The article in January’s issue of Fertility Flash, Conception at 40 and Beyond – Does IVF Help? contained some errors in the table. The following is a reprint of the article with corrections.

We all know that fertility declines with female age but what is not certain is how much does in vitro fertilization improve one’s chances of conception if a woman/couple is having problems conceiving on their own?

The table below is one I often use when counseling patients 40 and over about their chances of conception with in vitro fertilization.

This table represents pregnancy outcomes with PFC patients from January 2003 to March 2008, so most of the viable pregnancies tabulated here have been delivered.

One thing to note is that over half of the patients that get a positive beta-hCG result do not end up delivering a baby. This is consistent with the observation that most embryos from women 40 and over have abnormal numbers of chromosomes.

Another thing to note is that pregnancies after age 43 are exceedingly rare, even with IVF. We encourage most women over age 43 to strongly consider ovum donation.

World-wide, over half the babies born from assisted reproduction to women over age 40 are born from ovum donation, not from their own eggs.

We all know that fertility declines with female age, but what is not certain is how much in vitro fertilization (IVF) improves one’s chances of conception if a couple/woman is having problems conceiving on her own.

The table below is one I often use when counseling patients 40 and over about their chances of conception with in vitro fertilization.

This table represents pregnancy outcomes with PFC patients from January 2003 to March 2008, so most of the viable pregnancies tabulated here have been delivered.

One thing to note is that over half of the patients that get a positive beta-hCG result do not end up delivering a baby. This is consistent with the observation that most embryos from women 40 and over have abnormal numbers of chromosomes.

Another thing to be aware of is that pregnancies after age 43 are exceedingly rare, even with IVF. We encourage most women over age 43 to strongly consider ovum donation.
World-wide, over half the babies born from assisted reproduction to women over age 40 are born from ovum donation, not from their own eggs.

An Example X-Ray of a normal HSG	An example X-Ray of an abnormal HSG

Infertility due to blocked fallopian tubes was a common cause of infertility in the 1970’s and 1980’s. Some textbooks from that era quote an incidence as high as 25% of all infertility causes. At Pacific Fertility Center in 2005, only 10% of our in vitro fertilization patients were noted to have a tubal factor contributing to their infertility. Fallopian tube damage is most commonly due to prior infection with a sexually transmitted disease such as gonorrhea or Chlamydia. Most chlamydial pelvic infections are relatively asymptomatic and may go unrecognized; therefore many patients with tubal obstruction are unaware they have a tubal problem. Better safe-sex practices and improved screening of young women are possible factors for the lower incidence of tubal disease we are seeing, at least in our Bay Area infertility population.

Even though there is less tubal factor infertility these days, if there is a tubal obstruction, the course of fertility treatment becomes quite definitive: in vitro fertilization. No other treatments, including surgery, are likely to result in a healthy intra-uterine pregnancy. Therefore, we are still advocating some type of screening test for tubal factor in the evaluation of infertile couples.

There are two common ways to determine whether there is tubal obstruction. One is surgery, where dye is passed through the cervix, uterus and tubes, and there is direct visualization of the flow of the dye out the ends of the tubes into the pelvis. The other is the HSG, or hysterosalpingogram. The HSG is an X-ray procedure that involves placing into the cervix a small flexible catheter with a balloon around the tip to hold the catheter in place and close off the cervical opening. Radiographic contrast dye is then instilled into the uterine cavity, using a syringe attached to the tube. Under X-ray visualization, the dye is tracked into the uterine cavity and into the tubes. Pictures are taken during this process to document the shape of the uterine cavity and whether or not the dye enters and flows through both tubes into the pelvis.

HSG procedures are usually performed by radiologists; however, if there is difficulty placing the catheter securely into the cervix, the radiologist may ask the patient’s gynecologist to assist. This test is valuable in determining tubal blockages, but it has some disadvantages. It is very important to get the balloon properly inflated in the cervix to keep enough pressure on the fluid (no back flow into the vagina) so it will enter the fallopian tubes. Unfortunately, this pressure on the walls of the uterus can cause the uterus to contract, causing the patient to experience significant cramping. For this reason, it is recommended the patient take 2 or 3 ibuprofen prior to the procedure.

In some cases, the pressure is enough to cause the smooth muscle walls of the fallopian tubes themselves to spasm, blocking any dye from entering the tube. Sometimes the dye flows so easily through one tube that there is not enough pressure generated to get the dye to fill the other tube. These are some of the drawbacks of the procedure. This is why, even when we get a report of one-sided tubal obstruction, we are often skeptical that this is really due to some abnormality of the tube.

Although there are some false positives associated with this test, if the dye fills both tubes and does not flow out the ends of the tubes, this is highly suggestive of true tubal obstruction. In this instance, IVF is indicated.

1. A healthy woman in her late 30’s or even in her 40’s, will have the fertility of a younger woman.
   Although it is always better to be healthy, especially when it comes to carrying a pregnancy, the likelihood of conception is tied to the age of a woman’s eggs and is not closely related to her general health.
2. You should have sex every other day during the fertile window.
   For most men, sperm recovery is very rapid. Sometimes when an IVF cycle is done and there are many eggs to fertilize, we ask for a second semen sample. We are often amazed when the second sample, collected just 2 hours after the first sample, has even better numbers. So, rather than attempting to “save up good sperm” by having less frequent intercourse during the most fertile time period, we recommend more frequent intercourse. A home ovulation predictor kit is useful to time sex to ovulation. When using the ovulation predictor kit, we recommend sex on the first day of the LH surge and the next day too.
3. Fertility medications are associated with a higher risk of cancer.
   In the early 1990’s, some concerns were raised that taking fertility medications might be associated with a higher lifetime risk of ovarian cancer. Since then, several studies have been published that did not find this to be true. Because of this thorough and extensive research we feel comfortable using these medications not only on patients, but our egg donors as well.
4. Fertility medications (especially injectable fertility medications) cause women to be emotional wrecks.
   Although Clomid (clomiphene citrate) has well-known side effects related to its anti-estrogen effects, the injectable fertility medications do not tend to cause the same negative mood alterations. These drugs increase estrogen levels, a hormone which tends to have positive affects on mood.
5. Using fertility drugs and getting multiple eggs might use up my future eggs and cause me to go into menopause earlier than expected.
   Humans usually only ovulate one mature egg each month. This egg is contained in the dominant follicle and grows in one ovary or the other. For each dominant follicle that develops in any particular cycle, there are several other follicles/potential eggs available that are also trying to become that dominant follicle. The number of these other “antral” follicles varies from woman to woman and to lesser degree, from cycle to cycle. In general, the number of antral follicles declines with female age. Once the dominant follicle has been selected and the egg ovulated, the menstrual period or a pregnancy begin, and the other antral follicles, undergo programmed cell death, called atresia. The use of fertility medications rescues this group of antral follicles from atresia. For this reason creating multiple mature follicles and obtaining multiple eggs in any one cycle does not use up future eggs. We are simply rescuing eggs that would have otherwise died that month.
6. Having a miscarriage is a good sign that a woman is fertile.
   Approximately 70% of miscarriages are due to abnormal chromosomes (DNA) in the embryo. As a woman ages, more and more of her eggs become abnormal In fact, at age 40, only 1 in 10 eggs on average has normal chromosomes; so a woman at that age may only ovulate one normal egg per year. While a miscarriage may indicate that fertilization and implantation can occur, it doesn’t necessarily mean that overall egg quality is good. Egg quality is the best indicator of the ability to produce a viable pregnancy.
7. Stress is a major cause of infertility.
   There is enough circumstantial evidence to indict stress as a collaborator when it comes to fertility; however, there is very little evidence to convict stress as a major perpetrator. Usually there is some other underlying cause to the problem, even if it is just age-related sub-fertility (decline in fertility due to female age and therefore higher numbers of abnormal eggs). Stress, however, can compound the problem and possibly negatively impact egg quality and uterine lining quality. Look for a new addition to our website, the Domar Fertility Stress Questionnaire, to assess your stress levels.
8. In Vitro Fertilization can help women in their late 40’s and even 50’s to conceive with their own eggs.
   Despite the number of celebrities having babies in their mid-forties and beyond, these babies may not necessarily have been the result of an in vitro fertilization process using their own eggs. While we respect a woman’s right to privacy and their decision not to divulge this little detail, the perception left with the public is that fertility treatments can extend one’s reproductive life. Unfortunately, this simply is not true. There is a very, very low probability of improving one’s success of conceiving after age 43 by using assisted reproduction, unless the woman considers using donor eggs.
9. In Vitro Fertilization success rates are low.
   Across the United States, including patients of all ages, the delivered success rates for in vitro fertilization have risen from about 20% in the mid-1990s to about 35% in the mid-2000s. During this same period, fewer embryos were being transferred to the uterus per cycle and the triplet and higher-multiple pregnancy rates dropped dramatically. Though it may take more than one attempt to conceive, the majority of patients are successful.
10. Very few people ever experience infertility.
    Many fertility patients feel they are the only ones in their circle of friends and acquaintances suffering from infertility. At times, it seems as though everyone else is having a baby. Actually, one in six couples is having trouble with conception, they just may not talk about it. Since they are not pushing a stroller, there is no outward visible sign of their fertility status. When couples decide to share the story of their fertility quest, they often find there are many of their peers experiencing similar difficulties. They discover friends who can not only relate but also provide valuable support.

For those of us with an interest in human reproduction, scarcely a day goes by without us hearing or seeing something related to oocyte freezing. The topic has generated a lot of hype and it is difficult to avoid the frequent magazine and newspaper articles, advertisements and TV features that generate excitement on the subject.

We have already discussed oocyte freezing in a previous newsletter article (Keeping Egg Freezing in Perspective; January 2005) and readers unfamiliar with the technology are encouraged to visit our website where they can read this in the newsletter archive. Having already discussed the methods for freezing, and their merits, we now address the achievements of oocyte cryopreservation on this, the 20-year anniversary of the first success.

There are two technologies used in oocyte freezing, and the primary aim of each is avoiding ice formation within the cell. The first is the slow freeze method (used so successfully with embryos) that dehydrates and cools the cells gradually, over three hours. The second is an ultra-rapid procedure that is performed so quickly that the cell contents turn to a glass-like substance. This latter method is called vitrification and it is gaining in popularity for oocyte and embryo freezing. And since no ice forms, the cells are technically not frozen, but “vitrified.”

In reviewing the scientific literature since the first success in 1986, the importance of oocyte freezing is apparent by the sheer volume of publications on the subject. For the purpose of this article, the many papers that report on the technique only have been excluded, and here we will only report on the pregnancy outcome data. However, even this is difficult since some patients may have become pregnant from the first few thawed oocytes, leaving us with no data on the many oocytes still frozen on their behalf. Also, even though there are reports that detail only one or two pregnancies, there are probably many other isolated successes around the world that have gone unreported in the scientific literature.

Most of the pregnancy outcome data has been pulled together in a single review paper by Dr. K. Oktay and colleagues at Weill Medical College in New York (Fertility & Sterility, 2006, Vol 86 (1), pages 70-80). The 47 papers reporting outcome data for slow freezing were analyzed and from these, only 26 provided sound usable data. The others were excluded either because sub-optimal procedures were used, the pregnancies had not yet delivered or the authors could not be reached to clarify the data. The 26 useful papers collectively documented the freezing of 4,564 oocytes from which 4,000 had been thawed in 397 patient cycles. Out of 95 pregnancies, 76 resulted in live births, and since some of these were multiple pregnancies, the total number of children born was 97. If we add in the excluded data, the number of pregnancies becomes 170, resulting in 106 live births and 11 ongoing pregnancies. Because of ambiguities in the excluded data, a final number of children is not stated. However, the data suggest that the number of children that are alive today as a result of 20 years of slow freezing of oocytes is approximately 200. Taking all the data into account, the clinical pregnancy rate per thawed oocyte was a mere 2.3%. The live birth rate in the 26 usable papers was 1.9% per oocyte thawed.

Unfortunately it is not possible to give rates per oocyte frozen since some papers are not complete, but more importantly because many oocytes are still in the freezer.

Vitrification, which is a technology that came late to oocyte preservation, is quickly gaining ground on the slow freezing method. By June of 2005 there were only 10 reported births following oocyte vitrification, but a year later the numbers reported by Oktay are 61 pregnancies from which 42 have delivered live infants and 7 are ongoing. With limited data, vitrification appears to be a more highly efficient preservation method than slow freezing. The latest numbers, based on admittedly limited data, shows that >90% of oocytes survive and about 90% of these fertilize. Overall, 50% of vitrified oocytes make blastocysts in culture which is as efficient as fresh oocytes. These numbers are reported by Masa Kuwayama at the Kato Ladies Clinic in Tokyo. Also, from 29 embryo transfers, 12 pregnancies have yielded 7 live infants with 3 not yet delivered at publication time (Kuwayama et al., 2005, Reprod Biomed Online, Vol 11 (3) pages 300-308). We can compare this data to the latest results with slow freezing where the experience of 20 years has been incorporated. Using sodium-depleted medium, in which oocytes are slow cooled and frozen, 59% of oocytes survived and 68% of these fertilized. Nine pregnancies were established in 28 thaw cycles from which 5 delivered and 1 was ongoing (Boldt et al., 2006, Reprod Biomed Online, Vol 13 (1) pages 96-100). For those women who want to rely on oocyte cryopreservation to postpone motherhood, these data should be sobering. While we don’t expect the technology to ever be 100% successful, it currently offers no guarantees.

Expecting too much from today’s procedures could leave many women very disappointed. Further, many of the pregnancies reported in these studies were achieved by preserving the oocytes from young women. Since oocyte quality declines as a woman ages, the success rates for older women are likely to be less than reported here. Women considering oocyte preservation will need careful counseling and a good understanding of the success rates before putting their eggs in this basket.

– Joe Conaghan, PhD

The laboratory team here at Pacific Fertility Center tested the over the counter Male Fertility Test from Baby Start. The test, also marketed by Embryotech as “FertilMARQ”, comes with everything needed to test two separate semen samples. We found the instructions easy to follow and we used semen samples from several men to run our tests on the kits.

The kit is FDA approved and readily available from major drugstores and through the Internet. It claims to tell you if you have a normal sperm count, which according to the World Health Organization (WHO) is having > 20 million sperm per milliliter of semen. The test does not measure any other parameters of the semen sample such as sperm motility (how many are swimming) or sperm morphology (size and shape).

We ran the test multiple times using kits that the manufacturer had supplied and asked us to test. We used a variety of semen samples with different sperm counts.

The kit contains a small test strip with 4 “wells” labeled A through D, and it looks similar to a home pregnancy or ovulation predictor test. Two of the wells (A and C) are controls and are a blue green color. The other 2 wells (B and D) are used for testing the semen samples and these change color depending on how many sperm are in the test sample. If the color is as dark as or darker than the control well, you have sperm. If the color is lighter than the control well, you have little or no sperm.

To perform a test, a fresh semen sample is collected either into the supplied cup or condom. If collected with the condom, this is simply emptied into the cup, which contains some small flakes of a dried enzyme. The enzyme helps to liquefy the sample over a period of at least 15 minutes and then the semen is ready to be tested. One drop of semen is added to a test well, followed by 2 drops of “blue solution” 1 minute later. After another minute, 2 drops of “clear solution” are added to the test well. The color of the test well is then compared to the control to determine if normal sperm numbers are present in the sample.

The kit comes with everything that is needed to perform the tests. All you will need to supply is a clock or timer. The instructions are clear and simple with helpful diagrams for guidance. The rules for when you should test are acceptable: no more than 3 days since your last ejaculation before you run the first test, and 3-7 days abstinence before running the second test. The instructions also contain common questions, with answers that might arise when you are doing the test. We also found a good and helpful frequently asked question page at http://www.webwomb.com/fertilmarq_faq.htm.

In our trials, the test easily distinguished between samples with normal sperm counts and those with little or no sperm. Clear positive results were obtained with sperm counts of 99, 73.5 and 32.6 million sperm/ml. Clear negatives were obtained with samples that we counted as 0, 3 and 4.4 million sperm/ml.

Only when we analyzed samples close to the test threshold did we find any discrepancies (a sample counted at 18 million sperm/ml came up positive).

The kit is no substitute for testing in a clinical laboratory. The main shortcomings are that the test only looks at sperm number and not other parameters in the semen sample that are equally important for fertility diagnosis and treatment. If you have sperm, but they are not swimming, you would pass this test. Also, individuals with sperm counts that are slightly below normal can pass the test perhaps giving certain men a false sense of security. For these reasons, your fertility physician may order a more detailed sperm analysis.

In general, the test is easy to perform, readily available and inexpensive. The test kits that we received were part of a batch being shipped overseas, perhaps to a location where good clinical testing is not as accessible as it is in the US. And men that are too shy or embarrassed to go to their doctor for a semen analysis now have a better alternative.

Two of the wells (A and C) are controls and are a light blue green color. The other 2 wells (B and D) are used for testing the semen. Wells B and D change color depending on how many sperm are in the test sample. If the color is as dark as or darker than the control well, you have sperm.

– Joe Conaghan, PhD

The public’s appetite for promising pills that purportedly slow down the aging process is stronger than ever. Sensationalized claims revolving around Dehydroepiandrosterone (DHEA), a natural steroid hormone produced from cholesterol by the adrenal glands, has followed this trend.

DHEA is a hormone secreted by the adrenal gland whose level in the body peak at early adulthood and then decline with age. As the most abundant steroid in the body, DHEA is chemically similar to testosterone and estrogen.

Because low DHEA levels brought on by aging also correlate with age-related diseases, DHEA supplements are openly marketed to prevent the effects of aging. Because a woman’s fertility declines with her age, it is no surprise that DHEA has been associated as a “promising” drug to offset age-related infertility. Yet there have been no scientific studies or evidence revealing that adjusting DHEA levels changes the development of age-related diseases. Nor has there been evidence that DHEA slows down the decline in fertility. Simply stated, there is no evidence that increasing DHEA slows down, stops, or reverses the aging process.

Some past rodent studies indicated DHEA was effective in controlling obesity, and prevented cancer, arteriosclerosis and diabetes. As a result, DHEA was quickly promoted as a miracle weight-loss drug. Yet no human studies have duplicated these results.

Nevertheless, DHEA has received considerable acclaim, with some authors touting it as a “superhormone” or “the youth and health hormone.” Articles on DHEA abound. In fact, DHEA received over 850 citations in a Medline search and 52 publications come up on an Amazon.com search.

A search of serious scientific research examining DHEA’s impact on fertility is scanty. There are less than a handful of scientific presentations or papers on the topic. Just last year a study (Fertil Steril. 2005; 84(3):756) conducted at the Albert Einstein College of Medicine announced: Increased oocyte production after treatment with dehydroepiandrosterone. This paper focused only on one 42 year old woman, whose number of oocytes retrieved increased after undergoing eight IVF cycles over the course of a year with DHEA supplementation. Not only did she take a DHEA dietary supplement, she also underwent acupuncture. Since she froze her embryos, it is not reported whether any of her eggs led to a successful pregnancy.

To date, no sound or controlled scientific studies have been designed to examine whether DHEA is able to reverse the results of aging on ovarian reserves.

A research paper was presented at the 2005 ASRM conference (O-101 by D. H. Barad and N. Gleicher). This retrospective cohort study examined 45 women previously diagnosed with decreased ovarian reserve who were treated with 25 mg DHEA for 4-48 weeks before undergoing ovulation induction for IVF. The study concludes that DHEA increased oocyte production and quality. Yet no pregnancy or live birth outcomes were reported. Both Drs. Barad and Gleicher are already offering “DHEA Therapy” in their practice.

Very little of the encouragement to self-administer DHEA is coming from the physician community, especially those who are initiating viable scientific research. Elizabeth Barrett-Connor, MD, professor and chair, department of family and preventive medicine at University of California, San Diego calls DHEA “a modern day snake oil”. Her initial research revealed that higher natural levels of DHEA in older men may help protect them against heart disease yet she recognizes the need for more studies.

Self-medicating by using DHEA supplements is a form of testosterone therapy. It is not likely to affect each individual in the same way due to variable existing androgen levels in the body and a lack of consensus on what are normal or benchmark levels. Increasing DHEA (and thus testosterone) may well lead to additional facial hair and possibly acne for women. Until more is known, taking DHEA is a risky gamble based on insubstantial evidence.

The hype about DHEA as a way to improve fertility will only continue as the public seeks information that they want to hear. An entire chapter is devoted to DHEA in an online book called “Mothers over 40”. If there were such an easy panacea to reverse the impacts of aging on infertility, the benefits would have been known much sooner.

– Eldon Schriock, MD

Is the Future of Egg Freezing Here?
On the surface, it sounds remarkable that one can now shop for frozen oocytes through a start-up company called Cryo Eggs International, which offers single frozen oocytes for sale for $2,500 apiece via mail order. Based in Arizona, the company offers no guarantees whatsoever. The company claims that couples can save money and reduce their risk by choosing individual frozen eggs over the more involved and expensive process of working with a donor to produce fresh oocytes for fertilization.

Oocyte cryopreservation technologies have been evolving since 1986, and there is little doubt that there is a strong future in egg freezing. Young women are expected to have the choice of “banking” a cache of their genetic material for later use. Infertile women may indeed turn to a frozen egg bank, much the way that frozen sperm is marketed, to choose available eggs.

But is that time now?
A handful of infertility clinics are offering female patients a chance to undergo an IVF cycle and freeze their eggs for future use. Eventually PFC expects to offer this. Yet the majority of these clinics insist on prominently displaying the disclaimer that egg freezing technologies are still evolving and are highly “experimental”.

Indeed, as of early 2005, less than 1% of eggs that had been frozen and thawed had resulted in live born infants. (Keeping Egg Freezing in Perspective). Most certainly, egg-freezing technologies advancing cryopreservation of oocytes are evolving rapidly. (A Few Good Eggs). Yet the research community is still weighing the advances of different freezing mediums and methodologies, such as rapid vs slow freezing and thawing.

Responsible researchers/authors publishing their work in the global body of scientific literature are calling for several more years of studies with larger numbers of participants. Most of the current research is based on very small groups.

Cryo Eggs International attributes its success to the advances of Dr. Jeff Boldt, an associate professor of medical and molecular genetics and scientific director of Assisted Fertility Services at the Community Health Network, Indianapolis. He is also reportedly the scientific director at Cryo Eggs International. Yet Boldt’s primary published work in a scientific journal reported the results of a study that only involved 11 women. He is quoted in the media as having a larger number (33) of cycles from which results were comparable to standard IVF procedures, yet this study has not yet been published in a peer-reviewed science journal.

Can one tell if an egg is good or bad upon thawing?
Unlike sperm, of which mainly healthy ones are frozen, there is no sure way to determine quality control of a donor’s eggs short of conducting a DNA analysis of the resulting embryo. In this regard, Cryo’s customers are essentially asked to purchase single oocytes not knowing if they are viable.

Associated Costs with Frozen Eggs
After oocytes have been frozen they may have a thicker outer wall, otherwise known as the zona pellucida. This generally requires the embryologist to apply additional costly methodologies such as assisted hatching and ICSI.

Healthy Quarantine
The six months of freezing that is required before the frozen eggs can be released is no different than the six month testing requirement that a typical donor must go through to test for infectious diseases. In this regard, it is misleading for the Cryo Eggs International web site to claim that this process is any safer than conventional donor cycles.

Successful Approach
A donor cycle at Pacific Fertility Center has yielded a consistent 65% or greater success rate for many years. A key point here is this record has improved incrementally over the years after decades of experience and applying evolving technologies.

It is every physician’s wish for his/her infertile clients’ to have inexpensive choices to tackle their life dream of conceiving. It is also important for people to be as well informed as possible so their money may be spent for the most cost-effective and successful method for their particular situation.

– Carolyn Givens, MD

The U.S. marketplace is punctuated with products and services trying to lure desperate parents into believing that somehow, someway, it must be possible to predict and even select the outcome of the baby’s gender through various hocus pocus methods. Perhaps not coincidentally, many products and services, such as www.fortunebaby.com, appear to be subsidiaries of companies based in China and India where male babies are prized over baby girls.

In the line-up of such products, Baby Gender Mentor blood test hit the marketplace with great Public Relations fanfare including a brief interview on the Today Show and a headline in the Boston Globe. Sadly, both of these popular press outlets focused squarely on the debate about gender selection ethics and never seriously questioned the accuracy of such a test. As a result, millions of viewers and readers may have assumed the expensive test results were accurate. Acu-Gen charges $275 to mail order the test.

This was in June. Now, three months later, enough women who were lured into buying the test and assured by the company’s guarantee that it will reimburse misdiagnoses with 200% of their money back, are asserting the test doesn’t work. Many women are trying to get refunds and are being told by Acu-Gen that a “vanishing twin” may have caused the test to fail.

National Public Radio, taking a more critical stand, recently broadcasted a story pointing out that Acu-Gen offers little proof of its claims and admits that it is not required to undergo FDA testing to verify accuracy. On its web site, the company describes how the process purportedly works.

Gender-specific DNA from the fetus floats around in the mother’s blood stream after having crossed over the placental walls. The presence of the Y chromosome in the female blood via a finger-prick blood tests indicates a “male-positive” baby.

A visit to Acu-Gen’s Gender Mentor test web site reveals some other questionable assertions. Men are not allowed to be anywhere near the pregnant woman as she is having her blood drawn for the test. Acu-Gen also lists on its web site the names and publications of noted experts on fetal DNA testing, some whom NPR interviewed and deny any involvement with the company.

The notion that just five weeks into a pregnancy a simple blood test can accomplish what amniocentesis or ultrasound can do much later in a pregnancy is at this point wishful thinking. A dedicated web site: www.in-gender.com takes a more comprehensive and critical look at the claims of many sex-prediction and selection techniques and includes descriptions of the high-tech methods that do work.

– Eldon Schriock, MD

Some patients might have noticed claims that an Inhibin B blood test can better help determine her egg quality. We at Pacific Fertility Center have examined this topic carefully and have chosen not to incorporate this test as a routine procedure.

Currently we use a number of parameters to determine egg quality, or ovarian reserve. For most patients this includes review of:

1. The female partner’s age,
2. Results of cycle day 3 FSH and
3. Estradiol (estrogen) testing or
4. A complete clomid challenge test (CCCT), and
5. Ultrasound to determine basal antral follicle count (AFC).

With these parameters we can help determine chances of success with each treatment modality.

We are constantly looking for ways to better determine ovarian reserve. One proposed adjunct is a blood test for Inhibin B. Inhibin B is a protein secreted by the resting antral follicles in the ovary, and is responsible for inhibiting the secretion of FSH in the early part (follicular phase) of the menstrual cycle. There is also a second inhibin called Inhibin A. This inhibin is secreted by the selected and growing follicle in the second (luteal phase) part of the menstrual cycle.

Inhibin B is secreted by the group of small, resting follicles in the ovary and indicates a woman’s ovarian reserve. The higher the Inhibin B level, the more ovarian follicles are present in the ovary, the greater the chance of growing a number of follicles with stimulation medications, the greater the chance of achieving a pregnancy. Most studies indicate that an Inhibin B level = 45 pg/ml would indicate adequate ovarian reserve. Inhibin B levels decrease as women age and total follicle numbers decline. Women with very low Inhibin B levels (<20 pg/ml) have such poor ovarian reserve that they have a very high chance of cancellation in an IVF cycle.

Inhibin B is a direct measurement of the hormonal dynamics of the ovarian follicles. FSH testing is an indirect measure of ovarian reserve, but the FSH test is readily available at most reference laboratories. Inhibin B testing is more laborious, and few labs offer this test. Additionally, numerous studies have shown that doing an Inhibin B test alone does not provide more accurate information nor better predict one’s ovarian reserve, compared to an FSH test alone. Therefore, these 2 limitations have not allowed for the incorporation of routine Inhibin B testing in a fertility evaluation.

– Isabelle Ryan, MD