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.
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.
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!