Tune your radios to KGO 810 AM, tonight. Dr. Givens will be the featured guest on the Pat Thurston Show from 10 – 11 p.m. PST. Dr. Givens will be discussing many fertility issues including treatments, outcomes, and ethical issues. She will also be taking questions from callers. You may also stream the show live on the KGO website.

Title: Everything Conceivable
Subtitle: How Assisted Reproduction is Changing Men, Women and the World
Penguin Books, 2007. 343 pages, with 57 pages of footnotes and references.
By: Liza Mundy

This is a very interesting book about the current state of affairs in the world of assisted reproduction. It is comprehensive in its coverage of almost all the latest technologies and the author has been very thorough in researching the subject. On most topics, there are insightful observations on the societal implications of current technologies. In this regard, it is a thought-provoking book.

In the epilogue, the writer states, “It was my goal to help readers understand why certain changes in the family are taking place and what their likely consequences might be. Why there is so much demand for donor eggs, now. Why there are so many more triplet sets than there once were. What life is like for those triplet parents. How embryo research and embryo politics are influencing our thought on human life and its origins. What is the real, rather than the imagined impact of medicine and science on families and culture.”

I think this would be an excellent resource if one were a health care policy maker or if one were writing a term paper or thesis on the subject but I don’t really think it’s a book to inform the infertility patient about fertility options or what to expect with treatment. It really does not seem to be intended for fertility patients as the target audience.

However, the book does provide a lot of useful information in a somewhat scholarly fashion. Most of the facts are correct, with some of the usual journalistic license.

One of the biggest challenges we face as fertility medicine specialists is how to do more to help our least-likely-to-succeed patients. What I mean here is the 42-and-over age group, patients with high FSH levels (decreased ovarian reserve), patients with very low responses to fertility medications, or those with very poor quality eggs. Some patients have a combination of the above which leads to a really dim prospect of having a baby with their own eggs.

Some people get the impression that fertility clinics avoid these patients like they have a communicable disease. They get the impression that we try to cherry pick patients to keep success rates high and make the CDC stats look good.  My impression from talking to my colleagues across the country and certainly from our own practice is that we do not try to discourage patients with poor possibilities from making a consult appointment and discussing treatment options. We all have such patients. In fact, we have so many of them at PFC, I don’t think we would have many patients at all if we tried to pre-select our best prognosis patients for IVF. When it comes to treatment, although there are challenges and sometimes the rewards are few, we don’t just throw up our hands and give up. We try to come up with a strategy to achieve the goal, looking at the emotional reserves and financial resources we have to work with, and start by making a plan.

Sometimes that plan will be to try a couple of cycles of low-tech approach, like just intrauterine insemination or Clomid + insemination, or a mid-level approach, like injections of FSH along with  insemination. We would see how things go and play it by ear from there. Sometimes, the plan will be to blast ahead to the big guns, full steam ahead to IVF. Sometimes, it’s counseling with our marriage and family therapist to begin the discussion: are we ready to move on to donor eggs? Sometimes it’s a sequence of all of the above. There really is no one plan for any one person. It’s just too complex to say one size fits all.

A certain percentage, even of the-less-likely-to-succeed patients will get pregnant with their own eggs and go on to deliver a healthy baby. The remainder may be faced with a tough decision. Do we just stop here and live child-free?  There are certain perks to that plan (sleeping in on the weekends, eating in nicer restaurants, adult vacations to name just a couple) but most people want to have a family no matter what or how. So then there is the adoption vs. egg donation question. There is no right or wrong choice here, either: just choices.

Progress has been steady at the Center this week. From last Sunday up until this coming Saturday we will do 13 egg retrievals, 14 fresh embryo transfers, 6 frozen embryo transfers and one hysteroscopy. It looks to be a fairly typical week.

Last Saturday I attended an investigators’ meeting, along with our lab director, Dr. Joe Conaghan, for a new clinical research study that we may be undertaking with Gene Security Network (GSN). GSN is one of the pre-implantation genetic diagnosis/screening (PGD/PGS) laboratories with which we work. I really can’t discuss the details of the study at this time, as we have signed a standard non-disclosure agreement with GSN, but this will be a big study to investigate how useful PGS will be to the average IVF patient.

This leads me to the topic of today’s blog: clinical research. Although PFC is not an academic institution, we are still interested in research because this is how the field of reproductive medicine advances. In fact, since there are so many private IVF clinics, much of the research on IVF is currently being done in the private sector. We would not have the field of assisted reproduction today if it were not for clinical research and for the thousands of patients who have participated in this research to this point. I’d like our readers to know that participation in research is not taken lightly by anyone conducting the studies. As investigators, we all have to be trained in the ethical conduct of research, to make sure the risks of participation are minimized and that there is potential benefit to patients from participation. Our number one goal is still to get our patients a healthy pregnancy. We will not compromise that goal for the sake of a clinical study. The study protocols are carefully reviewed by an independent Institutional Review Board (IRB), tasked with ensuring there is no harm or undue coercion to participants. In most good studies, the design of the study includes a “control arm” and the patients who are randomized into this arm receive current standard treatment. The patients randomized to the “treatment arm” receive the treatment under investigation. It is very important that the patients in the treatment arm should be expected to be at least as successful, if not more so, than the patients in the control arm.

This year, PFC is participating in at least 4 clinical studies. Some, like our acupuncture study, are designed by PFC and are only being done at our facility. Some, like the GSN study, are being designed by the company and will be done at multiple IVF centers, then GSN will pool the data.  If you are interested, please let us know. I will be posting more details very soon to our PFC website.

UPDATE: Research web page is live

It’s looking to be another typically busy week at the Center. Although the overall patient volume at PFC in 2009 was down about 10% from 2008, 2008 was a record year, so 2009 was more typical of the volume in the last 10 years. So far in 2010, we are up over this time in 2009. Many clinics in California and around the country are seeing decreased demand for IVF services, likely due to the poor economy. I heard on the radio the other day that the number of vasectomy procedures was up sharply in 2009 as well. A sign of the tough economic times, I suppose.

In 2007, the last year for which U.S. IVF clinics have official results tabulated from mandatory reporting to the CDC, the total number of  fresh IVF cycles performed in 430 reporting clinics was 142,435 resulting in 43,412 live births and 57,569 infants*. It is estimated that in western countries, about 1% of babies born are now from assisted reproductive technologies. Overall, about 36% of embryo transfers resulted in a live birth. This number continues to climb nationwide, at the same time the number of triplets and more is dropping (now at only 1.8% of live births, which is excellent). The twin percentage is still too high at 30% but we hope to also see this number declining in the coming years as overall success rates improve and we continue to emphasize to our patients the  much better outcomes of singleton pregnancy as compared to twin pregnancy.

Delayed childbearing still continues to be the biggest issue for human reproduction and fertility in the post-industrial world. This is especially true in the San Francisco Bay Area. The median age for women doing IVF in the U.S. was less than 35 but at PFC it is age 39. This may partly to do with the fact that in California, insurance coverage for fertility treatment is not mandatory, like it is in some states like Massachusetts and Illinois. Therefore, couples wait longer before availing themselves of the most effective treatment for infertility. This is also why the proportion of women undergoing IVF nationwide diagnosed with decreased ovarian reserve (i.e. diminished egg quality, a diagnosis that tracks with female age) is 10.3% but this diagnosis represents 31% of the patients at PFC.

*2007 Assisted Reproductive Technology Success Rates National Summary and Fertility Clinic Reports U.S. Dept. of Health and Human Services Centers for Disease Control and Prevention www.cdc.gov/ART/

It’s been another busy week at Pacific Fertility Center. Since Monday, we have done 13 egg retrievals, 11 embryo transfer procedures and one hysteroscopy. One thing is certain – our lab is very hard working. I’m really proud of our embryologists. We have 8 embryologists, including 2 PhDs. They are very enthusiastic and never complain about the work load. They put in the hours and virtually never make mistakes. They really are professionals.

Many people wonder why IVF is so expensive. One reason is that, unlike other medical procedures, it’s often not covered by insurance, so patients have to pay out of pocket and that can hurt. If you were undergoing, say, a kidney transplant procedure, with the attendant technological and complicated procedures involved, no one really questions the costs, mainly because medical insurance covers so much of it. Until infertility is seen as a medical condition for which treatment should be universally covered, we are unlikely to see a change in the perception of the high expense. Although IVF does cost about $15-20K for one cycle, with all possible expenses included, the increase in costs over the last 20 years have not risen to anywhere near the extent that other medical services have risen in this time period. This is because we all try to do what we can to be as efficient as possible, mindful of what it costs patients out of their own bank accounts.

Last night, the MDs and PFC managers met for our monthly meeting (usually a 3-4 hour marathon meeting!). We have managers for the following departments: nursing, billing, IT, medical records, the Egg Donor Agency, HR, clinical research and our Laboratory Director. One of the topics under consideration is how we are going to wire the Center to accommodate a large diesel generator we just purchased. We never really use the generator, it’s only there for emergency power losses. Yet we must have a functioning generator to keep the Center running in case of minor power losses, or heaven forbid, the big quake that damages significant infrastructure. We decided last night to go with the “Cadillac” plan for re-wiring, allowing us to run the entire Center for several days off the generator and allowing for flexible allocation of the electricity to some or all areas. The difference in cost was $25K for basic wiring and $39K for the most extensive and flexible arrangement. Along with rent, salaries for 70+ employees, including some very highly educated staff, these are some of the “hidden” expenses that are essential to running a world-class IVF center.

UPDATE: This study is currently on hold while we attend to some administrative details. Please check back to this blog often, as we will keep our readers updated.  You may also call the New Patient Coordinators at 415 834-3095 for more information.

PREVIOUSLY: Pacific Fertility Center is pleased to announce that as of October 1st we are enrolling patients into a groundbreaking research study to determine the value of combining acupuncture with IVF. Traditional

Chinese medicine has been practiced in throughout Asia for thousands of years:in the last decade, the west has been following suit.

There have been sufficient peer reviewed studies to warrant a clinical trial in which there are predictable parameters of patient involvement. One of the first studies involving acupuncture and IVF was published by Paulus et al in the journal Fertility Sterility in 2002. The Paulus study reported the influence of acupuncture on the pregnancy rate in patients who undergo assisted reproductive therapy. Clinical pregnancies were documented at 42.5% of patients in the acupuncture/IVF group, whereas pregnancy rates were 26.3% in the control group, using IVF alone. In this study, the acupuncture was performed before and after embryo transfer only.

How does acupuncture affect fertility? A review article in Alternative Therapies (Anderson 2007) suggested four possible mechanisms by which acupuncture could improve the outcome of IVF: modulatingneuroendocrine factors; increasing blood flow to the uterus and ovaries; modulating cytokines; and reducing stress, anxiety, and depression.