Fertility FILE

The Best Candidates for IVF

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. =)

What's So Great about IVF?

In an earlier post, we looked at the world explosion in the number of healthy babies born through IVF, gradually improving in the past 25 years and rapidly so in the past 10 years. But what exactly is the concept behind the success of IVF? How does it help so much?

Recall our past discussion regarding how to make a baby. You need to start with the two components: the sperm and the egg. To have a baby, you need to have a genetically perfect sperm unite with a genetically perfect egg. In nature, the way this happens is the egg emerges from the ovary during the process of ovulation. Then it will float around freely inside the abdominal cavity waiting for a chance to be picked up by the Fallopian tubes.

You know those things that they use to automatically clean swimming pools. They float around on the surface and randomly suck up leaves and debris? The Fallopian tubes work a lot like that. After ovulation, the egg floats in a thin layer of fluid. Imagine if you will, tossing a ping-pong ball into a swimming pool and waiting for the pool cleaner to suck it up. Eventually, given enough time, that sweeper will make its rounds throughout the entire pool and suck up everything. However, eggs have a limited life span of less than 24 hours. So in our pool analogy, imagine if the ping-pong ball was set to self-destruct in 2 hours, that would make it unpredictable whether it would make it into the sweeper before that time was up.

So IVF helps in at least three ways.
1. The sperm and egg are physically brought together for sure. This is a big advantage. No longer do you have to rely on the tubes to suck up the eggs. This is especially important in patients with blocked tubes or with extensive endometriosis or pelvic adhesions (scar tissue)
2. With, IVF, we start out with multiple eggs instead of just one so there is a much higher likelihood that at least one of the sperm-egg pairings will consist of perfect sperm and a perfect egg coming together.
3. The sperm can be directly injected to fertilize the egg. Without help, even if the egg makes it into the Fallopian tube, and there is sperm waiting, that does not guarantee that a sperm will actually fertilize it, either because of failure to physically collide or because of deficiencies in the sperm that make it less capable of entering the egg.

IVF is a great treatment for infertile couples with tubal problems or severe sperm problems. It is also a good backup plan for times when everything else fails.

Fertility 2007. Our world is changing!

Prior to 1978, for many couples with infertility, the chance of cure was as bad as the chance of cure for many terminal illnesses such as some types of cancer, meaning there was almost nothing that could be done. These couples either successfully adopted or they proceeded to have a childless life.

The discovery and development of In-Vitro-Fertilization (IVF) changed that tremendously. There are three types of problems that contribute to infertility – problems with the wife’s eggs, problems with the husband’s sperm and problems with the “plumbing” (the anatomic pathway which allows the sperm and egg to come together and nourish a thriving baby). In medical terms, this refers to the woman’s fallopian tubes, uterus and cervix.

IVF involves taking the sperm and egg and bringing them together in a laboratory for a few days before being put back into the mother’s body as an intact embryo. The rest of the pregnancy journey takes place just as it always has in nature, inside the mother’s womb. Initially, IVF was thought of as just a way to solve the plumbing problems. Instead of relying on a sperm and an egg to come together inside the body under natural conditions, women with scarred or missing tubes could still have a baby by having the sperm and egg introduced to each other outside the body under ideal laboratory conditions. Over time, IVF has evolved to help couples with severe sperm problems and even couples with significant egg issues. Couples with extremely severe egg issues can not be helped through IVF, unless they are willing to enlist the help of an egg donor. While IVF is still not 100% in its usefulness to infertile couples, it has come a long way.

Rather than be some space-age oddity, IVF has become an everyday household word. As of 2006, over THREE MILLION IVF BABIES have been born. In fact, over 1% of the healthy babies born in the US today arrive as a result of IVF. In certain other countries, that ratio is higher than 3%. As with any new scientific advancement, there are questions as to long term consequences. The issue of future health in IVF babies has successfully breached new hurdles as each generation of IVF babies successfully finishes infancy, childhood and now, early adulthood without any major surprises. As time has passed, we have reached the moment when the first generation of IVF babies are starting to have their own normal babies and the majority of them appear to be doing so naturally, without the need for any infertility treatment.

Today, there are still some people who promote the extreme view that all scientifically advanced ways of assisting reproduction, including In-Vitro-Fertilization, should be banned. While it is true that as mankind discovers more advances that push the limits of nature, such as cloning and genetic selection, we need to constantly evaluate the differences between what we CAN do vs. what we SHOULD do. However, to argue for elimination of IVF would unfairly deprive many infertile couples of the option of having a baby. IVF is now a proven effective way to help most couples exercise their privilege (or their RIGHT) to be happy parents.

UCLA In-Vitro Fertilization Conference

I just returned from the 20th Annual UCLA In-Vitro Fertilization review course held in Santa Barbara each year, where dozens of reproductive endocrinologists from around the world convene to review the latest on IVF.

During the drive there, I was rewarded with a soothing view of the Pacific Ocean on my left, as I looked forward to spending time at the Four Seasons Biltmore. I like these meetings for reasons besides getting to improve my knowledge about topics ranging from the optimal ovarian stimulation protocols, embryo transfer techiniques and patient management strategies. I like them for the chance to catch up with old friends and colleagues in the field from around the world. There's a lot to be learned, not only from the lectures, but also from trading tips and stories at night around the dinner table. I first attended this particular meeting when I was a UCLA Reproductive Endocrinology fellow, but find there's always plenty of new things to learn each year. It's helpful to see what other people are doing in their practices to help their patients get pregnant, meanwhile being respectful that there are many ways to accomplish the same goals.

Also present at these meetings are reps from the major companies that manufacture IVF equipment, embryo culture media and the medications that we use in our work.

The highlight for me this year came when I found myself in the auditorium watching a slide on the large screen showing a family with mom, dad and two lovely daughters in their late teens / early 20's. About 20 years ago at UCLA, one of the earlier IVF cases involved an egg retrieval done by ultrasound guidance through the bladder. One of the embryos that was created became the older daughter and another embryo was frozen and then transferred a few years later to give birth to the second daughter. The speaker at the lectern was Dr. David Meldrum, the physician who performed those procedures. He had just got done giving an excellent talk about the history of IVF. Afterwards, to the delight of the audience, one of the two daughters in the slide came on stage and gave him a plaque and a warm thank-you for helping bring her into this world. It was a touching reminder how all our work with sperm, eggs and catheters gives rise to very real babies and families!

This year, as always, I came back with a few new ideas to incorporate into my practice. I didn't bring my camera this time, but I hope to take pictures when I go to the next big conference, the annual meeting of the American Society for Reproductive Medicine, which will be in Washington DC this October.