A few weeks ago, I was giving another infertility lecture to the third-year medical students at UC-Irvine College of Medicine. There was a visiting exchange student from one of the Scandinavian countries and our discussion turned to how IVF was free for all the citizens there, paid for by the government. He mentioned that the trend was continuing further in that there was talk of extending the free IVF services to all couples, regardless of sexual orientation. Denmark has been successful in keeping up the birth rate, while many other European countries have seen a decline in the number of babies born each year as a percentage of the number of women. A story in the news yesterday even tells of a Russian governor declaring a special holiday for people to stay home and have sex in an attempt to boost their low birth rate.
In the US, however, IVF is not universally free but rather, is limited to couples with the greatest demand for it. The reason we can't offer IVF to everyone is that we are limited by a lack of manpower in how many cycles we can perform. A single IVF cycle can require several dozens of people including reproductive endocrinologists, embryologists, nurses, medical assistants, anesthesiologists and laboratory personnel. In my opinion, if we try to push our limits and do more cycles that we can comfortably handle, we run the risk of decreased success, especially with respect to the work of the embryologists. They have to meticulously handle the delicate eggs, sperm and embryos. The process has to be tedious and careful in order to be successful and it is especially important that they are not overworked.
These are the categories of patients who are the prime candidates for IVF.
1. WOMEN WITH BLOCKED OR MISSING TUBES: This was the original reason IVF was developed. In nature, to achieve a pregnancy requires the Fallopian tubes picking up the egg and transporting the sperm to go meet the egg. With IVF, this process is entirely bypassed and the sperm and egg are perfectly united outside the body.
2. MEN WITH EXTREMELY BAD SPERM: In the past, men with very bad sperm had only two options if they wanted a child -- adoption or donor sperm, or vasectomy reversal in the case of those men who have had vasectomies. Nowadays, we have the ability to easily inject a single sperm into a single egg with a process called Intracytoplasmic Sperm Injection (ICSI) and ensure fertilization.
3. COUPLES WHO HAVE TRIED EVERYTHING ELSE ALREADY: IVF is a highly effective treatment for patients with unexplained infertility. Couples who don't get pregnant on their own and those who don't get pregnant with inseminations will often succeed with IVF.
4. COUPLES WHO NEED SOME CONTROL OVER THE GENETICS OF THEIR BABIES: With Preimplantation Genetic Diagnosis (PGD), it now is possible to get information about an embryo prior to implanting it. We can tell gender and whether or not certain genetic defects may be present, thereby allowing us to choose which embryos will have a chance to give birth.
5. SITUATIONS IN WHICH ONE WOMAN'S EGG ARE USED TO DEVELOP A BABY IN ANOTHER WOMAN'S BODY: In the past in order to have a baby, you needed to have good eggs and the ability to carry a pregnancy. Nowadays, if you lack eggs, you can have a baby with the help of someone else's eggs. If you have good eggs, you can have someone carry your baby for you.
There is one last category of couples who are NOT the most medically appropriate for IVF, but yet choose to do so because of personal preference. These are COUPLES WHO WANT A BABY ON DEMAND. Many couples PROBABLY have a good chance of being able to conceive either on their own or with low-tech treatment within the next 2-3 years. However, they don't want to take the risk of waiting that long only to find themselves still not pregnant. So they make the choice to do IVF to get pregnant right away and not have to worry any more.
Thirty years ago, none of the above couples had the privilege of doing IVF to get a baby and would most often end up childless (unless they adopt). With the advances today, miracles happen all the time for couples seeking to grow a family, and my team and I are reminded daily of how blessed we are that the harder we work, the more likely that one more happy baby will come into the world. I realize this sounds overly sentimental, but we really do enjoy our work. =)