There's More to Healthy Babies Than Good Eggs

We tend to focus on the very key component of viable egg cells in assisted reproductive technology. There's no doubt that "good eggs" are needed to make conception and pregnancy happen. A piece of the pregnancy puzzle that doesn't usually get as much attention is the impact of uterine health.

It makes sense, of course, that once an egg is fertilized, the resulting embryo needs a healthy place to implant and grow. The lining of the uterus, known as the endometrium, is that place. In cases of women with average to good fertility levels, the endometrium is primed for implantation by a variety of hormones relaying through her body. It's all part of the menstrual cycle. [Here's an explanation of how the endometrium works.] Timing is crucial -- both in natural and assisted conception -- because the lining is re-created and either used or sloughed off through menstruation on a cyclical basis, approximately every 28 days. If a woman's hormones are imbalanced, the result is sometimes an endometrium that's not ready to receive and nourish a conceived embryo. This can be a type of infertility.

We administer endometrium-enhancing medications -- such as progesterone supplementation -- to some patients, regardless of the assisted reproductive technique they're using to conceive. Ultrasound monitoring is used to view and gauge the health of the uterine lining, just as we use ultrasound to see how well a woman's ovaries are ovulating. Still, there's more to solving the pregnancy puzzle, and researchers have recently unveiled a new potential key.

A study of mice has resulted in the newly discovered connection between a protein called Hand2 and the control of the uterine lining's proliferation. The researchers' findings could eventually lead to more ways for fertility experts to help patients who have endometriosis or previously unexplained infertility.

Answering the question, "Why can't we get pregnant?" requires attention to many variables within each patient's situation. The responsive functioning of a woman's uterus is increasingly becoming the focal point of research. After all, there's a lot more to having a baby then simply creating an embryo.

~ Sonja Kristiansen

ASRM Embryo Guidelines Should Improve Overall Picture for Fertility Patients

This year, the American Society for Reproductive Medicine took an expected step forward to increase the safety and health of prospective IVF moms and their future babies. They issued guidelines stating specifically that women under age 35 should have no more than two embryos transferred per IVF treatment cycle.

The goal is to prevent multiple pregnancy, which is full of risks to both mother and babies.

The patient's prognosis, not just her age, should also be taken into account. In cases of a woman younger than 35 having optimal chances at pregnancy, the ASRM further recommends that single embryo transfer be considered.

Other ASRM embryo transfer recommendations, by which Houston Fertility Center adheres, are:

Patients 35 to 37 years old with good prognosis -- 2 embryos
Same age group with less optimal prognosis -- up to 3 embryos (or up to 2 resulting from extended culture)

Patients 38 to 40 years old with good prognosis -- up to 3 cleavage-stage or 2 blastocysts
Same age group with less optimal prognosis -- up to 4 cleavage-staged or 3 blastocysts

Even in cases of patients who typically have the least optimal chances of pregnancy -- women 41 to 42 years old -- no more than 5 cleavage-stage or 3 blastocysts should be transferred.

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.