My son is starting his second year residency in obstetrics and gynecology. He, like I was 30 years ago, is turned on by reproductive medicine and enjoys performing gynecologic surgery. When I decided then to specialize in reproductive endocrinology and infertility (REI) I was looking forward to being on the frontier of fertility medicine. The details of Reproductive physiology were being unraveled in real time and IVF had just reported its first successful pregnancies. In those days, microsurgery of the fallopian tubes was commonly performed by REIs as well as endometriosis and fibroid surgery.

During my fellowship, surgery was a huge part of my training. I travelled to Nashville to train with one of the world’s experts in laser laparoscopy. I practiced my tubal microsurgery skills weekly on anesthetized rats in a plastic surgical lab. I assisted on reproductive surgery several cases every week throughout my fellowship.

Myself and other fellows performed research on basic reproductive physiology questions that had yet to be worked out. Personally, my interest was polycystic ovarian disease and its relationship to weight gain. I studied male hormone production in the ovary and the adrenal gland before and after significant weight loss. I discovered that there was an inverse relationship between weight loss and male hormone production and that this was mediated through insulin. These were exciting times. If only we had metformin back then, I would have proven that in addition to weight loss, we could decrease insulin levels and therefore male hormone levels with metformin.

Today, discoveries in reproductive physiology are much more esoteric than it was when I was a fellow. Reproductive surgery, in particular tubal microsurgery and laser laparoscopy for endometriosis and adhesions is usually replaced with in vitro fertilization (IVF) which has become so much more successful, less invasive and therefore a preferable option. Most causes of infertility, if they are not successfully treated with ovulation induction and intrauterine insemination (IUI) can be overcome with IVF.

In the 1980’s when I was a fellow, IVF was grossly inefficient and we had to transfer multiple embryos to achieve a pregnancy. Consequently, triplets and quadruplets were not rare occurrences. In many programs, they constituted over 10% of all pregnancies. Today, we can often transfer one embryo at a time minimizing the risk of multiple pregnancies. We can freeze excess embryos so many patients need go through only one stimulation and retrieval and still have multiple transfers providing them with an excellent chance of conceiving a baby from their efforts.

Today, we get excited about advances in preembryo genetic screening and diagnosis and contemplate the current and future potential of eliminating hereditary medical disorders. This involves highly trained laboratory personnel who perform the latest technologic advances. In 2010, the REI, in general is removed from a hands on involvement with the frontiers of Reproductive Medicine and instead works like a film producer gathering his team including these lab personnel, nurses, etc and directing them as to how to approach his patients’ fertility problems. It used to be that he used the microscope and laser laparoscope to perform the tubal and endometriosis surgery. The IVF retrieval and transfer were new procedures that were still being perfected.

Today, they are the routine cases performed daily by the REI.

My son looks at the REI of today as a doctor who starts his day with 1-2 hours of ultrasound that is part of the daily ovulation monitoring for IUI and IVF. Many REIs no longer perform more surgery than hysteroscopy and occasional laparoscopy or myomectomy in addition to their retrievals. These are all considered routine procedures now. The current frontier in infertility is limited pretty much to the laboratory. Though many of us consider ourselves expert in stimulations, retrievals and transfers and while we know we make a significant difference in our patients’ outcomes our work does not appear or feel as glamorous as it once did. Perhaps, he will decide, as I did, that the pleasure in helping women build their families is sufficient reward. Or perhaps, this Nintendo generation, will seek a more apparently exciting lifestyle. How about that Robotic surgery?

According to the Center for Disease Control, reported in the same NY Times issue, thousands of premature deliveries would be prevented resulting in a $1.1 Billion savings if elective single embryo transfer was performed on good prognosis patients. That brings us to regulating how many embryos to transfer as Octomom went through IVF with transfer of six embryos. At East Coat Fertility, we make it cost neutral to transfer only one embryo at a time by offering free cryopreservation, free embryo storage and free embryo transfers until a patient achieves a live birth, all for the cost of a single IVF cycle. Patients are encouraged by this program not to put all their eggs in one basket. Success rates with an elective fresh single embryo transfer with IVF at our program, is 50% and with subsequent frozen embryo transfers it is over 64%. It is possible that East Coast Fertility is the only center in the country doing this. That is the shame of it.

Fertility treatment without IVF is even more hazardous since as many eggs that are developed with treatment may implant and lead to a hazardous multiple pregnancy. In a perfect world, where a patient’s welfare was put before insurance companies, IVF would be a covered service for all people, and the use of fertility medications in an uncontrolled IUI cycle would not be used anymore. In this perfect world, we would also regulate how many embryos are transferred. It is time to put our professional recommendations of the Society of Assisted Reproductive Technology (SART) into law. There is flexibility built into the recommendations taking into account critical factors such as patient age, embryo quality and past experience.

It is not until we discourage the use of gonadotropins without IVF by offering IVF as a regulated covered alternative will we eliminate risky multiple pregnancies. Until then, all of us including society, the government, insurance companies and employers are to blame for letting these dangerous multiple pregnancies occur.

Octomom was a result of IVF with an embryo transfer of six embryos. This far exceeds the number that the Society of Assisted Reproductive Technology (SART) has recommended as the limit. Physicians have known for many years the dangers of multiple pregnancies and have worked steadily to formulate evidence‐based guidelines for the number of embryos to transfer in IVF cycles. The current rate of triplets in IVF cycles nationally has dropped in 2005 to only 2% of cycles. At East Coast Fertility our triplet rate has been below 1% since 2002 and not one of these occurred from transfer of more than 2 embryos..

However, the Tunisian woman who is expecting six male and six female babies conceived using gonadotropins in combination with insemination. Unfortunately, one does not have the same control with insemination as you do with IVF. As many eggs as is stimulated by the gonadotropin injections can implant with intrauterine insemination (IUI) or without the benefit of retrieval of the eggs as one performs as part of the IVF procedure. With IVF one can limit the number of embryos transfered to a woman’s uterus. Insuance companies do not typically cover IVF but are more likely to cover IUIs. However, if one considers the cost of multiple pregnancy; including hospitalization for mother and babies born prematurely requiring the neonatal intensive care unit (NICU) and care for babies born handicapped, it would be a lot cheaper for insurance companies and employers, the government and society to cover IVF and have the control to prevent these high risk multiple pregnancies.

The dozen babies happened because the safer alternative, IVF was not performed. Gonadotropins without IVF are dangerously risky due to this lack of control over how many eggs may fertilize and implant. Society, the government and insurance companies in partnership with employers discourage IVF yet encourage gonadotropin therapy without the protection of IVF. They are at fault since they deny women coverage of IVF services. If IVF was covered by their insurance, physicians would not need to administer gonadotropins in such a dangerous and risky way. Perhaps gonadotropin treatment without IVF should be illegal or at least have very strict regulations regarding its use. Again, if IVF is a covered alternative who would not choose the safer more successful treatment?

That brings us to regulating how many embryos to transfer as Octomom went through IVF with transfer of six embryos. At East Coat Fertility, a financial incentive is offered to patients to transfer a single embryo. Cryopreservation of embryos is offered for free as well as storage for up to 1 year for patients in the Single Embryo Transfer Program. In addition, patients may return for their frozen embryo transfers for free until a baby is born. Patients are encouraged by this program not to put all their eggs in one basket. Success rates with a fresh single embryo transfer with IVF at our program, is nearly 50%.

If IVF were a covered service as I recommend to avoid the dangers of uncontrolled gonadotropin use without IVF than we need to regulate how many embryos are transferred. The SART recommendations regarding the number to transfer should be law to prevent such aberrations as Octomom from happening. There is flexibility built into the recommendations taking into account critical factors such as patient age and embryo quality. One can even factor in past experience.

I believe it is not until we discourage the use of gonadotropins without IVF by offering IVF as a regulataed covered alternative will we eliminate risky multiple pregnancies. Until then, all of us including society, the government, insurance companies and employers are to blame for letting these dangerous multiple pregnancies occur

I was at a meeting with one of the insurance companies when I was asked, “How do you educate patients regarding the risks of multiple pregnancy?” I realized that as much as I try to counsel patients and teach them that we had limited written materials and no audio visual. It was at that point that we decided to create our patient education program. First we hired an expert patient educator, Pamela Madsen, former founder and president of the American Fertility Association. With her assistance and with the help of my son Dan, we have produced a number of online tools for our patients:

We launched this blog, the fertililty doc, insights, information and musings on the world of fertility, infertility and reproductive medicine which covers everything from current news to new programs offered to informational videos and more.

We have developed a message board to assist patients in reaching out for answers to their questions. There is also a cycle buddy board that patients can utilitze to connect with and offer support to their fellow patients going through similar experiences.

The newest of our projects is an ongoing video series called Journey to the Crib: Fertility Talk with Pam and Dr. Dave which will consist of a new topic each week. We went with a casual format that actually takes place in the living room of my house.

Here are the first two episodes of Journey to the Crib, the first is an introduction to the series and the second one which is the topic for this week is High Order Multiple Births. I welcome you to visit our new educational sites as often as you wish. I hope they work to help educate you on fertility and increase your knowledge and awareness to help you in your own personal journeys. Please feel free to ask questions and to comment by clicking the comments button below.