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!

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

The Back-Up Plan

Just saw movie “The Back-Up Plan”. Was cute with a few funny lines. Can’t help but wonder if this is really the best back-up plan. Donor inseminations may work but being a single parent is tough. Other alternatives such as egg freezing (oocyte cryopreservation) may really be a better option. Costs are higher with egg freezing and it is considered experimental but a reproductive insurance policy may be just what a women is looking for when her biologic clock is thought to be ticking away. If she waits too long and is unable to use her own eggs, adoption, egg donation and embryo donation are alternatives.