductive endocrinologists focus on creating new life, our goals as physicians are to provide healing for our patients. Sometimes that means knowing when to say "when."

Technorati Tags: infertility treatment,adoption,child-free

Leftover Sperm: Too Much of a Good Thing?

In some ways, Canada's a lot like the States. Their "rules" about reproductive medicine are almost as wide open as here in the U.S. -- so far. In this article from The Canadian Press, fertility specialists discuss the increasing problem of "abandoned" frozen sperm.

The freezing of sperm cells is now a fine-tuned technology. Much of the credit for that goes directly to the little cells themselves, of course: sperm cells are simply built in a way that helps them survive the freeze-thaw process and come out intact enough to fertilize an egg. Eggs, on the other hand, have proven trickier to get through that journey for later use, but we're far better at it recently than ever before (thanks mostly to the Italians, who were given few choices by their intervening government!)

Sperm cells that were frozen for nearly 30 years have been successfully thawed and used with IVF to result in healthy babies. We haven't been freezing eggs that long yet, so there are some unanswered questions on the female side of delayed conception.

Men who froze semen samples in the past don't always come forward later to use their sperm. So now, some cryopreservation facilities are finding themselves with forgotten stock. So many years have gone by now, these older labs are literally running out of storage room. The technicians and administrators find themselves in a bit of an ethical and pragmatic dilemma. This article points to Health Canada, the country's Federal department in charge of health care, as being in the process of creating some related guidelines.

It will be interesting to see how Canada deals with the problem.

Also interesting -- the article notes that frozen eggs are typically not abandoned, and says a possible reason may be the far different procedures that are required to acquire sperm versus egg cells.

Technorati Tags: frozen sperm,canada,cryopreservation,fertility,ivf

 

The Canadian Press: Sperm banks seek men who have forgotten 'little swimmers'