Practicing medicine for the past 30 years, I have developed an enormous respect for those things that happen to people that are beyond our control.  Sometimes, the issue of preventability is a gray one and defies definitive blame assignment.  Yet, when the dust settles there remain victims who are harmed for whom we are all sympathetic.  It is for this reason that we are compelled to do everything within our power to ensure that tragic errors do not occur.

Elsewhere in society there are potentially devastating outcomes to human error and, like in medicine, it may be difficult to unravel how much fault is from natural calamity and how much we could have avoided with more rigorous human controls.

Just over a week ago, the world was exposed to perhaps the worst of Mother Nature’s natural disasters: a severe earthquake with multiple aftershocks, followed by a massive Tsunami.  Aside from the horrendous devastation that took place in Japan, ongoing danger persists from damage to several nuclear power plants.  

These unintentional, uncontrollable catastrophes occur naturally and are arguably nobody’s fault.  And although some claim that nuclear power is dangerous because of the history of accidents like at Chernobyl and Three Mile Island, nuclear power plants continue to be constructed throughout the world because many perceive that the benefits of this alternate source of energy outweigh the risks.  We are assured by those responsible that these plants are safe even in the face of the worst disasters… until we learn they are not.

 It is our human condition to speculate how to prevent these complications from occurring.  In IVF, perhaps the greatest potential disaster we face is the mixing up of embryos.

 In February, 2009, a case of a mix-up of frozen embryos in a Michigan IVF program occurred to a couple who already had a set of twins as a result of a successful IVF.  Their embryos were mistakenly transferred into the wrong woman, who then carried the pregnancy and after delivery handed the baby back to his biological parents. Reports of the mix-up have triggered calls from some to make IVF illegal.  This sounds like the recent calls to decommission nuclear power plants and stop production of new facilities.

Mixing up gametes and embryos is tragic and society must do everything humanly possible to prevent it… except disallow the practice of IVF. As with other societal advances, accidents are rare but have unfortunately happened in the field of IVF. But, weighed against the benefit of all the babies who otherwise would never have been born, we should strive to improve the safety of IVF, not eliminate it.

Many of the greatest advances have had tragic results, unintended accidents that could sometimes been avoided. Sometimes, like the post-earthquake nuclear disasters in Japan, they are spawned by natural causes.  But other times, there is an element of human error often preventable with the institution of carefully designed safeguards with a system of checks and balances.

Significant risk, including that of injury or death, is part of nearly everything we do in life today. The construction industry has always been plagued with accidental deaths. Not a bridge or a great high rise has been completed without misfortune. Do we stop construction? No, we ensure that all possible regulations that could protect those involved are in place and followed as strictly as possible to prevent further accidents.

Cardiac bypass surgery and other surgeries save lives and relieve suffering but, occasionally, patients intended to benefit are hurt or even killed accidentally. Rules and regulations are instituted to avoid problems such as performing the wrong operation on the wrong patient, using the wrong medication, operating on the wrong limb. Yet situations do occur rarely, usually because of a human slip. Rules are broken and mistakes result. When they do, hospitals review the procedures and protocols to better insure a sufficient system is in place to catch future errors before they effect patient care.

Just as we have safeguards in the operating room, we have them in place for identifying gametes and embryos with checks and balances that should prevent a mix-up such as the one in Michigan.

In our operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date. As soon as the ovaries are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is double-checked with the patient’s record which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.

Every attempt is made to confirm the identity of the gametes and embryos repeatedly throughout the IVF process from retrieval through transfer. A similar system of double checks of patient and embryo identity exists for frozen embryo transfers as well.

In over 25 years of practicing IVF, my program has not mixed up gametes or embryos.

There are approximately 3 million babies born through IVF and only a few rare mix ups reported. Perhaps we don’t hear …or know…about every mix up. I’d estimate that less than 1/100,000 pregnancies from IVF have occurred with some mix up in the embryo or gamete. When it occurs, it is tragic and requires the attention of our field and a refocus on those checks and balances we have in place to prevent such mishaps.

When it comes to institutions whose impact on society is of such great magnitude, it is essential that governing regulatory agencies ensure that all possible checks and balances are in place to ensure the greatest degree of safety.  All involved must work hard to maintain the highest standards and then we can only pray that we have done everything possible so that such disasters never have such devastating consequences.

Two months ago I had my first IVF cycle & it did not work. I was wondering what common reasons there are a body would reject the 2 embryos that seemed to look good on the 3rd day?
A few years ago I had a healthy child that came naturally with out even trying. In the past 2 years I’ve had an ectopic pregnancy resulting in removing a tube as well as a miscarriage. It’s hard to understand why it was so easy to get pregnant naturally a few years back & why everything we have done since that time has not worked. Also, if a fresh embryo transfer didn’t work on day 3, would you recommend trying a frozen transfer or a fresh transfer again.

Still Not Pregnant

Dear Still Not Pregnant,

I often hear patients refer to a failed embryo transfer as an embryo rejection. I suppose it appears to make sense as the embryos that are being transferred appear completely normal. The disconnect between what appears to make sense and the reality of the procedure of IVF is that the creation of life is an enormously complex process truly beyond the level of human understanding.

Great strides have been made in the process resulting in pregnancy rates exceeding 60% for some groups. However, the apparent quality and grade of an embryo predicts the likelihood of a resulting pregnancy. It is far from guaranteeing a pregnancy. New tests for the viability of an embryo are being developed such as metabolomics and proteinomics. These assess an embryo by analyzing products of an embryo in culture. They will further the likelihood of achieving a pregnancy from a transferred embryo.

Remember, that though an embryo may be otherwise viable it may still be abnormal genetically which will diminish pregnancy rates and usually result in miscarriage when implantation does occur. The likelihood of a genetically abnormal embryo developing increases especially as the age of the woman increases as well as with severely decreased sperm counts in the male.

The decision to go forward after a failed fresh transfer with a frozen transfer of sister embryos or a new fresh transfer should be individualized based on the quality and grade of the frozen embryos, the age of the woman, her

insurance coverage and her tolerance for the stimulation and retrieval as well as her motivation and patience. I recommend you have this conversation with your physician who can advise you better about your specific situation.

I wish you the best of luck!

IVF’s Early Years

Practicing reproductive medicine during the ’80s was like having a new love or beginning a new romance — all of it seemed liked a miracle, and everything was about helping patients get pregnant using this new technology and educating the world about what was now possible. This was an exciting time, and the 15 percent pregnancy rate was achieved by transferring six embryos at a time.

But our excitement was often tempered by the consequence we experienced with many high order multiple pregnancies. Unfortunately, these were often complicated and did not always end well. Aside from pregnancy and neonatal complications, many of the marriages also suffered. It was hard to balance a new family’s anticipation and heartfelt joy with the sometimes painful and unforeseen consequences — babies who suffered and families that fell apart.

Sometimes beginnings are like that. They start off so bright, and then they get tempered.

The Middle Years—Safer and Not So Sexy

Thankfully, I am now in the “middle years,” of IVF which is so much more successful and no less a miracle. We can attain pregnancies in greater than 60 percent of retrievals for women under 40. These rates are accomplished while transferring one, two or, at most, three embryos at a time. Cryopreservation, or freezing embryos, has also improved our pregnancy rates per retrieval, giving us multiple opportunities to get a patient to conceive from a single IVF stimulation and retrieval.

The middle years of IVF are not like the beginnings of a romance — this is the wood chopping time. The freshness of the technology has worn off, and the focus on making the treatment affordable, accessible and safe may not seem as sexy. But it is the middle years of any pursuit — whether it is marriage, raising a child or practicing medicine — in which the gold is often mined.

A Time for Reason, Not Headlines

The middle years of my practice mean we are making an effort to encourage safer single-embryo transfer and avoid risky multiple pregnancies. We introduced a program in 2007 at East Coast Fertility for patients who transferred one embryo at a time, offering free cryopreservation, storage and frozen embryo transfers until a live baby was born.

Still, patients don’t commonly choose single-embryo transfer. They haven’t seen what I have seen — they still believe that the technology will some how fail them, that IVF won’t work. But from our experience, similar to others’, there was no significant difference in pregnancy rates between patients who chose to transfer one embryo vs. those who chose to transfer two embryos.

While there was a trend toward higher rates for the two-embryo transfer group, it was practically eliminated when frozen embryo transfers were added. These groups were age-matched with no difference except for a 40 percent twin rate and one triplet in the two-embryo transfer group, compared to the single-embryo transfer group in which no twins were created.

It is hoped that these results will encourage a higher percentage of patients with a good prognosis to transfer a single embryo, which is the safer option.

The middle years of practicing reproductive endocrinology captivate my heart. It is a time for reason — not headlines. And for me that is just perfect.

It was fifteen years ago that I sat listening to a lecture about the hazards of multiple pregnancy and how IVF had increased multiples so drastically in the preceding ten years. What a depressing thought. I loved helping women conceive. I was living my dream, practicing the infertility and IVF I had learned ten years earlier at the Jones Institute with Howard and Georgeanna Jones themselves as well as Zev Rosenwaks and other masters of the IVF craft.
I had seen quadruplets created first hand as a result of our IVF efforts. But, that was a necessary side effect of transferring a sufficient number of embryos to offer a patient a reasonable chance for a successful transfer. IVF was very inefficient back then and our pregnancy rate even in 1995 with transferring 3-4 embryos was at best 40%.
The sobering truth is that multiple pregnancies — even with ‘just’ twins — are sometimes dangerous to the health and well-being of mother and babies let alone the triplets that were still occurring in 7-10% of the pregnancies at the time.
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 and is currently much more efficient so that the live birth rate for women under 35 years of age at East Coast Fertility is greater than 60% per retrieval.
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 analyzed our success with elective single embryo transfer and compared it to our success with elective double embryo transfer since the opening of our lab in 2005.
Fresh eSET was less likely to result in pregnancy than eDET 39/75=52% vs. 342/561=61% though this difference was not significant statistically. When frozen embryo transfer pregnancies were added this difference was 64% vs. 68.3%. There were no multiples in the eSET group but a 27.8% twin rate in the eDET group with 2 cases of triplets. 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 they have a baby. This represents a savings of up to over $12,000. It also ensures a much better chance of a healthy baby.
Is SET for you?
Each patient’s case is considered individually. Each factor impacting conception and pregnancy is taken into account, such as; the age of a patient, embryo quality, the number of prior failed IVF cycles and embryo quality. Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high, including; women younger than 35 years, women who conceived with first IVF cycle, women with concerns about multiple gestation and 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.

As a reproductive endocrinologist (and, therefore, a supposed expert on heredity), I’m often asked how much of a child’s development and ultimate personality is a result of genetics (nature) and how much is a result of its environment (nurture). Typically, this question arises when dealing with patients contemplating using donor sperm or donor egg.

I don’t have the answer to this question; it’s one I, myself, have spent much time considering. I’m one of five children and I have four children of my own and, so far, three grandchildren. Though the environment and the genetics of my siblings and and my children doesn’t appear to be so different, each of us has developed unique characters and personalities. Some are significantly different.

I think the nature vs. nuture question is like a Jackson Pollack painting. When you raise a child, different colors of nature and nurture are tossed randomly up in the air and what we call “life” dresses the canvas below. Sometimes the picture it creates is breathtakingly beautiful and other times you wish you could start with a new canvas.

Now, if you are a conscientious parent, then you are most careful about how and what colors of nurture you toss. With nature however, even with that which comes from you, there is no control.

So, I tell my patients who are screening donors and are so concerned that their donor has a particular color hair, eye color or even personality type, that they are putting too much faith in just one can of paint that they get to choose to toss up in the air. People with blue eyes and blonde hair have other colors from ancestors that randomly did not appear on their body. But their gametes contain them and these cans of paint will potentially have more impact on the canvas that the blue eyes and blonde hair that the recipient is hoping for.

The characteristics I prefer in a donor are healthy with good odds for successful conception and a generally appropriate mix of physical and behavioral characteristics to match the recipient.

Then I pray for G-d’s blessing.

A new article appearing in Medical News Today, “Obese Women Undergoing Infertility Treatment Advised Not To Attempt Rapid Weight Loss”, suggests that weight loss just prior to conception may have adverse effects on the pregnancy, either by disrupting normal physiology or by releasing environmental pollutants stored in the fat. The article points out what is obvious to many who share the lifelong struggle to maintain a reasonable Body Mass Index (BMI): Weight loss is difficult to achieve. Few people adhere to lifestyle intervention and diets which may have no benefit in improving pregnancy in subfertile obese women.

The bias in the field is so strong that when I submitted a research paper demonstrating equivalent IVF pregnancy rates for women with excessive BMIs greater than 35 to the ASRM for presentation, it was rejected based on the notion that there was clear evidence to the contrary. Here’s the point I was trying to prove: IVF care must be customized to optimize the potential for this group.

Women with high BMI need a higher dose of medication. Those with PCOS benefit from treatment with Metformin. Their ultrasounds and retrievals need be performed by the most experienced personnel. Often their follicles will be larger than in women of lower weight. Strategies to retrieve follicles in high BMI women include using a suture in the cervix to manipulate the uterus and an abdominal hand to push the ovaries into view. Most importantly, a two-stage embryo transfer with the cervical suture can insure in utero placement of the transfer catheter and embryos without contamination caused by inadvertent touching of the catheter to the vaginal wall before insertion through the cervical canal. Visualization of the cervix is facilitated by pulling on the cervical suture, straightening the canal and allowing for easier passage of the catheter. The technique calls for placement of one catheter into the cervix through which a separate catheter, loaded with the patient’s embryo, is inserted.

Using this strategy, IVF with high BMI patients is extremely successful. With regard to the health of the high BMI woman and her fetus, it’s critical to counsel patients just as it is when dealing with women who live with diabetes or any other chronic situation that adds risk.

We refuse to share in the prejudice that is nearly universal in this field. It’s horrible and hypocritical to refuse these patients treatment. Clearly, with close attention to the needs of this population, their success is like any others.

Women who have time and motivation to lose significant weight prior to fertility therapy are encouraged to do so and I try to support their efforts. Unfortunately, many have tried and are unable to significantly reduce prior to conception.

What right do we have to deny these women the right to build their families?

It can be hard to deal with obesity and even more so when combined with infertility. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. I advise you to ask your doctor about support groups and for treatment that can help you including fertility treatment.

Remember, though this condition can be annoying, aggravating and even depressing, seek an REI who is interested in supporting you and helping you build your family and reject those who simply tell you to return after you have lost sufficient weight.

Back in 1985 when I started my fellowship at the pioneering mecca of IVF, the Jones Institute For Reproductive Medicine, there were still many people and religious leaders who objected passionately with the use of Assisted Reproductive Technology to help people in need conceive.  Arguments ranged from accusing IVF of being immoral to the potential dangers of playing God.

Physician defenders of this nascent technology offered comparisons to other medical problems that have been helped by technology, such as immunizations to prevent infectious diseases like polio, chemotherapy to cure cancers like lymphoma, kidney transplants, etc.  To them, a world unwilling to use technology to aid the suffering is unethical.  They see it as criminal to stand by and ignore the cries for help.  To have infertility, is to be cursed with an inability to satisfy that basic human need, sited in the bible as a commandment to “go forth and multiply”, to procreate and build a family.  How, in God’s name can a physician with the technology and know how, ignore such pleas from the suffering?

Yet, Jennifer Lopez feels it appropriate to speak up in 2010 against IVF saying, “I…believe in God and I have a lot of faith, so I just felt like you don’t mess with things like that”…”And if it is (meant to be), it will.  And if it’s not, it’s not going to”.

I wonder if she would feel the same without the ability to cradle her babies in her arms.  Or for that matter, if she developed a disease that required the use of some other “God-like” technology would she let herself suffer rather than take advantage of a potential cure.

I respect others’ opinions and beliefs and would never tell them they were wrong in following their faith.  I wish that people like Jennifer Lopez would share the same respect for suffering infertile couples who think that IVF is an ethical treatment offering these patients their only chance at building their families.

What Do You Know About Your Biological Clock?

Women have a biological clock. Everyone knows that. The problem is that a lot of the information people think they know about their fertility and reproduction is not true. The blurring of fact, opinion, myth and misunderstanding makes for a treacherous misinformation landscape. The knowledge gap has claimed millions of victims, people who learned about their limited reproductive lifespan too late to help them have the genetically linked offspring they always assumed would be theirs. Armed with essential and accurate information, you don’t have to join their ranks.

What is still not understood across the board is the time line of the biological clock. Most women don’t have a clue about their own.

So, we’re asking the question: What do you know about your fertility? Over the next three days we’ll be learning a lot more about it.

But, right now, if you’re like most people, the answer is not as much as you might believe. Just to give you a little perspective, a spate of recent surveys reveals that the overwhelming majority of U.S. women:

• The trajectory of reproductive capabilities peaks in a woman’s early-to-mid-20s and begins to decline, typically, around 27.
  However wonderfully youthful and fit a 42-year-old might be, her eggs are operating on an independent and fixed timeline.
  The stark truth is women at that age are more likely than not to require medical intervention.
  Sleep, diet, exercise and environment can all impact your fertility.

• Don’t understand the biological clock.

• Mistake overall good health as an indicator of fertility.

• Believe they can get pregnant easily until their 40s.

• Don’t know that lifestyle factors can have a profound effect on the ability to have a child.

This basic information can make a critical difference in the life of every person who dreams of having a child. If you know about your body’s reproductive lifecycle, you can take steps to protect and preserve your fertility and have the children you want – if and when you choose.

Statistics and general truths aside, every woman is unique. Given just how complicated it is to make a baby in the first place, understanding your own body’s reproductive capability and the changes it might undergo from year to year is an invaluable planning tool.

Marking Time: The Biological Clock and You

Each woman’s oocytes (eggs) supply is finite. That means the body doesn’t produce new ones. So the 7 million or so eggs each female is born with is all she’s going to have. By the time the average girl hits puberty, only about 250,000-300,000 oocytes remain in her ovaries. With each menstrual cycle one egg is released, and an additional thousand eggs each month are lost through a process called artresia, the natural breakdown of the eggs by the body. After ovulating an average of 400 times through her life, typically at around 50 years of age, the store of oocytes is tapped out. That’s menopause.

Then there’s the matter of oocyte aging. Eggs age along with the rest of the body. The older oocytes are more likely to have chromosomal abnormalities making them unlikely to become viable embryos. It’s important to note that a fertilized egg with abnormal chromosomes is the single most common cause of miscarriage. As a general rule, women in their 20s have about a 20% chance of having a miscarriage each time they become pregnant, a woman in her 30’s has a 30% chance, and a woman in her 40s about a 40% risk of miscarriage.

The bottom line is the older we get, the less likely we are to conceive and have a successful pregnancy. Fertility starts to decline when a woman is in her 20’s but when she hits 35, it take a sharp downturn. At 40, fertility falls off even more dramatically.

Of course, some women in their late 30s and a few in their 40s conceive effortlessly, and carry and deliver healthy babies. But the likelihood of that happening without medical intervention becomes more remote with each passing year.

For women under 30, the estimated chance of becoming pregnant in any one cycle is between 20% and 30%. When women turn 40, that probability plummets to approximately 5%. Even more significant is that when a woman experiences difficulty conceiving in her 40’s it is a far greater challenge to achieve a live birth using her own eggs even with the best medical technologies.

Learn More About Your Fertility

So, the good news is, there are some steps you can take to preserve your fertility and stay on top of your biological clock.

We’ll be back with:
Tomorrow: Fertility Screening for Your Reproductive Life

I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.

If you have endometiosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.

Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.

Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.

The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.

There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman’s age, length of infertility, and the presence of pain or other symptoms.

Treatment for Mild Endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three – six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).

Treatment for Severe Endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.

Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging.

Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.

Recommendations

As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.

Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.

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.