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.

Stillbirth, loss of a baby at delivery, is a painful challenge.  The suffering associated with the loss of a child, even before birth, can be overwhelming.  Especially acute for women that have conceived utilizing assisted reproduction, the loss of a pregnancy fought through reproductive technology can overwhelm a couple.  Stillbirth is a rare risk of pregnancy; the challenge facing us as reproductive medicine experts and obstetricians is how to reduce that risk.

The technologies of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) have enabled pregnancy for thousands of families with sperm, egg, and uterine problems.  With IVF, egg quality can be optimized using fertility drugs to produce more eggs.  Blocked fallopian tubes can be bypassed.  Weak sperm can achieve pregnancy by ICSI, where, using a microscopic needle, the sperm cell can be introduced into the egg.

No-one should expect these techniques to be foolproof.  While mechanical problems can be improved, other weaknesses in the reproductive system cannot.  Small deviations in the genetic code of the sperm or egg, missing chromosomes, aging, uterine defects, etc cannot be fixed by treating the sperm cell or embryo.

Thus the problem – these pregnancies established by high technology, are at higher risk.

A recent study from Denmark looked at stillbirth in children born after IVF/ICSI  and found that the risk was higher in children born after IVF/ICSI than natural pregnancy.  Out of 16,525 births to fertile women the chance of stillbirth was 0.37%, that is, 3.7 out of 1000 births.  Out of 742 babies born to women after IVF/ICSI there were 12 stillbirths, 1.62%, that is 16.2 out of 1000 births.

But more importantly to our patients, the liveborn baby rate after a successful IVF/ICSI treatment  and pregnancy is 98.4%.  The liveborn baby rate after a successful natural conception and pregnancy is 99.6%.  Almost all of the successful pregnancies after IVF/ICSI are liveborn.

Reproductive technologies, like IVF and ICSI, are enabling pregnancy and family building where it was not possible before.  All of our patients must be informed of and recognize the risks associated with fertility treatment.  These risks should not, however, dissuade anyone from considering these therapies.  On the contrary, the overwhelming likelihood is that, once a pregnancy is established, it will progress successfully to delivery and a healthy child.

We need to recognize these risks to provide help understand and take measures to reduce the risks to all children.  We will continue to watch these studies carefully in our ongoing effort to assure our patients of excellent pregnancy rates, at low risk.

Footnote:

1. K. Wisborg, H.J. Ingerslev, and T.B. Henriksen  IVF and stillbirth: a prospective follow-up study  Hum. Reprod. Advance Access published on February 23, 2010.

We are excited to introduce a new website FertilityWire, http://fertilitywire.com.  This site is separate from our current website www.pacificfertilitycenter.com.

FertilityWire will provide access to a wealth of fertility information, news, and social content. Please take a moment to check out this exciting new resource. You can let us know what you think in the comments section.

Enjoy!

-Robb Mayberry, Director of Development

This past fall, over 6000 of the world’s leading researchers in reproductive medicine gathered in Montreal, Canada to participate in the annual conference of The American Society for Reproductive Medicine (ASRM). ASRM is an organization of 8,500 physicians, researchers, nurses, technicians, and professionals dedicated to advancing knowledge and expertise in reproductive biology.

PFC partners Eldon Schriock, Isabelle Ryan and Joe Conaghan attended the conference this year. Here they share with Fertility Flash readers highlights from a chosen handful of the presentations.

Nicotine Damage to Sperm Better Understood

An experiment led by researchers from the State University at Buffalo School of Medicine revealed that chronic male smokers could experience a reduction in their fertility of up to 75% as compared to non-smokers. Lani Burkman led the study to provide more details on past research, which had shown that when nicotine and its by-product, cotinine, were added to sperm in the lab, these chemicals changed the way the sperm moved.

In this recent research, sperm from both smokers and non-smokers were combined in two different Petri dishes with oocytes derived from one source. The sperm’s ability to bind to and penetrate the zona pellucida (outer shell) was carefully observed. In summary, the smokers’ sperm were less effective in binding to the zona pellucida. The sperm of chronic smokers – people who have smoked a minimum of four cigarettes a day for at least two years – maintained an average of 75% less capacity to fertilize compared to nonsmokers. The researchers also discovered that light smokers’ sperm performed better than chronic smokers’, suggesting that men trying to start a family will have better results even by cutting back on the smoking.

Knowledge of Egg Freezing Advancing Rapidly

Fourteen papers on the topic of oocyte cryopreservation were presented. Some focused on studying overall results since egg freezing was first introduced in the late 1980s, while other presentations reported on testing specific methodologies, such as slow vs rapid freeze and thaw techniques, or the use of different cryoprotectants. Results continue to bode well but specifically for women who are relatively young.

In what the media hailed as a breakthrough, one research team presented what could be the highest success rate for oocyte cryopreservation to date. Led by John Jain, MD, an associate professor of Reproductive Endocrinology at University of Southern California, the team’s egg-freezing protocol involves the use of slow freezing and fast thawing, in addition to a specific culture medium that applies choline for stabilizing the egg’s membrane.

The research was derived from a small study involving only eight infertile women with tubal factors, all around the age of 31. Out of the eight women trying to conceive, five achieved pregnancies with their own previously frozen oocytes. For the particular study group, this translates into a 62% success rate per patient, which is comparable to fresh embryo transfers. However, Dr. Jain stressed that considerably more research needs to take place before egg freezing should be used in standard clinical practice.

More good news for oocyte cryopreservation came out of a research team from McGill University in Montreal, Canada. This team applied a proprietary blended cryoprotectant formula and used only the vitrification (rapid freeze) method in contrast to the more standard slow freeze protocol. In this case, 180 oocytes that were derived from 15 women of mean age 31.7 were vitrified. Out of these, 169 survived the fast freeze process (93.9%), and 126 oocytes fertilized normally (74.6%). Out of the original 15 patients, 4 are currently showing signs of successful pregnancies and one has already delivered.

More Worries About Multiples

Ongoing research continues to identify problems with multiple gestation births, some involving assisted reproduction, some not.

Genetic Testing Important for Twins: Researchers at UCLA’s School of Medicine working with the Cedars-Sinai Medical Center identified higher rates of cytogenetic abnormalities in the first trimester of twin gestations conceived through IVF compared to spontaneously conceived twins.

The team set out to discover whether the previously suggested increased incidence of aneuploidy in twins might be related to IVF. This retrospective case-controlled study analyzed women at least 35 years of age carrying dizygotic twins who underwent chorionic villus sampling (CVS) at these institutions between 2000 – 2004. The average age of the patients carrying twins from IVF was slightly higher (2 years) than those with twins who conceived naturally.

Out of the 27 women carrying twins conceived through IVF, the incidence of aneuploidy was 14.8%. Out of the 14 women carrying twins conceived spontaneously the aneuploidy incidence was 0%. Because genetic abnormalities can be identified through CVS early in the pregnancy, the paper points to the importance of counseling. (Note: Those who require IVF may already have an increased incidence of genetic abnormalities unrelated to the IVF process. Continued study is needed.)

Vanishing Twins Provide Clues: A research team at UCSF studied the gestational sacs of 244 births resulting from IVF/ICSI and found that singletons born with a so-called vanishing twin were more likely to have adverse perinatal outcomes including low birth weight, premature birth and stillbirth incidences, suggesting abnormalities start in early placentation. They are now calling for a larger sample size to confirm the data. Female Twins Reach Early Menopause: Weill Medical College of Cornell University researchers presented data suggesting that female twins are more likely to undergo premature menopause. Although identical twins showed a higher incidence than non-identical twins, both groups showed significantly higher rates than their non-twin counterparts from the general population. Statistically speaking, only about 1% of women reach menopause by age 40. The twins from this study revealed that about 5% reached premature ovarian failure and showed menopausal symptoms by age 40. In some cases, only one twin out of a pair entered early menopause. This joint study involved a survey of 850 women from different twin populations around the world collected by the Queensland Institute of Medical Research in Brisbane, Australia; St. Thomas’s Hospital in London and St. Luke’s Hospital in St. Louis, Missouri.

Infertile Women Want Twins: While the news about multiple gestations continues to raise concerns, a group out of the University of Iowa, Carver College of Medicine confirmed earlier research indicating that infertile women desire twins at twice the rate of their fertile counterparts. This research team used a questionnaire-based prospective study to survey over 1000 maternity patients and found that 20% of infertile women conveyed a preference for twins compared to 10% of fertile women.

Pollution Has Impact in Brazil

Two research groups from the School of Medicine at the University of São Paulo in São Paulo, Brazil are studying the impacts of air pollution on reproductive health. One study group focused on early miscarriage by exposing mice to ambient air pollution from rush hour traffic, compared to a control group placed in a less polluted environment. The exposed mice group had 80% of the early gestational miscarriages recorded out of the combined set. Specific pollution types and quantities were not listed in this study.

The other study analyzed the possible impact of increased ambient air pollution on gender outcome of live births of both humans and mice. In this study the researchers correlated live birth data to 15 air pollution monitoring stations in the city of São Paulo. They analyzed birth registries between January 2001 and December 2003, and correlated conception dates to the pollution levels of each station. In the least polluted area the sex ratio was 51.7% males for 34,795 births recorded, and for the most polluted area the proportion decreased to 50.7% for 48,023 births recorded, indicating a difference of 1% in total male births. Similar findings were observed in the experimental study involving mice placed in polluted vs filtered chambers. In the filtered chamber the male/female ratio was 1.34 opposed to 0.86 in the non-filtered chamber.

Left to right: Front row: Carl Herbert, MD, Isabelle Ryan, MD
Back row: Joe Conaghan, PhD, Eldon Schriock, MD, Carolyn Givens, MD, Philip Chenette, MD

The physicians at Pacific Fertility Center are internationally recognized specialists in reproductive endocrinology and infertility. They have completed top-level medical education, published groundbreaking professional papers, and held positions on the faculty of leading research universities. They continue to participate in reproductive research. All MDs are Board Certified by ABOG as Reproductive Endocrinology and Infertility Specialists. Our state-of-the-art laboratory has one of the most highly trained teams in the country.

Acupuncture, one of the world’s oldest and most established healing practices, is growing in popularity as a way to complement the modern procedures of ART – Assisted Reproductive Technologies. Although the scientific evidence behind acupuncture is scanty, belief in this technique is so strong, some patients having just undergone implantation after IVF will head straight to their TCM (Traditional Chinese Medicine) practitioner for an immediate acupuncture treatment.

Acupuncture is just one component of Traditional Chinese Medicine (TCM), which also involves herbs, pelvic massages and dietary adjustments to garner a “whole body” systems approach to health. Following a track record of over 4000 years, nearly one quarter of the world’s population turns to TCM for their primary heath care. In Western societies, acupuncture is frequently cited as providing almost instantaneous relief to debilitating ailments such as bad backs and sports injuries.

Tiny sterilized needles are inserted into key points of the body and left there for 20-30 minutes. Barely felt, the needles reportedly open up Qi (pronounced Chee), which is vital energy defined by increased blood flow and the benefits of the body’s systems working together to break down so-called blockages.

Only two scientific research studies have examined the benefits of acupuncture with IVF treatment. The most talked about was reported in the journal Fertility & Sterility, April 2002 (Vol. 77, No.4) involving 160 IVF patients in Germany. Half of them underwent acupuncture before and after embryo transfer and the other half served as the control group. 34 out of the 80 women who received acupuncture revealed clinical pregnancies (42.5 %), whereas, 21 out of 80 women in the control group became clinically pregnant (26.1%).

Although the physiological mechanisms are not fully understood, it is believed that acupuncture optimizes endometrial receptivity and enhances blood flow to the pelvic area. According to TCM principles, energy flows through the body along pathways, or meridians. Acupuncture is a means of enhancing this energy and coaxing the body’s responses to induce a desired physiological effect. Ideally, according to TCM practitioners, women should undergo acupuncture treatment 3-4 months prior to an IVF cycle instead of as a last minute flurry.

We at PFC encourage our patients who inquire about acupuncture to pursue it, and we provide a list of Bay Area TCM practitioners who are certified by the National Acupuncture and Oriental Medicine Alliance and licensed by the state of California. (UPDATE: PFC now provides in-house acupuncture services.) However, under no circumstance do we condone the use of herbal supplements that are sometimes provided with acupuncture for women undergoing infertility treatment at PFC. Most TCM practitioners agree with this approach, and will communicate your treatment protocol with our physicians here at PFC.