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?

Reading these “news” stories one may get the impression that Fertility is a thriving business bearing little resemblance to the medical specialty of reproductive endocrinology requiring seven years of post medical school training. The medical pioneers Drs. Steptoe and Edwards in the UK and Drs. Howard and Georgeanna Jones Jr. in the US envisioned a world in which couples inflicted with the curse of an inability to procreate, would, with the benefit of this technology that they developed, give these couples the ability to build their own families. They were excited that as the technology improved and became more efficient and the cryopreservation of embryos became routinely available that risky multiple pregnancies could be eliminated. They believed that insurance companies would pay for an IVF benefit that had a high success rate and could deliver healthy singleton pregnancies with far greater confidence than any alternative treatment especially intrauterine inseminations (IUI). They were unhappy that in the early years when IVF was inefficient, many embryos needed to be transferred in order to give a patient a reasonable chance for success. This resulted in multiple pregnancies, many of which delivered prematurely requiring expensive neonatal intensive care and unfortunately many did not end well. Today, we have control over this with IVF by transferring one embryo at a time but not with IUI.

They also did not believe that women should be subjected to the medications, blood work and retrieval process without a fair chance for a successful outcome. The idea of subjecting a 49 year old woman to IVF for what may be a 1% chance of conception with a greater than 50% chance of miscarriage is not medically reasonable. Women of this age have a 70 to 80% chance for conception through egg donation. This is how the 50 something celebrities are getting pregnant. They are not using their own eggs. Misleading the public with news stories that feature these older pregnant celebrities gives patients the misconception that they too can create their families at the same age using their own eggs.

We have recently performed IVF on two perimenopausal patients with FSH levels over 50 at age 45 after days of counseling regarding the extreme low odds of pregnancy and a live birth. In both cases, they felt they needed to give it one shot before moving on to egg donation. They had one follicle each and both resulted in pregnancies with a gestational sac seen on ultrasound. One has since miscarried and will now move on to egg donation where her odds of having a live baby jump from less than 5% to 60% per attempt. The other remains pregnant and is miraculously the exception to the rule.

IVF is a medical procedure that is part of a proud tradition of reproductive endocrinology. It is a medical treatment that can cure one of the cruelest maladies known to man, the inability to have a child. This problem is featured in the bible with several references including from the woman’s perspective with Hanna weeping for a baby of her own. The Old Testament proclaims the commandment to procreate. This is part of the human condition. Does it not make sense then that insurance companies provide the financial coverage to allow IVF, a treatment that can be controlled by transferring one embryo at a time to result in a singleton pregnancy? Regulations to prevent costly dangerous multiple pregnancies and the performance of IVF in patients with unreasonably low odds of success need to be instituted. Financial programs that make it no more expensive to patients to transfer one embryo at a time such as our Single Embryo Transfer program at East Coast Fertility need to be the news highlight of the day not the 49 year old who conceived on her sixth try.

The sobering truth: multiple pregnancies — even with ‘just’ twins — are sometimes dangerous to the health and well-being of both mother and babies.

I was on the cutting edge of IVF development in the 1980’s, a time when assisted reproductive technology was so new and inefficient, transferring six embryos in one IVF cycle was the norm.

Since then, thanks to dedicated research to fine-tune IVF, much has been learned about both clinical practice and laboratory technique. IVF is no longer experimental.

One of the most important recent developments — single embryo transfer, or SET — is being consistently backed up by study after study as the optimal IVF method for patients with a good prognosis.

The SET Program

The safest pregnancy with the greatest chances for an optimal outcome — a healthy baby — is a singleton pregnancy. In 2007, East Coast Fertility started leading the field of reproductive medicine by establishing our own SET Program.

Confidence in our high quality embryology laboratory and immensely successful embryo cryopreservation program has afforded ECF the ability to limit the number of embryos transferred, essentially eliminating the risk of triplets or more.

We understand that you’re anxious for fertility treatment to work. Besides your compelling desire to have a baby, you’re coping with worries about the costs — in time, money, and discomfort — of IVF.

So to encourage patients with good prognosis to utilize SET, we offer the following incentive:

For the cost of an IVF cycle, SET Program patients will receive free cryopreservation of their embryos, free storage and free frozen embryo transfers until you have your baby. This represents a savings of up to over $12,000. It also ensures a much better chance of a healthy baby.

Plus, some patients can take advantage of MicroIVF and save even more money and physical discomfort.

Is SET for you?

Each patient’s case is considered individually. Each factor impacting conception and pregnancy is taken into account, such as:
patient’s age
embryo quality
number of prior failed IVF cycles
use of frozen-thawed embryos

Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high. This may include:
women younger than 35 years
women who conceived with first IVF cycle
women with concerns about multiple gestation
donor egg recipients

Single Embryo Transfer is revolutionizing the practice of reproductive medicine, and the team at East Coast Fertility is committed to their collective pledge to lead the way in creating safe, healthy pregnancies.

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.

Jon and Kate Divorce

Over the years, I have seen numerous high order multiple pregnancies, a side effect of transferring numerous embryos with an inefficient procedure. I have experienced through my patients, pregnancy complications, antenatal and postnatal demise and difficulties and complications suffered by the babies. Many of these marriages failed to survive the stresses, some of the patients suffered depression and there were many issues with the babies.

I still feel the pains I experienced with my patients during those early years of IVF. We infertility doctors were responsible for many high order multiple pregnancies that often did not end well. And I carry that in my heart. When I opened East Cost Fertility, I swore that I would not be responsible again for any conception greater than twins. The only triplets I have had since 2002 are from an embryo transfer of two where the embryos split and created a third baby. I don’t ever want to be responsible for anything like that again. Then IVF was inefficient, today, the implantation rates are far superior. There is no excuse for octomom or sextuplets like Kate has had. I don’t feel gonadotropins with IUI is as safe as IVF where you can limit the number of embryos. We need to enforce the guidelines provided by the American Society of Reproductive Medicine so that programs and patients are compelled to be responsible and limit risk. There is a competitive pressure felt by IVF programs to transfer more embryos as their statistics and success rates are inspected by prospective patients. Programs have not unifomly followed these guidelines. It is only through outside regulation that we can prevent the cause of these high order multiple pregnancies.

I started the Single Embryo Transfer program at East Coast Fertility to encourage patients to limit the number of embryos replaced into the uterus to one in good prognosis patients by eliminating the financial factor. These patients are offered free cryopreservation, embryo storage and frozen embryo transfers so there is no financial pressure for patients to put all their eggs in one basket. This represents a savings of up to over $12,000 and ensures a better chance of a healthy pregnancy and healthy baby. It is my sincere hope that situations that led to the sextuplets of Jon and Kate and octomom are eliminated through regulations and financial incentives such as the Single Embryo Transfer program.

Cryopreserved Embryos

At East Coast Fertility, we are realizing the Jones’ dream of safer, more efficient and cost effective IVF. By utilizing the ability to cryopreserve embryos in 2007, 61.5% (118/192) of patients under 35 were successful in having a live birth as a result of only one egg stimulation and retrieval cycle! In addition, because of our outstanding Embryology Laboratory, we are usually able to transfer as few as 1 or 2 high quality embryos per cycle and avoid risky triplet pregnancies. In fact, since 2002, the only triplet pregnancies we have experienced have resulted from the successful implantation of two embryos, one of which goes on to split into identical twins (this is rare!). By cryopreserving embryos in certain high-risk circumstances, we are able to vastly reduce the risk of ovarian hyperstimulation syndrome requiring hospitalization. At East Coast Fertility, safety of our patients comes first. Fortunately, our success with frozen embryo transfers is equivalent to that of fresh embryo transfers, so that pregnancy rates are not compromised in the name of safety, nor are the babies.

Today, as reported in the Daily Science: “The results are good news as an increasing number of children, estimated to be 25% of assisted reproductive technology (ART) babies worldwide, are now born after freezing or vitrification” (a process similar to freezing that prevents the formation of ice crystals).

The study, led by Dr Ulla-Britt Wennerholm, an obstetrician at the Institute for Clinical Sciences, Sahlgrenska Academy (Goteborg, Sweden), reviewed the evidence from 21 controlled studies that reported on prenatal or child outcomes after freezing or vitrification.

She found that embryos that had been frozen shortly after they started to divide (early stage cleavage embryos) had a better, or at least as good, obstetric outcome (measured as preterm birth and low birth weight) as children born from fresh cycles of IVF (in vitro fertilisation) or ICSI (intracytoplasmic sperm injection). There were comparable malformation rates between the fresh and frozen cycles. There were limited data available for freezing of blastocysts (embryos that have developed for about five days) and for vitrification of early cleavage stage embryos, blastocysts and eggs.

‘Slow freezing of embryos has been used for 25 years and data concerning infant outcome seem reassuring with even higher birthweights and lower rates of preterm and low birthweights than children born after fresh IVF/ICSI. For the newly introduced technique of vitrification of blastocysts and oocytes, very limited data have been reported on obstetric and neonatal outcomes. This emphasises the urgent need for properly controlled follow-up studies of neonatal outcomes and a careful assessment of evidence currently available before these techniques are added to daily routines. In addition, long-term follow-up studies are needed for all cryopreservation techniques,’ concluded Dr Wennerholm.

The use of frozen embryos has become a common standard of care in most IVF Programs. At East Coast Fertility we are able to keep multiple pregnancy rates down – by only transferring one or two embryos at a time – while allowing patients to hold on to the additional embryos that they may have created during the fresh cycle. It is like creating an insurance plan for patients. We developed a unique financial incentative program using the technology of cryo-preservation to encourage patients to transfer only one healthy embryo at a time. In order to ensure the best out come for mother and child – these special pricing plans take the burden off the patient to pay for the additional transfers and the cryo- preservation process. We have eliminated the cost of cryopreservation, storage and embryo transfer for patients in the single embryo transfer program. Thus, patients no longer have that financial pressure to put all their eggs in one basket! We truly believe we are practicing the most successful, safe and cost effective IVF utilizing cryopreservation.

Nadya Suleman

The American public has been stunned by the news of a mother of six giving birth to octuplets. This shocking news is compounded by the stories broadcast by the mass media regarding the woman’s family situation and that she used IVF for these pregnancies.

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. In fact 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. In addition, up to 3 frozen embryo transfers are offered for free until a baby is born. Patients are encouraged by this program not to put all their eggs in one basket. Unfortunately, this was not the case for this woman. Success rates with IVF, especially, in the good prognosis patients exceed 50% even when 1 or 2 embryos are transferred. It is hard to imagine a situation where it would make sense to take such an extraordinary risk like was done in this case in California.

We should keep this case in mind when considering how many embryos to transfer. It is rarely worth the risk to put more embryos back when one can alternatively keep the embryos in frozen storage until a patient is ready to conceive again.