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/

Imagine a website that allows you to search for the very latest information on fertility. Well, it’s here and it’s called fertilitywire.com.

PFC is proud to present fertilitywire.com as a completely unique website that offers real-time and fresh information on fertility and infertility related topics. It’s a resource for people engaged in the process of becoming pregnant through fertility treatments or people studying this field who want to explore it.

And, it’s a unique resource in that it’s powered by a type of search called “browsing or universal search,” which is how we’re able to pull together all of the content for any given search term you see. You are able to see, in one place, the latest fertility related news, blogs, tweets, videos, images, articles and books.

We are excited by the positive feedback we have been receiving about fertilitywire.com. Here is one testimonial that sums up the experience very well:

“This website has a friendly approachable tone. It also covers so much, by the time I was done navigating, fertility issues seemed not intimidating but manageable and that there is a world that one could enter, (your center) and not be a stranger. At the same time, it seems like there is hope; if not here and now–it is being developed right around the corner.”

— Michael Lynn, PFC Patient

Visit fertilitywire.com. We hope you find everything you are searching for!

In the press today we see that the “world’s oldest new mom dies” at age 69 (see our earlier blog post clarifying that PFC did not treat this patient), three years after giving birth to twins conceived through IVF. Maria del Carmen Bousada apparently lied about her age to the Los Angeles Physician who helped her become pregnant, creating a firestorm of criticism in the press.

The case demonstrates one of the most basic dilemmas that we face in helping women become pregnant: at what age is a woman too old to become a mother?

Most of us might agree that a 25 year old woman is young enough to receive help, but that a 70 year old is too old. However, drawing the cut-off line at some point between these extremes is not easy. With the help of in vitro fertilization and donated oocytes, women like Maria can become pregnant at an age where nature would naturally prevent the possibility of conceiving. Typically, women run out of oocytes in their early 50’s and without oocytes and the granulosa cells that surround them, they lose their ability to make estrogen. This natural process, called menopause, can happen earlier or later for a given individual, but the ability to get pregnant and deliver a healthy baby declines rapidly for women in their late 30’s and on into their 40’s. The age of the woman is a determining factor of her since a 40 year old woman is trying to get pregnant with a 40 year old oocyte, and these older oocytes don’t perform well. For example, the older oocyte is not good at keeping track of its own DNA, as evidenced by the increasing incidence of genetic defects such as Down syndrome in older mothers. And as if this wasn’t bad enough, the rate at which oocytes are lost from the ovaries (also know as a woman’s biological clock) doubles at about age 38. If this doubling didn’t happen, we think that women wouldn’t reach menopause until their early 70’s. It is thought that the speeding up of the biological clock in the late 30’s is nature’s way of clearing out the remaining oocytes, so that women lose their ability to become pregnant but are then around to raise the children that they already have.

Based on nature’s model, we might consider limiting IVF treatment to women that are in their early forties or younger. But with donated oocytes, this limit can be pushed and there are no legal age limits for pregnancy. So, who gets to decide when it’s too late to become pregnant? As far as following “nature’s model”, is age different than other factors that lead to infertility? Do we make rules? And do the rules apply to men too, where nature doesn’t have limits?

Note: Pacific Fertility Center does have both lower and upper age limits in place.

News broke earlier today about the death of a 69 year old mother who had undergone fertility treatment at age 66. She gave birth to twins in December 2006.

This is a very unfortunate incident and we express condolences to the loved ones, especially the children who are left behind. However, it is necessary to clarify that Pacific Fertility Center was not involved in the treatment of this patient. The AP article printed the name of the clinic as “Pacific Fertility Center”, which is an error of ambiguity since there are two fertility clinics with similar names. The fertility clinic where this woman received services was Pacific Fertility Center-Los Angeles. Our center, which is located in San Francisco, has no affiliation with the clinic in Los Angeles. While our names are similar, our standards of practicing medicine are much different. To begin, here at Pacific Fertility Center in San Francisco, it is standard procedure to verify the identity and age of the persons being treated at every visit.  Our physicians would not have treated a woman at the age of 66, since we believe this to be unethical. At Pacific Fertility Center in San Francisco, we believe it is our foremost and ethical responsibility to assure the children that are a result of our services are provided loving and caring families.

In southern California last month, a set of octuplets were born via Cesarean section. The mother, Ms. Nadya Suleman, recently divulged that this pregnancy resulted after undergoing in vitro fertilization (IVF) treatment. Most previous cases of high-order multiple births have occurred after treatment with injectable fertility drugs combined with intrauterine insemination (IUI). This case is unusual in that the treatment was IVF, where the number of embryos transferred back to the patient is a conscious decision on the part the patient and her physician. We are reassured to hear that Ms. Suleman and the octuplets are thus far doing well, but certainly the potential complications of premature birth may not present themselves until much later in each of these octuplets’ coming days, months, or even years.

We are very concerned that such an event of a high-order multiple pregnancy has occurred, and would like to reiterate that PFC takes the issue of multiple gestation very seriously. PFC has been taking steps to minimize the risk of multiple pregnancy for several years. Balancing high pregnancy rates with low pregnancy risk improves pregnancy outcomes. Achieving that balance and reducing the risk of multiple pregnancy is our goal. In all treatment cycles that we perform here at PFC, our ultimate aim, and any recommendations we provide, are with the hope of achieving a singleton pregnancy- the safest pregnancy.

Fertility physicians are very aware that one of the most important side effects of fertility treatment is multiple gestation. Our governing organization, the American Society of Reproductive Medicine (ASRM), as well as the Society for Assisted Reproductive Technology (SART) have worked steadily to formulate evidence-based guidelines for the number of embryos to be transferred in assisted reproductive technology (ART) cycles. These guidelines were first established in 1996 and were updated in 2006 to reflect improved success rates with ART. Over the past decade we have seen a significant decrease in the number of high-order multiples in the US.

We at PFC adhere to the ASRM and SART guidelines. These guidelines provide the flexibility to give each patient treatment individualized to her needs, and her best chance to become pregnant; while minimizing the risks of a high-order multiple pregnancy.

SART member clinics are committed to following these guidelines, although it would appear that the guidelines were not followed in Ms. Suleman’s case.

Interested in self-diagnosis of fertility? The ability to screen for fertility in private, on one’s own schedule, with an at home diagnostic kit is an appealing option. A company from the UK, Genosis, has developed such a kit, called Fertell.

Fertell is a testing kit that offers a basic assessment of male and female fertility.

Fertell for the male is a specimen collection and testing kit that measures the concentration of motile sperm. A sperm specimen is collected into a cup and allowed to liquefy and then warmed to body temperature. Motile sperm pass through a filter and are colored red by exposure to a gold-coated antibody. Appearance of two red lines in a testing chamber indicates a sperm count over 10 million total motile.

Fertell for the female is a conventional urine test strip very similar to an ovulation prediction kit. The female places the absorbent tip in her urine stream for 5 seconds. FSH in the urine reacts with antibodies on the test strip and shows as a red line in the result window. The intensity of this line reflects the FSH concentration (the darker the line, the more FSH present in urine). High FSH levels are indicated by two dark red lines.

Traditional semen analysis measures sperm volume, count, and motility. Multiplied together, these numbers yield the total motile sperm count, that is, the number of moving sperm in the ejaculate. Total motile sperm count is a reasonable predictor of fertility for men. Fertell establishes that the sperm count is over a specific value of 10 million total motile, a reasonable threshold for male fertility.

The male test kit is not able to determine subtle gradations of male fertility. It cannot detect the effects of treatment or change in lifestyle that may cause improvement in sperm count, nor can it detect alterations in sperm morphology (shape). More sophisticated testing is available at a sperm lab.

The female test kit is used as a screening test, and cannot detect subtle gradations in FSH levels, or the relationship of FSH to other important hormones such as estradiol. Such issues have dramatic effect on the patient’s prognosis.

Neither of these tests can replace an expert’s opinion. An expert’s ability to interpret test results with a broad knowledge base and experience remains the best way to diagnose and treat infertility problems.

Of primary importance is that, while both test kits have been correlated with existing assays, neither has been evaluated for its ability to predict pregnancy. Such research takes time, and hopefully will be forthcoming. For now, Fertell is an interesting option for those seeking a private screening assessment of their fertility.