We are approaching a time that freezing eggs will be a standard option for an IVF program much like Embryo freezing is today.  Despite the fact that hundreds of babies have been born apparently without an increase in defects or abnormalities, the American Society for Reproductive Medicine (ASRM) has proclaimed that Egg freezing is still considered experimental.

This is not just a scientific decision but is a philosophical and political one as well.  In the 1980’s, IVF was being performed likewise on an experimental basis.  Insurance companies denied that it had become standard of care until recently.  In fact, there are insurance providers who in an effort to deny claims continue to call IVF experimental despite the million babies already born without significant increases in abnormalities or defects noted.  However, the ASRM is afraid to push the envelope and take a risk that may make them appear to be promoting a procedure that could theoretically be associated with increased problems with the children created after egg freezing.

But why should we be interested in egg freezing anyway when we have IVF that is successful and known to be relatively safe after 33 years of experience?  The reasons are multiple.  A young woman who develops cancer and will have radiation therapy or chemotherapy that may affect her eggs or have her ovaries removed would with egg freezing have an option to preserve her fertility and still have her cancer treated.  In the past, the loss of a woman’s future ability to bear children was sometimes more emotionally depressing for her than the cancer itself.  The prospect of offering hope to such affected women is spreading throughout the community in part through the efforts of the Lance Armstrong Fund supported group, Fertile Hope.  They are attempting to educate not just affected individuals but oncologists and other physicians who come into contact with patients who may be able to take advantage of new IVF technologies to preserve their fertility while undergoing cancer treatment.

Another great potential use for frozen eggs is in the donor egg program.  Currently, our egg donors go through fresh IVF cycles coordinated in time with the recipients so that the eggs are fertilized fresh when they are retrieved.  This is highly successful in achieving pregnancies in approximately 80% of donations.  However, cycles can be delayed in trying to synchronize patients.   If programs can achieve similar success rates using frozen eggs it will allow recipient patients to choose donor eggs much like they select donor sperm today.

Yet, another benefit of the ability to bank frozen eggs is for women who either because of their career or lack of finding a suitable partner need to put off their childbearing until a time when they would otherwise put their future fertility at significant risk.  This is a more controversial use of this technology but a practical concern for countless women today for whom conceiving before age 35 is unrealistic.

Needless to say, egg freezing will be a great benefit for many when it becomes a safe acceptable IVF standard.  That time for consideration by patients is rapidly approaching and is something that the public needs to be made aware of.

You have that dreaded infertility diagnosis, “Over 40 With High FSH Levels.” And there’s no cure or magic herb that will turn back the hands of time. You’re desperate so you are willing to try it all anyway, including acupuncture and some internet recommendations such as DHEA (dehydroepiendosterone).

You hear that you can lower your FSH with DHEA or estrogen. The fact is, however, elevated FSH levels do not cause a problem with conceiving. They are merely a marker of diminishing ovarian reserve, a depletion of ovarian follicles and eggs that, combined with increasing age, means you have very few genetically normal eggs available in your ovaries to achieve a healthy child.

Reproductive endocrinologists typically counsel “Over 40 With High FSH Levels” patients that their chance of successfully achieving a live birth using their own eggs is small and that by using a donated egg from a young, fertile woman they can increase their odds of giving birth to greater than 70 percent per donation. Unfortunately, this comes as a shocking disappointment to most women. It’s often a reason for them to drop out of a doctor’s practice or even quit trying to conceive.

So what do you do when faced with this situation? Your answer needs to be individualized, based on your emotional and financial resources, your motivation and your comfort with using a donated egg.

At our clinic, we try to come up with a strategy with our patients that includes counseling to begin the discussion about donor eggs, as opposed to trying with less chance for successful outcome using a patient’s own eggs, or stopping therapy completely and adopting or living child-free.

Perhaps you will choose a low tech option such as insemination with or without hormonal therapy. Sometimes, the plan will be to blast ahead with the big guns using IVF with full stimulation or with less medication and cost using MicroIVF or Minimal Stimulation IVF. Some patients respond better to different stimulations such as sensitizing with estrace or even DHEA prior to stimulation, using a lupron flare or even using clomid in combination with gonadotropins. Unfortunately, it is hard to predict what will be the optimal stimulation for you until we give it a shot.

The bottom line? There’s no right or wrong choice for you. Remember, a family can look many different ways and still be a healthy, loving unit. Your physician, nurses and counselors are available to assist you and support you with whatever decision you make.

There has been a lot of negative press recently about “reproductive tourism” – or cross-border reproductive care; that is traveling abroad for fertility services. However, the fact remains that in some areas couples struggling to start a family sometimes have no other option but to seek help away from their homes. This is the case for couples in the U.K. who must turn to egg donation as their only hope in order to conceive. For them, there is a three year wait for donor eggs. This is a huge obstacle for those anxious to start their families and for women already of an age where they can not afford to wait. In the U.S. the wait is much shorter. In fact, at many programs such as mine at East Coast Fertility we have a donor database with immediate availability. In an ideal world, patients wouldn’t have to leave their country and their local doctors to get the treatment they need in a timely fashion. But the reality in the UK is that many couples cannot afford to wait until a donor egg becomes available there.

Other reasons for patients seeking treatment abroad include limitations on medical technology, cost or even government restrictions on treatment that drives people to leave their home land for treatment.
The interesting thing about Cross Border reproductive care is that the currents of travelers go both ways in the United States. We have Americans who travel to India because they cannot afford the surrogacy fees in the United States, and to places like Israel, South America and Mexico for less expensive IVF.

Patients from countries such as Spain are traveling to the United States for procedures such as surrogacy which is outlawed in their country.

The flow of patients knows no borders. Everyone wishes that patients could receive treatment in their own country. Adding in the pressure of leaving one’s job, families, traveling to a country that you don’t know and perhaps even having language difficulties can make treatments that are already stressful – more so. But the desire to have a child also knows no borders – and patients will do what they need to do to achieve their dreams of parenthood.

Dr. Kreiner with Drs. Howard and Georgeanna Jones

In 1987, I completed my Reproductive Endocrinology and Infertility fellowship under  Drs. Howard W. Jones Jr. and his wife Georgeanna Seegar Jones, the two pioneers of in-vitro fertilization in the USA and the entire western hemisphere.

This picture was taken at their house on the Elizabeth River in Norfolk during one of the bimonthly journal clubs.  It was routine for the Joneses to host the journal clubs twice a month during which the entire Reproductive Endocrinology team would discuss interesting cutting edge research in the field.

Learn more about the History of IVF at the Jones Institute here.

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.

Patients often seek my help, desperate to try In-Vitro Fertilization (IVF) after having a previous cycle cancelled at an outside clinic. These patients stimulated with fewer follicles and therefore due to their lower pregnancy expectations were not allowed to proceed. We presented our data on IVF performed on patients with 3 or fewer follicles at the American Society for Reproductive Medicine (ASRM) (insert hyperlink to www.asrm.org) in 2008. Our pregnancy rate was 15% for this group. Though this is admittedly low, for those who were successful in having a baby using their own eggs it was felt by them to be miraculous because they were either not allowed to cycle at other centers or had their cycles cancelled.

We counseled them regarding their lower odds for success but some elected to give it a try. Previously, most of these patients were offered Intra-Uterine Insemination (IUI), a much less successful option that does not affect the programs reportable pregnancy rates.

Unlike most other fields in medicine, IVF results are subject to public reporting since the passage of the Wyden Bill in 1992. The intent of the CDC (Center for Disease Control) report and SART (Society of Reproductive Technology) report was to help infertility patients by informing them of the relative success of different IVF programs. Unfortunately, what sometimes creates the best IVF statistical outcomes in pregnancy rates is not always what is in the best interest of the mother, child, family and society. Now that prospective patients are comparing pregnancy rates between programs there is a competitive pressure on these programs to produce the best reportable rates. This means that patients with lower odds of success are less likely to be offered IVF retrievals and are diverted to IUIs or donor egg cycles.

The high order multiple birth rate was also fueled by competition in the field to have the highest success rates. The Wyden Bill results in competitive pressure to transfer more embryos to increase pregnancy rate as reported. Despite the fact that there is evidence that a program can achieve similar live birth rates by transferring a single embryo each time, the Wyden Bill creates a disincentive to do so. It is no surprise that the clinics with the highest success rates have also had the highest triplet rates. Live birth rates are reported per fresh cycle and those from subsequent frozen embryo transfers are not included. It is true that live birth rates are reported for frozen embryo transfers separately but again it is per transfer motivating programs to transfer multiple embryos to enhance their success rates. If live birth rates were reported per fresh IVF stimulation and retrieval (that part of IVF with risk) including those conceived from subsequent frozen embryo transfers then programs would be likely to provide the less risky option of single embryo transfer to patients.

William Petok, Ph.D the Chair of The American Fertility Association’s Education Committee reported on Single Embryo Transfer (SET) “Single Embryo Transfer: Why Not Put All of Your Eggs in One Basket?” He stated that “at the ASRM meeting in November of 2008 … data was reported that looks favorably at SET. A Center for Disease Control researcher said that although multiple rather than single embryo transfer for in-vitro fertilization is less expensive in the short run, the risk of costly complications is much greater. Universal adoption of single embryo transfer would cost patients an extra $100 million to achieve the same pregnancy rates as multiple embryo transfer, but this approach would save a total of $1 billion in healthcare costs.”

The risks of prematurity and pregnancy complications are far higher in multiple pregnancies than in singleton pregnancies. The financial and emotional costs to families and society are enormous. These multiple pregnancies result in much longer hospitalizations, NICU admissions, complications resulting in handicapped children and occasionally death. They often do not have a happy end including increasing the incidence of divorce. So does it not behoove insurance companies to make IVF available in such a way that encourages SET? Should not the government enforce the recommendations of SART regarding the number of embryos to transfer?

At ECF, we have, since 2006 offered our Single Embryo Transfer program to cover the financial cost for transferring one embryo at a time. For the fee of one IVF cycle, we offer free cryopreservation, embryo storage and unlimited frozen embryo transfers until a patient achieves a live birth.

We offer MicroIVF, minimal stimulation IVF, for $3900, less than the cost of 2 IUIs with three times the success rate and ¼ the risk of hyper stimulation syndrome. Since minimal stimulation does not result in as many eggs, many programs are uncomfortable offering it and therefore lowering their reported pregnancy rates.

If we are going to report pregnancy rates with IVF as is required by the Wyden Bill, let us put all programs on the same playing field by enforcing the number of embryos to be transferred and promoting minimal stimulation IVF as a safer and more efficient treatment than IUI.

The Wyden Bill without the teeth to regulate such things as the number of embryos transferred and reporting success per stimulation and retrieval and not by isolated embryo transfer does more harm than good. Let us support efforts to reduce the number of embryos transferred by removing the added costs to the patient of cryo-preservation, storage and subsequent frozen embryo transfers and by absorbing them ourselves as a profession. This will go a long way in eliminating multiple birth pregnancies, and will do the right thing for the patients, their families and for society. It’s time for us doctors to “Man Up”.

Maria de Carmen Bousada

This is one of the hardest things about being a doctor in a cutting edge field such as reproductive medicine. We are often put in the position of making decisions with our patients that have even bigger implications to society than the individual patient. I do my best to look at each patient, and each situation individually, but I do rely on my patients to treat me as honestly as I treat them. It is a two way street – and unfortunately, Maria lied to the clinic about her age, telling them she was only 53 years of age.

Questions are being raised regarding the responsibility of the IVF program to verify the veracity of information supplied to them by their patients in addition to confirming their health condition to carry a pregnancy.

Others, add that beyond a certain age, it is unnatural to become a mother and it puts the family at risk that she may not be around to help raise the child as what occurred in this case, or even if she is perhaps she lacks the energy and stamina to raise the child properly.

At East Coast Fertility, we have a cutoff of age 50 which is admittedly random and that limit is often broken when faced with an energetic couple with a woman who passes her stress test, medical and high risk maternal fetal medicine clearances. We recently celebrated our latest 54 year old patient’s delivery of a healthy baby that was highly reported in the press.

As I said, it is a struggle to separate my own personal feelings about the proper age to have a child which may be inappropriate for others who have a completely different perspective. My responsibility as the physician offering assistance to patients in need of help with procreation is to the health of my patients, the well being of the child and for the good of society.

Many women in their 50’s have the health and energy to carry a pregnancy and bear a child with no more increased risk than many woman 10-20 years younger whose interest in achieving pregnancy we would never consider questioning. That being said what about the risk that the mother may not still be around to raise the child to maturity. There is no question that a young healthy couple with sufficient financial support and emotional maturity is ideal for raising a family. But, happy, successful families can take on many different faces. Single parent families exist, survive and often thrive. One can never be certain that the condition of the couple at the time of conception will continue through the child’s birth or for that matter until the child has reached maturity. We do not know that a healthy woman of 30, 40 or 50 may not develop a lethal disease before a child has grown up. In addition, at least 50% of couples in the United States become divorced. One can argue that couples at risk of divorce should not get pregnant. I do not think that society is ready to conclude that any of these women should not be allowed to procreate.

So, what about the clinic’s responsibility regarding confirming that a patient is giving them truthful information? We have been deceived in the past that a couple who is requesting fertility assistance was unmarried when in fact at least one partner was married to someone else. This issue is especially acute as it can raise potential liability to the clinic. As in the case of Maria de Carmen Bousada, she lied about her age and perhaps was beyond the limit the doctors and society was comfortable assisting.

For me, and for our program we have raised our bar to do the proper due diligence realizing that we will not be able to get the truth in all cases but minimize the risk that we missed picking up a crucial lie. But I don’t want to be “The Fertility Police”. I am a fertility doctor – and my job is to help people have families no matter how different those families may look to you and me.