Sweet’s Rules: Four simple rules I use each day to guide me as I diagnose and treat my infertile patients

During National Infertility Awareness Week, I’d like to share my four patient care rules. I made them up rather spontaneously nearly 22 years ago and I still use them each and every day when I am uncertain of what to tell a patient or how we should proceed.

Before the rules are invoked, it is most important to first understand what brings patients to my clinic. By understanding the causes of their infertility, I will better be able to tailor a treatment plan specific to their needs. Some patients feel this is a waste of time and want to proceed immediately to treatment, but I strongly recommend understanding the issues first before proceeding forward.

So, once the evaluation is complete, my Sweet’s Rules are used to guide us forward-

1. Get my patients pregnant as fast as I can
Time can be an enemy and patients are not necessarily patient. We need to complete the evaluation quickly and move forward as most of my patients wanted to be pregnant many yesterdays ago. Some will call this a “duh!” rule, but it is still a good one to keep me moving forward as the patient desires.

2. Achieve success in the most cost-effective manner possible
We always want to choose the least costly conception method. This might even mean sending the patients on a date to try natural means for a tad bit longer. Hopefully, the successful patient potentially saves a bundle by my guiding them away from costly alternatives. Sometimes, adoption is also the best option and I’ll send them down this new road, if it is needed, even if the practice loses a patient. My cardinal rule is to treat the patients like family and tell them what I would tell someone close to me, regardless of the gain or loss to the practice. Practicing this way has always served may patients well.

3. Minimize complications (i.e., no litters)
I took an oath to do no harm and I take that oath very, very seriously. A multiple pregnancy can be a million dollar pregnancy with complications too long to list here. Always pull back, no matter how much pressure from the patient, if I fear a complication is likely.

4. Minimize the use of procedures with minimal chances of success
This may be the most important rule. I do not like being a “Gynechiatrist” (borrowed from the movie “Knocked Up”) by performing procedures that are unlikely to work. While some patients need to try a procedure destined for probable failure, to have closure and the inner knowledge that they gave it a shot, I prefer to move quickly through these treatments and get the patient to understand what will truly bring them to their goal.

I tell patients these rules when I am trying to guide them through their treatment plan. I believe it helps them to understand why I am telling them something, especially when they don’t necessarily want to hear it. Understanding my motivations, I believe, helps them to appreciate that I truly have their best interests at heart. By following these simple four rules, I will always keep my patients’ needs first and foremost.

While I may not be successful with all my patients, I will always try my best, give them the best information I can and provide options that simply make sense. Interestingly, these rules help me keep on the path, as much as they simultaneously guide my patients, as we make decisions and travel the infertility to fertility journey together.

By: Dr. Craig R. Sweet

Medical Director & Founder

Dr. Craig Sweet, April 22nd 2013 | Tags: , , , , , , ,
Posted in Questions & Answers

Free Contraceptive Insurance Coverage: A Good Idea?

The National Institute of Medicine finally suggested that women obtain contraceptive care with full insurance coverage and without large co-pays. From one perspective, it was about time. Nearly half of all pregnancies are unintended and families should be expanded when there is true intent and not because contraception was not available. Also, since men have medications for erectile dysfunction covered by insurance, it's seemed only fair.

That stated, there might be a downside. Since no co-pays will be obtained, will the insurance companies increase payment to make up the difference (doubtful) or will the physician’s office loose the income in an already existing atmosphere of dwindling reimbursements (more likely)?

Will the frequency of unwanted pregnancies and abortions really fall? Even though condoms have been made available at some clinics for free, having the contraception easily available didn’t mean it was used at all or used correctly. When one provides something for free, is as appreciated as when one has to pay an amount, no matter how small, to increase personal responsibility?

When care becomes free or nearly free, there is almost always an increase in utilization. Is contraception one area of medicine that we would welcome increased utilization? Most, except the religions that do not believe in contraception, will agree this is ultimately a step in the right direction. Even so, there is no free lunch. Will insurance companies increase the premiums to pay for the office visits and the contraceptive medications and pass the costs to everyone else? We suspect the answer is probably yes.

At first glance, requiring insurance companies to pay for female contraception seems like a great idea but there is the issue of unintended consequences. Please share your thoughts on our Facebook pagewhere we've started the discussion. We’d love to hear from you!

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Dr. Craig Sweet, August 10th 2011 | Tags: , , , ,
Posted in Family Planning, Health Care, In The News, Medical Ethics, Politics, Reproductive Politics

What to Say & What Not to Say to the Infertile Patient

By: Dr. Craig R. Sweet, Medical Director & Founder

(Reprinted from Florida Parenting News, February, 1994, revised September, 1999 and again April, 2011.)


Introduction:

Infertility affects nearly one in six couples. Approximately 40% of the time, the problem is related to the female partner, another 40% is related to male difficulties and 20% of the time both partners will have medical problems. Most of the time, infertility is a symptom of an underlying disease process, a disease process that the infertile patient has no control over. To these patients, infertility can be a crisis of the deepest kind. Every menstrual cycle represents a failure and is a time of grief for the potential child that never came to be.

The infertile patient or couple will often express their feelings through anger, frustration, feelings of inadequacy, depression and guilt. Relationships with family members who have children can suffer, marriages and relationships are strained and well-meaning friends and family can overload the patient with advice and pressure. Family and social gatherings become a reminder of infertility. Baby showers can be a traumatic experience. Mother's and Father's Day are often very, very difficult.

We want to offer some tips that provide support to patients who have not yet had the blessing of a beautiful child to love. With your assistance, most patients going though the process of trying to conceive can maintain a positive attitude.


What Not To Say…

Don't ask a childless person when they are going to have a child. They may be going through the process of trying to conceive, but have not yet achieved success. Asking them only reminds them of their problem and they need no extra reminders.

Don't relate stories of your fertility to them. Hearing “my husband just has to look at me and I get pregnant” is very annoying. While well meaning, the statement is insensitive and unhelpful.

Don't give advice such as “just relax,” “you are trying too hard” or “take a vacation.” All of these very common comments imply that patient has control of their fertility. Most of the time, these patients have absolutely no control over their fertility. Implying control leads to feelings of failure and guilt when this advice doesn't work. It simply is not their fault and they are doubtfully doing anything wrong in what they have done thus far.

Don't offer advice such as sexual timing, position, herbal medications or other totally unproven therapies. There are literally hundreds of old wives’ tales that, when followed, can drive an infertile patient nearly crazy. Their physician will have covered those natural aspects of their care that may maximize their chances for conception. Once again, please to not imply that they have a sense of control as they lost it long ago.

Don't express your derogatory personal opinions regarding insemination procedures, test-tube babies or adoption. Sometimes, these are their only hope for having a child. These are your opinions and uninvited advice is rarely neither desired nor constructive. You are absolutely entitled to your opinion; simply keep it your own. If they ask for your advice, then feel free to state your opinions, but do so in a kind and considerate manner.  Please, do not be judgmental.

Don't place blame by accusing the couple of exercising too much, eating the wrong foods or drinking alcohol. These patients may already be blaming themselves. Their physician will have already covered the medical and reproductive consequences of obesity, smoking, alcohol and recreation drugs. Support them in the cessation of these activities and minimize the guilt associated with their consumption. The guilt rarely leads to cessation but often moves the individual to increased consumption.

What You Can Say and Do…

Do provide couples with plenty of emotional support by saying “It must be difficult to go through this” and “I'm here to listen if you need to talk.”

Do remember that men can be just as emotional about the problem, sometimes even more so. They may feel their masculinity is at risk. Be sensitive to their egos and personality traits.

Do understand the couple's need for privacy.

Do try to understand that if they are your employees, frequent doctor's appointments may be necessary during business hours. Please try to accommodate them as much as possible. Not doing so may also be construed as a form of discrimination and place you at legal risk.

Do understand why they may not make it to a baby shower or a holiday event. These frequent events can become overwhelming for an infertile patient.

Do tell the infertile couple that there is hope.

Conclusions:
Please remember that the vast majority of infertile patients have minimal control of the diseases that causes their infertility. Giving them emotional support during this trying time is a wonderful way to assist them. Giving them subtle hints that they have control plants the seeds of personal failure in the minds of the infertile patient.

Please be kind, be thoughtful and always be supportive.

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Dr. Craig Sweet, May 5th 2011 | Tags: , ,
Posted in Diseases and Complications, Family Planning, Infertility, Questions & Answers

No Longer Silent – National Infertility Awareness Week

national infertility awareness weekEach year, physicians such as myself, fertility patients, their caregivers and families dedicated to raising awareness about the disease of infertility which affects 7.3 million Americans. RESOLVE, the national infertility association, has coordinated this week, April 24 through the 30 and we fully support it and encourage you to speak up in support as well. For information on how you can get involved in infertility awareness projects around the country and upcoming Advocacy Day on May 5, visit RESOLVE at www.resolve.org/takecharge.

At SRMS, we are committed to providing the highest quality care and support to patients and their families. Infertility is a disease, it is important and we are working to raise awareness on your behalf. For more information, visit www.dreamababy.comor call 239-275-8118.

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Dr. Craig Sweet, April 20th 2011 | Tags: , ,
Posted in Diseases and Complications, Events, Fertility, In The News, Infertility

Embryo Donation – Option for Infertile Couples & Waiting Lives

I recently had the opportunity to be on Theresa Erickson's Internet radio show, Voice America. Known as the Surrogacy Lawyer, Theresa is renowned for her work on behalf of many patients faced with infertility looking for third party options. During my interview, we discussed the option of embryo donation  from the physician, recipient and donor perspectives.

One of our donors, Tori, discussed her infertility experience as well as her and her husband's  decision to donate their remaining embryos following a  successful IVF procedure culminating in the delivery of her twins. You can see a picture of her twins and information regarding her amazing embryos by visiting our website.

Tori's Twins!

Tori and her husband decided that they wanted to “pay it forward” to other infertile couples. Here is a combination of her own words during the interview and some other comments she told me separately:

“Donating the embryos brought on a wide range of emotions; some expected such as the happiness to help another infertile couple, peace in setting the embryos ‘free’ by finally making a decision on their fate and others were a bit of a surprise  such as a brief feeling of sheer panic that I ‘forgot’ something after leaving the clinic. The donation experience to me is like paying it forward to other infertile couples. I did not see any reason to leave the embryos suspended in time, did not want to see them destroyed and there was no reason to donate them to stem cell research when there are so many infertile couples in the world going through the same anguish I went through.

That feeling of anguish kept coming back, that longing and yearning for something that was so easy for others to have, yet so very difficult for me to obtain. I wanted to help someone relieve that awful feeling and by donating my embryos, I had a very good chance of doing just that.”

To listen to the show, please visit our Audio Gallery and click the play button to the right.

I am so thankful for people like Tori and other donors who consider giving their frozen embryos life while helping other people building their families at the same time. If you'd like more information on the process, please visit our embryo donation page on our Website, contact us at (239) 275-8118 or e-mail us at Fertility@DreamABaby.com.

Also, for additional details on surrogacy or fertility via third party assistance, I encourage you to read Theresa's book: Surrogacy and Embryo, Sperm and Egg Donation: What were you thinking?

Please stay tuned for the launching of our expanded embryo donation program called Embryo Donation International! I hope that many couples will consider to “pay it forward” just as Tori and her husband did.

Your thoughts and comments are always welcome.

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Dr. Craig Sweet, September 24th 2010 | Tags: , , , , , , ,
Posted in Embryo Adoption, Embryo Donation, Fertility, In The News, Infertility, TV, Movies and Radio

Compensation for Egg Donors: Will Regulation Achieve the Goals?

Saw an interesting interview. Dr. Nicole Noyes, NYU Fertility Center, was discussing on ABC News Egg Donor reimbursement. The interview was candid and quite honest. You may view it here.

They discussed some of the outliers where egg donors were being offered up to 100K for their eggs. At NYU Fertility Center, they apparently offer 8K. Dr. Noyes acknowledged that the average reimbursement across the nation was probably closer to 4K.

As an alternative, she revealed that many women are beginning to cryopreserve (freeze) their own eggs, essentially becoming their own donors in the years ahead. a process that I think has great potential but should still be considered experimental, something that Dr. Noyes failed to mention.

I will admit, the country seems to be a little regulation happy. The answer to all things continues to be regulation in the minds of many.

Our lives are very complicated, I suspect more complicated than our parent's lives and their parent's before that. We humans continue to make our way through the maze of our lives feeling less and less in control. In times of turmoil, oil spills, a fractured economy, lost financial stability and the continual threat of terrorism, we seek stability and security. What better way to achieve this than through regulation? After all, regulation means that we don't have to even worry about that area any more and we can focus on the many other distractions in our lives.

In the real world, however, is the theme of unintended consequences. As we attempt to quell a leak in one part of the dam, another springs open thus relieving pressure. Regulation is almost always an uncontrolled experiment with the most wonderful of intentions. The problem is that  it rarely achieves its lofty goals and almost always complicates the maze further.

The answer to high reimbursements to egg donors is to not offer them. The answer does not include limiting donor reimbursement as it will result in the harm of many recipients.

My field of medicine is the most regulated in all of medicine. In no other field do physicians have to display their success and failure rates for all to see. I have always wondered for those that demand this information, if they would be willing to place their professional lives out there for everyone to see. Oh, I must be confused. Regulation is for everyone else.

Don't regulate the number of embryos to transfer. Don't regulate reimbursement. Guide it all. Suggest strongly. Let the market take care of those that abuse the system. Let patients do the research and make the decisions. An odd concept which may not be entirely popular but one, I can only hope, my readers will at least contemplate.

In this world of unintended consequences, I tend to prefer to walk against the traffic that is coming for I know exactly where to look rather than strolling, when all supposedly is clear, only to be clipped by something originally unseen and unsuspected.

Comments are encouraged.

Dr. Craig Sweet, June 5th 2010 | Tags: , , ,
Posted in Egg Donation, Medical Ethics

The Fertility Chase, Episode 4, WE TV, 5/22/2010

I was in a meeting starting Friday night, all day Saturday and then went to yet another one on Saturday evening, so I was a bit delayed on my post regarding the 4th episode of The Fertility Chase (TFC). I hope you will find that it was worth the wait.

A Woman’s Reproductive Age:
Maria Bustillo, Kimberly Thompson and Juergen Eisermann were the Reproductive Endocrinologists from the South Florida Institute of Reproductive Medicine in the first segment. I know all of these physicians and they do a very good job.

Angelique was the infertility patient. She went through six intra-uterine inseminations (IUI’s). I couldn’t tell if oral or injectable medications were used. Laparoscopy was the next step wherein “unexpected” problems were discovered. In vitro fertilization (IVF) was used next and she conceived and delivered her son, a “mini-me” of her husband. Really, the likeness was quite striking.

The theme was the influence of a women’s age in their quest for parenthood, a topic that has resounded through nearly all the episodes of TFC. It is the single most difficult issue for us to deal with as we cannot make ovaries younger or increase the production of healthy eggs when few exist.

Angelique did highlight a couple of interesting points. All of us have been caught by doing IUI procedures followed by a laparoscopy (out-patient belly button surgery) only to discover that the IUI procedures were unlikely to work because of problems found at the time of surgery. My feeling is that if surgery is to be contemplated, that one not perform too many IUI procedures before doing it. Understand, however, that laparoscopies do not always significantly improve the natural pregnancy rates, it is a “catch-22”. Even so, laparoscopies do often give us a diagnosis and provide us with enough information and confidence to continue the IUI’s procedures or to quickly move to other alternatives. As they say, hindsight is “20/20”, and it is always easier to look back and think of treatments that we would have modified and a bit tougher to do it from the get go.

My last comment has to do with fact that Angelique had infertility insurance coverage. I have seen numerous cases where the treatment plan was different compared to someone without coverage. For example, where a non-covered patient may only try 3-4 IUI procedures, a covered patient may try 6. While not a tremendous difference, each failed month takes it toll on the patients and it so easy to let the insurance coverage influence the treatment plan. I call this the “insurance trap”.

Polycystic Ovarian Syndrome (PCOS):
Edward J. Ramirez, M.D., from The Fertility and Gynecology Center, Monerey Bay IVF, was the Reproductive Endocrinologist in the second segment. Brandi and Monique were the patients featured.

For the readers, the diagnosis of Polycystic Ovarian Syndrome (PCOS) requires that at least two out of three of the following are true:

  1. The woman doesn’t release her eggs on a regular basis.
  2. Male hormone levels are increased in the blood or there is an excess of facial or body hair in such locations as the chin, neck, back, abdomen and chest. Acne can sometimes also present.
  3. That each of the ovaries have more than 12 small cystic structures, which we call antral follicles.

PCOS is the most common endocrine disease in reproductive age women affecting about 6% of the population. It is a very common cause of infertility.

Dr. Ramirez stated that 80% of the patients didn’t ovulate (release their eggs) on either clomiphene citrate (Clomid) or letrazole (Femara). I believe that number is a bit high. In fact, there is ample evidence that it is more likely that 80% will ovulate on the medications, although not all of these will conceive. Nevertheless, these oral medications are a good starting point in addition to treating the other issues that are commonly present including pre-diabetes and even diabetes itself. Problems with weight are also found in about 80% of the PCOS patients so diet and exercise are an essential, although difficult, component of the treatment plan.

I was struck by the words and phrases these young women used to describe their diagnosis of PCOS and infertility including “alone”, “not female”, “jealousy”, “shame” and “depression”. I was very concerned about Monique’s comment that she didn’t have “the will to live”. This level of depression must be treated seriously and be carefully followed by the clinician. Fortunately, Monique conceived and delivered. I hope Brandi soon does the same. Perhaps TFC can follow up on Brandi in the near future.

Male Factor Infertility, Spinal Cord Injuries:
Dr. Randall B. Beacham from the University of Colorado School of Medicine was in the next segment discussing spinal cord injuries inmen. Jasmin was the injured male patient who apparently was unable to ejaculate naturally. Dr. Beacham is well respected and well published.

This couple told a story of being seen by four doctors being told different things before finding Dr. Beacham. Male factor infertility really requires the assistance of a highly trained Reproductive Endocrinologist who also sees male patients and/or a Urologic Infertility Specialist such as Dr. Beacham. Both of these types of physicians are a bit rare so infertility patients have to seek them out.

Jasmin entered an experimental study where clomiphene citrate (Clomid), a medication usually reserved for women, was given to him in the hope of stimulating sperm production. This medication has been studied in the past and was not shown to be useful in the vast majority of men suffering from male factor infertility. I had to laugh when Jasmin said he bought six pairs of shoes and had an urge to shop while on the medication. In reality, Clomid hopefully increases the male hormone in men and the female hormone minimally, if at all. I think he just wanted an excuse to go out shopping.

It appeared that Dr. Beacham was able to stimulate ejaculation through a technique called “electro-ejaculation” wherein a probe is placed into the rectum and electrical current is released resulting in a type of spasm that produces an ejaculate. His wife underwent hormone stimulation of her ovaries to increase the number of targets for the limited quality and quantity of sperm. Presumably, she had an IUI procedure and conceived a little girl. The macho Jasmin clearly wanted a boy but I’m sure he will treat his little girl as a princess.

My only concern in this piece was that it needed to be emphasized that Clomid has not been found to be useful in the previous randomized and controlled studies and had fallen out of favor. I did a search to see if there were any prospective studies published on the subject over the past 10 years and found none. Dr. Beacham made it quite clear that there were no magic medications for male infertility but he apparently feels that this medication may be of some use in this particular kind of patient. If it is to be used, I urge that it be done in a study setting, as it was with Dr. Beacham, so as to not give false hope, waste time or result in unrealistic expectations.

Re-cap:
The last segment was a collection of past segments, including ours from last week about embryo donation. The show ended with the comments that infertility patients were misinformed, misled, suffered in silence and felt powerless. Clearly, TFC is trying to change that and more power to them. I’ll certainly support their effort.

As always, if you agree to disagree with whatever I write, please do not be shy and leave a comment or two. Questions will also be answered when possible. Until then, go forth and try to multiply.

Dr. Craig Sweet, May 23rd 2010 | Tags: , , , , , , , , , , , , , , , , ,
Posted in Uncategorized

The Fertility Chase, Episode 3, WE TV, 5/15/2010

The Fertility Chase (TFC) show today covered numerous concepts including genetic testing of the embryo, embryo donation (embryo adoption), egg donation and affordable infertility coverage.

Pre-Implantation Genetic Diagnosis:
Edward L. Marut, M.D., from the The Fertility Centers of Illinois was featured in the first segment. The infertility couple, Kelly and Tom, was unable to conceive over a three years. Basic treatments were performed without success wherein they underwent In Vitro Fertilization (IVF) twice and failed. The final and successful outcome occurred when they did a third IVF procedure combining it with Pre-implantation Genetic Diagnosis (PGD). In PGD, a single cell from each of the embryos is screened for chromosomal defects such as Down’s syndrome. Nine out of the possible 24 chromosomes were examined. PGD is commonly done for genetic disease, gender selection, to transfer a single embryo, recurrent miscarriage and when there is a history of failed implantation such as this couple. Apparently only two out of twelve sampled embryos were probed as normal. A male child was eventually delivered.

As women age, the quality and quantity of their eggs decrease. In this case, quality seemed to be the issue. While not every one agrees, it is thought that PGD may decrease miscarriage rates and decrease the delivery rates of genetically abnormal offspring such as Down’s syndrome. I too have used PGD to decipherer the reason why embryos have failed to implant and will frequently find that nearly all of the embryos are indeed genetically abnormal. PGD has its strengths and weaknesses, however, in this particular instance, it may truly have saved some time and heartbreak. I thought the piece was well done.

Embryo Donation:
OK, this is going to be hard to review as this was my own segment In the making for over a year, I thought Exodus Productions did a wonderful job with it. To view, please visit: http://www.vimeo.com/11762266.

Kerry (commissioning parent) and Christiana (surrogate) did an amazing job opening up their lives to the media to tell this important story.

Christiana (below) is the surrogate carrying Kerry's donated embryo.

Walt and Amy’s side of the story was that they would much rather donate their embryos than other alternatives should they never use them themselves. Amy is set to deliver very soon and I hope they use their own beautiful embryos for themselves but, in case their first child is a little hellion and they decide not to have any more (which I doubt), I would be more than happy to find a wonderful home for them.

Walter and Amy with baby in between.

None of this entire story would have been possible without the generosity of the couple that donated the embryos to Kerry. In addition, they did not stipulate that we couldn’t give their embryos to a single woman. This was an amazing gift from undoubtedly an amazing couple. Since these embryos came from a distant facility and not our own, I will probably never have the privilege of thanking them directly.

We will be covering the topic of embryo donation in great detail in the months to come. Right now, we have over 140 abandoned embryos and we are trying to get these designated to either personal use or embryo donation. I feel we are both patient and embryo advocates.

All kidding aside, I surely hope you enjoyed the segment as much as I did.

Egg Donation:
The third segment had many players from Long Island IVF, one of the busiest IVF facilities in the country. Reproductive Endocrinologists Dr. Daniel Kenigsbert and Steven Brenner and Embryologist Glenn Moodie, Ph.D. were the experts. Carolyn and Nicholas were a infertility couple and Donna was also a patient who sought treatment. The theme had to do with egg donation. As stated a few paragraphs above, as a woman ages, the quality and quantity of eggs decreased. At times, we also see young women who surprise us in that they seem to be very close or have actually entered menopause. When there aren’t enough healthy eggs around, an excellent option is egg donation.

I was struck by Donna’s story of four IVF cycles with one physician and another four with a different one. New York is a mandated state, which means that a certain amount of infertility has to be covered by insurance companies. I have unfortunately found that insurance coverage often leads to poor decisions. I had one patient recently that was told she was had to undergo six intra-uterine insemination procedures before doing IVF. The problem was that her Fallopian tubes were very damaged and severe pelvic adhesions were present. I recommended moving forward with adoption or IVF but IUI procedures were not on my radar screen. Doing IUI procedures was a very foolish and expensive (i.e., wasteful) step before IVF in this instance. Getting back to The Fertility Chase, Donna probably needed to move to egg or embryo donation long before the eighth IVF procedure. If none of them had been covered, she surely would have made the decision sooner and with less heartbreak.

Lastly, the egg donor stated it took weeks for her to complete the pages of needed information. Our patients have told us that it took less than 30 minutes to do it on our website (http://www.dreamababy.com/eggdonation.htm) . These are young patients and their medical histories should be pretty simple. Perhaps the donor was just being overly cautious but the TFC viewers or my readers should know that it isn’t that difficult or time consuming to do.

Cost of Infertility:
This was a great segment featuring the Gunderson Lutheran Fertility Center. Dr. Kathy Trumbull was the Reproductive Endocrinologist. Two couples were highlighted, Crystal and Larry as well as Bobbi Jo and Marty. Both of the men apparently had male-factor infertility, Crystal had polycystic ovarian syndrome and Bobbi Jo, stage I endometrioisis.

I couldn’t tell what treatments were used for which couple. Dr. Trumbull’s discussion regarding infertility patients seeing a general physician for the simple stuff but to find a Reproductive Endocrinologist when too much time passes or the issues are growing in their complexity. This is actually a statement that needed to be stated long before now so hats off to Dr. Trumbull. Infertility, especially the issues as presented by TFC, are well beyond anyone’s care besides a Reproductive Endocrinologist.

The issues of cost of infertility care will probably come up again in a future TFC program. It is a difficult issue but few areas of medicine require such a tremendous amount of physician and nursing training, continuous equipment upgrades and an extraordinary amount of time committed to our patients. Hats off to Gundersen Lutheran if they are truly able to make it more affordable in my home state of Wisconsin. I truly wish I could give it away free.

Summary:
Well that is it for now. It was wonderful to be part of The Fertility Chase. Even though my show has aired, my commitment is to continue to watch each program and report back to my readers my thoughts and comments. If you agree or disagree with whatever I say, please do not be shy and leave a comment or two. In the mean time, be fertile.

Dr. Craig Sweet, May 15th 2010 | Tags: , , , , , , ,
Posted in Egg Donation, Embryo Adoption, Embryo Donation

The Fertility Chase, Episode 2, WE TV, 5-8-2010

I liked today’s show a great deal. There was an abundance of information offered at a dizzying pace. Sorry, in advance, for the long post, but there was much to cover.

Single Embryo Transfer:
The University of Iowa Hospitals & Clinics discussed the concept of what is commonly called “elective single embryo transfer” or eSET. Bradly J. Van Voorhis, M.D., Director of the IVF program, was one of the physicians featured. The idea discussed was to transfer only one healthy embryo at a time significantly reducing the risk for multiple pregnancies. He published on this topic in 2007. In today's story, they claimed a 68% delivery rate with a single embryo transfer procedure. According to their previously published data, this probably included egg donation cycles where eggs are removed from very young women and then provided to women who need them.

There is no question that it is ideal to perform an eSET but there are two issues I need to bring up. In many IVF programs, ideal patients are the exception, so eSET may really only be practical for a minority of the patients. Second, other studies have shown a reduction in take-home rates with eSET compared to two embryos, so many patients still request two embryos, even after being warned of the many risks of a multiple pregnancy. It is rare that I am able to convince a patient to electively transfer a single embryo, especially if IVF is not covered by insurance. Americans love a two-for-one sale, even when told of the risks a multiple pregnancy involves.

Cancer and Reproduction:
The second story came from the University of Colorado. This involved the heart-wrenching story of Meghan and Barton. Meghan was diagnosed with some sort of cancer (never described), underwent surgery and radiation, had a recurrence two years later and then received additional surgery, chemotherapy and radiation. I was so very impressed with both of them, especially Barton who so lovingly supported her throughout the process. There was a great picture of the two of them bald probably after the chemotherapy. What a life partner!

After several attempts, a total of four embryos were frozen (cryopreserved). Meghan found an Oncologist who suggested transferring these embryos before the cancer came back, which seemed like an inevitability. I was impressed by Dr. William Schlaff’s honesty explaining the chances that these four cryopreserved embryos would result in a live birth were slim because of her past cancer treatments. I have heard Dr. Schlaff speak before and have always been impressed by his honesty and integrity.

Amazingly, Meghan and Barton became pregnant with the thawed embryos and we were able to see an ultrasound image of an early pregnancy. This case also brings up a very sensitive and difficult side of cancer and reproduction. For patients who have cancer and recurrence, it is really uncertain if they will remain disease free. Many of these patients want to experience life, which often means reproducing. For some, this means having children to fulfill their lives even understanding that some will not survive to raise the child. In addition, by having a child, a part of the cancer patient, a legacy of sorts is left with the surviving partner. I don’t know what cancer Meghan has or her prognosis but it would seem that she might have more trouble ahead. I think they are amazingly brave. She deserves to experience parenthood, which robs so many other cancer patients. Barton is a rare life partner and I truly wish them only the very best.

Dual Training of the Reproductive Endocrinologist:
The University of Colorado facility is unusual in that the Reproductive Endocrinologist are trained to evaluate male infertility. Those types of physicians are rare and are great to have around since one physician is then truly able to care for the couple as a whole rather than trying to get two separate physicians to communicate and agree on a treatment plan. I was fortunate to have been similarly trained and I estimate that at least 25% of my new infertility patients are male.

Egg Freezing (Oocyte Cryopreservation):
Continuing under the theme of cancer, Charles Coddington, III, M.D., Director of the Reproductive Endocrinology Division at the Mayo Clinic, brought up the story of Sarah. Sarah was diagnosed with breast cancer and underwent a double mastectomy, such a difficult decision for such a young woman. In her case, she eventually underwent an egg freezing procedure (oocyte cryopreservation). It is uncertain how many eggs were actually frozen. I thought this piece was well done showing what is possible with today’s technology. Tina was also featured in the segment electively freezing her eggs so she could have a “reproductive insurance policy”.

Trying to Not Create Excess Embryos:
The story of Ceresa and Jonathan was next wherein they tried to only fertilize enough eggs to transfer embryos and then freeze the excess eggs but not have any excess embryos frozen. From what I could tell, two IVF cycles were needed to freeze a total of five eggs. The two fresh embryo transfers resulted in one failure and one miscarriage. For the third procedure, the five eggs were thawed four survived, three fertilized and were transferred resulting in a twin pregnancy.

My personal experience with trying to not create cryopreserved excess embryos has almost always resulted in failure. Trying to get as many healthy embryos as possible, transferring the best and freezing the remaining still provides the best chance for success. Playing the game of fertilizing only a few eggs and freezing the rest does not improve success rates but, in all likelihood, reduces them. It also increased the costs of the cycles. Excess cryopreserved and thawed embryos can be transferred in the couple later or donated to needy patients, so I would almost always suggest fertilizing all the eggs, transfer fresh and free the excess embryos rather than freezing only a few eggs and hoping for the best.

The only issue I had with this entire topic was that it was never made clear that oocyte cryopreservation was experimental requiring a true study with a review board’s oversight. We here at SRMS do have an ongoing oocyte cryopreservation study. We had to go before the hospital Institutional Review Committee (IRC) to give us permission to move forward with the study. I know how careful the IRC is and they would have required to review this segment of The Fertility Chase should this have been my topic. I couldn’t tell if the Mayo Clinic had checked with their IRC before airing their segment but the fact that it was never mentioned that egg freezing was experimental makes me think the committee was never approached.

Please do not misunderstand my writings. I feel this is a very important area of reproductive medicine with the potential to liberate women much as the birth control pill did years many years ago. The reality, however, is that we need to emphasize that oocyte cryopreservation is really experimental and not over promise what we cannot consistently deliver.

Outsourcing Surrogacy:
Next came the couple Karen and Jean. Jean clearly had some difficult luck in that insemination procedures and egg donation cycles didn’t succeed wherein she was then diagnosed with breast cancer. In comes Proactive Family Solutions, which outsources surrogacy to Mumbai, India. From the best that I could tell, Jean’s sperm was combined with an egg donor (American?) and some of the embryos created were placed into an Indian surrogate.

There is no question that surrogacy can be expensive. I couldn’t find any information as to the overall costs Proactive Family Solutions charged but it is undoubtedly less than some locations here in the states. I suspect the option of embryo donation may very well compete in price with Proactive Family Solutions. I would really like to see a head-to-head comparison of the costs to see where the costs here in the states make surrogacy out of reach wherein we should do whatever possible to bring this process back to the states.

Next Week:
Lastly, I felt honored that our piece on embryo donation was the teaser for the next show. Please be sure to tune in next week. I guarantee you will not be disappointed!

Dr. Craig Sweet, May 8th 2010 | Tags: , , , , , , , , , ,
Posted in Infertility

The Fertility Chase, Episode 1, WE TV, 5/1/2010

My wife and I woke up this morning and watched the pilot show of “The Fertility Chase”. I felt the show did a wonderful job in portraying the emotional trauma that infertility patients go through. I thought the visual graphics, filming and editing was excellent. I applaud Exodus Productions for their very hard work in bringing this topic to others. Overall, they did a truly wonderful job.

The Reproductive Medicine Group, also here in Florida, did a great job discussing basic infertility. Dr. Goodman appeared extraordinarily comfortable in front of the camera. I have a high level of respect for these physicians and have asked their group to render a second opinion on a number of my patients.

I did agree with Dr. Lessey that it is very important to carefully evaluate the couple and search for the diseases that cause infertility. For my readers, the definition of unexplained infertility means that there has been a complete evaluation, including a normal laparoscopy, and that no diagnosis was found. It seemed as though many of Dr. Lessey’s patients really had not undergone the full evaluation so the term “unexplained infertility” in the segment may have better been termed “incompletely evaluated infertility”.

I feel that the usefulness of a laparoscopy in the treatment of endometriosis is controversial. There is (inconsistent) data that shows pregnancy rates do improve slightly following the diagnosis and treatment of stage I or II endometriosis with about 1/3rd of the patients conceiving within eight months of surgery. This would seem to differ slightly from the 50% in three months that was quoted by Dr. Lessey and I would encourage him to publish his data so we can all benefit from better his procedures and techniques.

It is uncertain that the surgical treatment of the more advanced stages of endometriosis (III & IV) improves overall pregnancy rates. I would absolutely agree that treatment of all stages decreases symptoms in the fast majority of the patients but fertility is a different issue. I feel there is room for discussion regarding the ultimate usefulness of laparoscopy in the infertile patient.

The comments regarding stress and holistic medicine were an intriguing segment. I agree that life is too short to be unhappy and/or stressed and that we should all seek methods to better cope with stress and try to be as happy as we can be. The effects of yoga, massage, acupuncture, exercise and other holistic treatments on fertility is a very complex issue. There is supporting data that stress management may reduce the number of miscarriages slightly but increasing pregnancy rates is a more challenging process. I wholeheartedly agree that all infertility patients should do what they can be become as healthy as they can and find a balance in their lives regarding work and family. To depend on a holistic approach as the only approach, however, may unintentionally delay diagnosis and treatment and potentially harm patients.

Remember that most infertility couples are getting pregnant on their own at a low 1-3% per month so anything that takes place during the month of conception is thought to have made the ultimate difference. The Internet, and even some published data, is full of “cures” that were most likely coincidence rather than truly causing a successful pregnancy. Since 1-3% of most infertility patients will get pregnant on their own every month, it becomes important to design studies that discover true cause and not just coincidence. These are complex issues and more carefully designed research needs to be done in this area before clear conclusions can be made.

I look forward to the next week’s segment on oocyte cryopreservation (egg freezing), a very important area of expanding research. Oocyte cryopreservation has tremendous potential for many women. It may provide women an unprecedented level of control regarding the timing of having children beating the biologic time clock through reproductive technologies.

Craig R. Sweet, M.D.
Reproductive Endocrinologist
www.DreamABaby.com

Dr. Craig Sweet, May 1st 2010 | Tags: , , , , , , , , , ,
Posted in Uncategorized
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