invitrodoc

[invitrodoc]

Gateway to IVF Success: The ABCs of PGS

In a poignant New York Times interview in 2010 with the highly revered Dr. Howard Jones, he asserted, "Fertility investigators today should figure out which one embryo is likely to make a baby rather than transfer several. That will reduce costs, the number of multiple births and significantly increase success rates of in vitro fertilization."

Dr. Jones established the first U.S. IVF clinic over 30 years ago in Norfolk, VA with his wife, Dr. Georgeanna Jones, and their team achieved the first IVF pregnancy in the U.S. Since that time IVF treatments have become more complex, and thousands of women and men face a myriad of “alphabet soup” IVF jargon to learn. How intimidating does it sound when an IVF blogger writes, "I went to the XYZ Center for IVF, ICSI, TE biopsy, and PGS so I could have a euploid blastocyst SET with my FET"? Can some of this IVF “alphabet jargon" be more clearly explained?

IVF has actually become more efficient over recent years, with the development of newer and better lab culture conditions. Exciting research developments exploring genes and DNA have yielded a perfect collaboration between IVF centers and genetics experts. With these advances, Dr. Jones' long-standing goal of “one embryo, one healthy baby” is now a reality. This advice can be embraced because we are able to learn more about the chromosome health of embryos through pre-implantation genetic screening, or PGS.

Approaches to PGS have become much more sophisticated and reliable over the past 10 years by utilizing streamlined DNA analysis, ensuring evaluation of all 46 chromosomes within a few cells carefully removed from each embryo. Some centers also refer to PGS as comprehensive chromosome screening, or CCS.

The key value of PGS and CCS is our ability to predict which embryo or embryos have a normal complement of 46 chromosomes prior to uterine transfer. When a normal mature egg containing 23 chromosomes is fertilized with a normal sperm (containing another set of 23 chromosomes), an embryo with 46 chromosomes can develop. However, many embryos start out with an incorrect number of chromosomes stemming from an abnormal egg, sperm, or improper chromosome movement within the fertilized egg.

As certain embryos develop in the lab to become blastocysts, usually four to five days after fertilization, it is not possible to accurately distinguish  normal (euploid) versus abnormal (aneuploid) embryos under the microscope, making accurate embryo selection a major challenge. This dilemma has led to several exciting discoveries demonstrating the importance of incorporating PGS into current IVF treatments:

• The chance of successful pregnancy after single embryo transfer (SET) and PGS is 55% to 65%.

When Dr. Jones and others performed IVF treatments in the 1980s, the success rates were only about 10% to 20%, even when multiple embryos were transferred. For many years, IVF doctors didn't think success rates would ever surpass 20%, the average monthly chance of natural conception for a fertile couple in their 20s. Transferring multiple embryos at one time became the norm to enhance IVF success rates, but with that strategy came the unintended consequences of multiple gestation, profound prematurity, cost, and significant emotional turmoil.

• Age matters, but not as much with PGS.

If a 40-year-old woman has a euploid blastocyst transferred to her uterus, her chance of normal pregnancy is about the same as a 25-year-old IVF patient. While this is an astounding finding, it is very clear that older women are much less likely to create multiple embryos that are normal when compared to younger women. It is also more likely that older women might not produce any normal embryos in a given IVF cycle. A very high percentage of abnormal PGS results are caused by an abnormal number of chromosomes within the mature egg—a significant age-dependent event.

• A single normal embryo can be transferred in a fresh or frozen embryo transfer (FET) cycle following PGS, yielding similar success rates.

 This provides great flexibility in how and when treatments are carried out and empowers women and men to design their own specific family building pathways. Our colleagues in the maternal-fetal medicine and neonatal fields have published compelling data to suggest that FET actually yields fewer maternal and fetal pregnancy complications. They have also strongly urged that SETs be carried out to minimize risks. Most IVF clinics offering PGS utilize FET cycles.

• Miscarriage rates are much lower after PGS.

 Since the majority of early miscarriages—including “chemical” pregnancies—are caused by chromosome errors in the embryo, it makes sense that many miscarriages can be prevented with PGS testing. Transfer of a single euploid (46 chromosome) embryo results in miscarriage in less than 10% of pregnancies. Miscarriage creates a significant emotional burden for our patients in addition to other costs and delays in care.

• PGS as performed in 2014 is just the beginning.

As DNA testing becomes more sophisticated and less costly, PGS will be fine-tuned to further enhance IVF success. IVF researchers are already discussing the use of DNA sequencing and other molecular modalities to better predict the health status of an embryo. The tiny trophectoderm  (TE) cells biopsied from the blastocyst for PGS contain a powerhouse of molecular information about the embryo, which can be analyzed for many different diagnostic markers.

In the future, it is possible that maternal age alone will not be the “done deal” many have come to accept. Univfy researchers and collaborators have clearly found that many factors other than age alone can greatly impact and predict IVF success. Individualized patient and clinic-customized prediction testing holds great promise when our patients seek guidance for their IVF decision-making.

One major goal of IVF physicians is to identify proven health interventions that will optimize the vitality of eggs, sperm, and embryos, leading to enhanced fertility and family building options for our patients. PGS has given us a significant glimpse into the mysteries and wonders of human reproduction. With PGS, the vision of Dr. Howard Jones and the future of IVF are looking much brighter.

[invitrodoc]

Three Years of IVF Results Show Value of Embryo Chromosome Testing

In vitro fertilization (IVF) outcomes from over 1,000 treatment cycles spanning 2010 through 2012 demonstrate a significant improvement in successful pregnancies when pre-implantation genetic screening (PGS) of blastocyst embryos is utilized prior to uterine transfer, reports Reproductive Associates of Delaware (RAD). PGS utilizes molecular DNA tests for the presence of normal chromosomes within embryos.

Of 416 delivered and ongoing healthy pregnancies, 68 (16%) occurred when PGS was performed. In patients over 34, PGS led to 43% of RAD's successful IVF pregnancies, and over 90% of these pregnancies occurred after single embryo transfer. When compared to IVF data published annually by the Centers for Disease Control, RAD had the highest total percentage of single embryo transfers and the lowest IVF multiple pregnancy rate in the U.S.

"Our results with IVF and PGS have clearly had an important impact on success rates, as well as increased utilization of single embryo transfer," noted Dr. Ronald F. Feinberg, IVF Medical Director at RAD. "The higher implantation and ongoing pregnancy rates with PGS are both statistically and clinically significant for patients over age 34. Most IVF clinics utilize multiple embryo transfer to enhance pregnancy rates in these patients, whereas PGS allows us to select single embryos for uterine transfer yielding a safer and higher chance of pregnancy." Embryos with abnormal chromosomes either fail to implant or commonly cause miscarriage, and are increasingly common in women over age 34.

When PGS is utilized, implantation and pregnancy rates for patients over age 34 at RAD are almost identical to the rates seen in younger women, and far surpass the rates seen in fresh non-PGS IVF transfer cycles. When PGS combined with frozen/thaw embryo transfer were carried out at RAD, the embryo implantation rates were over 60% across all ages, with a successful pregnancy rate of 56.2% and an average of 1.1 embryos transferred. The miscarriage rate was 10.5% in PGS cycles across all ages, whereas in non-PGS cycles the overall miscarriage rate was 18% in both fresh and frozen/thaw embryo transfers. Miscarriage prevention is a common indication for IVF and PGS.

"Our results suggest that PGS could prove to be highly cost-effective to help our patients maximize their singleton IVF pregnancy chances, along with much lower miscarriage risk, stated Linda Morrison, Director of Laboratory Services at RAD. "This should ultimately reduce the number of treatment cycles that many patients will need to achieve a safe and healthy pregnancy."

IVF pregnancy outcome following embryo transfer is also enhanced when the uterine environment has been optimized. During a frozen/thaw treatment cycle, the uterus has not been subjected to very high hormone levels commonly created during fresh IVF cycles. And other risks of fresh IVF transfer, such as ovarian hyperstimulation syndrome, can be virtually eliminated when frozen/thaw transfers are employed. "Recently, a respected research group at New York University published their results with PGS and single embryo transfer during frozen/thaw cycles, and demonstrated a 58% implantation rate over a four-year period," noted Dr. Feinberg. "This provides further evidence that single embryo transfer in conjunction with PGS is safe and effective."

RAD has previously presented its IVF and PGS results at the American Society for Reproductive Medicine annual meetings. To view details of RAD's comprehensive PGS and non-PGS results for the three-year period visit http://ivf-de.org/pgs-pgd/ and http://ivf-de.org/success-rates/.

RAD's IVF Center, established in 1995, is part of a full service subspecialty fertility practice with locations in Newark, Wilmington, and Dover, Delaware. RAD’s Board certified physicians are Drs. Barbara McGuirk, Ronald Feinberg, George Kovalevsky, Adrienne Neithardt, and Lenore Tietjens-Grillo. RAD’s IVF, Fertility Care, and Fertility Wellness Centers are located on the main campus of the Christiana Care Health System in Newark. For more information about Reproductive Associates of Delaware visit http://www.ivf-de.org.

[invitrodoc]

Just Another Manic Hormone (AMH)?

With apologies to The Bangles, the implications of AMH testing is causing some real mania and concern throughout infertility clinics worldwide.

What exactly is AMH, and what information does it provide?  What impact does AMH have on IVF success?  Should women interested in future fertility have their AMH level checked now?

AMH stands for Anti-Mullerian Hormone.  This is a rather paradoxical name for this hormone, particularly in women, where the embryologic female organs known as the Mullerian system develop into the uterus, cervix, and fallopian tubes.  (In male fetuses, it has been known for decades that the developing testes produce AMH to prevent development of a Mullerian system).

In women, AMH has not been assigned a biological function.  However, it is produced by a very specialized group of ovarian cells called granulosa cells.  Granulosa cells directly surround eggs within follicles, and are the key cells that divide and grow throughout each menstrual cycle, producing cyclical levels of estrogen and progesterone.  So it might be presumed that AMH serves some functions associated with follicle and egg development, and possibly menstrual cycle regulation.

Many fertility centers, including ours, measure AMH levels for patients as part of the diagnostic evaluation.  Based on available literature it appears that AMH levels correlate with the number of active and viable follicles present within our patients' ovaries.  AMH levels appear to correlate with how the ovaries respond to fertility medications, particularly during IVF.  So women with high AMH levels tend to be "super-responders" to ovarian stimulation, whereas women with low AMH levels are often "low responders" during IVF stimulation.

The general assumption about low AMH (typically less than 1.0 to 1.5), particularly in women who are suffering with infertility, is that a low AMH could be a marker for diminishing ovarian reserve.  Diminishing ovarian reserve is a "gentle" description of having reduced numbers and quality of eggs.  The implication of a low AMH is that perhaps fertility treatments should be more timely and aggressive, including IVF sooner than later.  AMH levels may correlate with the normal genetic and chromosomal makeup of the eggs.

A low AMH level has also been correlated with endometriosis, and we are caring for many younger women (under age 30) who present with both endometriosis and very low AMH.  We have wondered if AMH somehow regulates endometriosis, and if a low AMH allows "permission" for endometriosis cells to grow and flourish.  There is some scientific evidence that endometrial cells are regulated by AMH, which may give some insight into the actual function of AMH.

On the opposite end of the spectrum, women with a high AMH (greater than 2.5 to 3) tend to be "high responders" to fertility medications, produce many follicles during IVF stimulation, and often fall into the polycystic ovary group.  Many women with polycystic ovary syndrome (PCOS) have ultra-high AMH levels; we've seen levels of AMH as high as 30 to 40 in some PCOS patients, suggesting extremely high numbers of follicles within these women's ovaries.

So AMH results can cause tears or cheers, depending on the results obtained.  More information is desperately needed to determine what AMH actually does, whether it is a hormone closely related to future fertility potential, and how it might impact a disease like endometriosis and/or the metabolic hormone disorder known as PCOS.

[invitrodoc]

I'm sorry if I'm not impressed that Endo and Impotence get the same amount of attention. I don't see not being able to "get it up" as important as this debilitating disease that has ruined my life. And I really do believe that if men also suffered from this disease, we would have it more figured out than we do now and the treatments would be less harsh. I don't think it's sexist of me to say that. It's just how the world works.

Thanks for your comments and interest.  You are preaching to the choir; my point was NOT to equate endometriosis with impotence.  Of course most rational professionals in reproductive medicine believe that endometriosis is a horrible and debilitating disease that deserves more research, awareness, funding, insurance coverage, and prioritization as a major healthcare problem.  Allow me to be clear: the way our society generally approaches endometriosis is terribly sexist against women.

[invitrodoc]

Endometriosis: A Disease of Theories

In a somewhat sexist and backhanded taunt it has been said: "if men suffered with endometriosis, we'd have a cure by now."

For what it's worth, the world's biomedical literature is not ignoring endometriosis, with PubMed (the online repository of the U.S. National Library of Medicine) containing 19,232 journal articles with the search term "endometriosis" as of this morning.  About 10% of these articles were published just in 2012.  By contrast, the male-only disease "prostate cancer" yields 106,342 entries, and a less deadly (but highly Pharma-profitable) condition "impotence" yielded 19,861 entries.  So do endometriosis and impotence get about the same attention in the world's biomedical literature?

To be fair, we have learned a great deal about endometriosis since Dr. Sampson first proposed the somewhat simplistic theory of retrograde menstruation almost 100 years ago.  Back then it seemed "obvious" that some menstrual tissue could, every month, flow backwards through the fallopian tubes and land in the pelvis, where some viable cells implanted and continued to growth.  In fact these commonly-seen implants of endometriosis, whether found in the ovaries or on the surfaces of peritoneum, do resemble the glands and connective tissue of the uterine lining, known as the endometrium.

At one extreme, women who have an anatomic blockage or abnormality within their uterus or cervix appear to be at very high risk of developing endometriosis.  And at the other extreme, women who lack a uterus or never menstruate rarely have endometriosis.  So a dose effect of "seeding" the pelvic cavity with endometrial tissue, whether with a lot of menstrual tissue or virtually none, does seem to directly impact risk of the disease.  And as stated, it's a rare male that has endometriosis (I did find one case report in PubMed published in 1985; this male had a embryologic remnant of the uterus embedded in his prostate).

In Dr. Sampson's day we didn't know much about genetic predisposition, how the immune system reacts to or promotes growth of endometriosis cells, or how stem cells can magically form new cells in our bodies.  We also weren't exposed to reproductive toxins and food additives that act like estrogen.  Or plastics that leach out hydrocarbons and disrupt our endocrine systems.  The average age of puberty was older in Dr. Sampson's era, and the average number of menstrual cycles women experienced were many fewer.  Birth control pills didn't exist, and fertility and pregnancy rates were higher.

So our best bet on this disease of theories is that there are many interlocking modern factors that contribute, and there is not likely just one theory that will adequately explain the origins of endometriosis.

And to all biomedical researchers, both male and female, if you unlock the many mysteries of endometriosis you might find new cures for other major diseases with similarly curious abnormal cells, such as cancer.

[invitrodoc]

What Determines A Normal Embryo?

"My embryos were normal but I didn't get pregnant" is one of the most common statements we hear from many of our patients coming to us for second or third opinions.

So how do we know that embryos created by IVF are normal before we transfer them to the uterus?

The chance that an embryo will successfully implant is about 37% for women under age 35, according to CDC national averages from over 400 IVF clinics in the U.S.  For women within ages 38 to 40, those implantation chances drop to 18% and at ages 41 to 42, less than 10% of embryos will successfully implant.  With increasing age, miscarriage rates also increase.

"But my doctor assured me that my embryos were quite normal"

Simple question: OK, but by what criteria?

There are three potential criteria that embryologists can use to assess embryo quality, and to help physician colleagues maximize IVF success:

1) Developmental.  A fertilized egg starts as a one cell entity that should start dividing within 24 hours, and by 48 hours reach the 4 to 10 cell stage (preferably 6 to 8 cells).  This so-called 'day 3' stage is when most clinics in the U.S. transfer embryos to the uterus, and often several at a time.  This is a shotgun attempt to bring about pregnancy because it is virtually impossible to determine that any single day 3 embryo is normal.  IVF labs with more advanced experience will follow day 3 embryos to the blastocyst stage, or so-called 'day 5'.  Many embryos also become blastocysts on days 6 or 7, and there is good evidence that many of these blastocysts can also lead to normal pregnancies.  The chance of a single 'day 5' blastocyst implanting successfully is much higher than a 'day 3' embryo.

2) Genetic.  Most day 3 embryos stop growing and don't develop into blastocysts.  Embryos that arrest in development at day 3 or 4 are probably abnormal (either genetically and/or metabolically), and will either not implant or can lead to miscarriage.  Unfortunately, blastocysts often harbor chromosome abnormalities, and it has been proven that across all ages about 50% of blastocysts also have the wrong number of chromosomes.  Our selection of a chromosomally normal blastocyst by a technique called Preimplantation Genetic Screening (PGS) will reliably lead to embryo implantation 55 to 65% percent of the time.  This has been published and presented at national meetings by several well-regarded IVF centers, including ours.  Many IVF patients could benefit from PGS and subsequently require fewer treatment cycles.

3) Metabolic.  This is the next frontier for embryo health determination, and may allow us to improve implantation significantly beyond 55 to 65%.  Stay tuned on the topic of embryo diagnostics, and possibly even embryo therapeutics that will lead to better IVF success in the future.

"So how will I know my embryos are normal, even with PGS?"

Answer:  We won't, but PGS will improve the odds.  And we're just scratching the surface scientifically to determine what defines a truly normal embryo.

[invitrodoc]

Why Endometriosis Hurts Everyone

Endometriosis hurts.  There's no question about it.  Millions of women suffer in the U.S., and around the world.  The clinical terms that doctors use to define the pain and suffering are well-known to many women, particularly as they try to seek some answers.  These pain words all start with "dys": painful menstruation (dysmenorrhea); painful intercourse (dyspareunia); painful bowel movements (dyschezia); and painful urination (dysuria).  And all of these "dys" problems are strongly associated with chronic and unpredictable bouts of pelvic pain, spastic bladder, irritable bowel, abnormal bleeding, back pain, and infertility.

Endometriosis hurts because there is so much ignorance, particularly amongst physicians and other health providers.  When women with endometriosis are told ignorant things or have ignorant treatments that quickly leads to depression, questioning of self-worth, relationship breakups, loss of productivity, and feelings of isolation.  And ignorant treatments can lead to actual physical harm ("iatrogenic" is the term).  Luckily, this ignorance can readily be overcome when women with classic endometriosis symptoms turn to the Internet and social media, where it is easy to find that they are not alone.  And through that information often comes empowerment and a plan of action.

Endometriosis hurts when women have trouble conceiving.  In our experience, over 95% of women labeled with "unexplained infertility" actually have endometriosis.  If I blogged everyday about every patient in our practice who has unexplored infertility causes, i.e. endometriosis, I'd be blogging for many years.  In reality, endometriosis is by far the #1 diagnosis identified and treated in our subspecialty practice.  My colleagues in reproductive endocrinology and infertility do their patients a huge disservice when they label 20-30% of their patients with the non-diagnosis of "unexplained infertility".

Endometriosis hurts even when it doesn't cause pain.  Millions of women with endometriosis have no symptoms, or have mild cramps.  This is so-called "silent endometriosis".  About one third of our patients have this, because they come to see us to determine why they are having trouble conceiving.  Many "unexplained infertility" women fall into the "silent endometriosis" non-diagnosis.  That's because it is hard to diagnose endometriosis in the absence of symptoms.  Women with "silent endometriosis" and "unexplained infertility" deserve a thorough laparoscopic evaluation, though this has become controversial amongst infertility specialists.  Better to jump to expensive treatments without diagnosing and treating endometriosis?  Better for whom?

Endometriosis hurts when fertility treatments fail, including IVF.  While powerful and expensive treatments like IVF often can overcome infertility caused by endometriosis, it is very clear in the biomedical literature that endometriosis interferes with ovarian response, egg and embryo quality, and embryo implantation.  How or why all of this happens is vigorously discussed amongst academic-minded physicians and basic scientists.  We don't have all the answers but many of my colleagues are ignoring the science that already exists.  I could also be blogging for many years about each patient seeking second or third opinions, especially for failed IVF cycles.

Endometriosis hurts when families can't grow because of infertility.  Endometriosis hurts those who like or love a woman with endometriosis because they don't know how to help.  Endometriosis hurts future parents, grandparents, aunts and uncles, cousins, and Godparents.

Endometriosis hurts everyone.    

[invitrodoc]

From one of our patients . . .

"My husband and I heard all of these and worse. I think it is so difficult for people struggling with infertility to be advocates because it is a such a painful situation, people don't understand it (especially if it was easy for them to conceive) and it feels embarrassing and awkward to speak about. My husband and I actually deeply explored adoption before looking to addressing our medical issues and it was nearly impossible, mostly because we had been married for less than 5 years, so it really infuriates me when people suggest that adoption is such an easy alternative."

[invitrodoc]

Impediments to Advocacy for Infertility Care

When it comes to infertility medical care we often hear hurtful opinions voiced, especially directed against people who advocate for greater awareness and access.  Since infertility is such a private and personal matter, it is very difficult for people affected by infertility to mobilize and speak out against much of the ignorance that exists in our society regarding infertility.

Here are a few “gems” I’ve encountered: “There are already enough children in the world”

Comment: Many countries, including the U.S. have fertility and birth rates leading to negative population growth

“Why should I have to pay for someone else’s fertility problem?”

Comment:  Why should society pay precious insurance dollars for diseases brought on or worsened by overeating, smoking, and inactivity?

“Those people just waited too long”

Comment:  Yes, many productive professionals in our society spent years in education and training to potentially take care of society’s problems.

“IVF is unnatural”

Comment:  Sure, and so are heart stents for clogged arteries, chemotherapy for cancer, and virtually every other medication and piece of medical equipment.

“If you can’t get pregnant it just wasn’t meant to be”

Comment:  Most cases of infertility will be overcome by carefully diagnosing and treating specific underlying diseases.

“If you can’t get pregnant, just adopt”

Comment:  Adopting a child is a wonderful thing, but there are significant challenges to overcome in the adoption process.

“Just what we need, more Octomoms”

Comment:  That case was an extreme aberration and the physician in charge lost his license; current technology allows now for mostly singleton births.

“Those infertility doctors just want more patients so they can make more money”

Comment: No comment

[invitrodoc]

Top 5 Priorities for Optimal Fertility Care in 2013

1)  Advocate for better insurance for people needing infertility & IVF care

2)  Improve recognition and treatments for endometriosis

3)  Educate our patients and community about preconception genetics, very real age challenges, and fertility wellness

4)  Enhance acceptance of preimplantation genetic screening (PGS) for comprehensive chromosome assessment of blastocyst embryos

5)  Extoll the virtues of single embryo transfer with IVF to yield the healthiest babies possible

[invitrodoc]

Hi Doctor. My Fiance and I have been having unprotected sex since last October. Neither of us want children and are very thrilled with not becoming pregnant but I'm very curious who the lucky one is, what could be causing it and if it could be a sign of any serious health issues. I'm a 20 year old, 5"3', 98lb, non smoker and drinker with a healthy 28 day cycle and my Fiance is a 23 year old, 6"1', 155lb, light drinker/heavy smoker.

Hello Anonymous, I can't really make any legitimate conclusions based on the information you have provided.  However, if your goal is to avoid pregnancy, why wouldn't you and/or your partner use effective contraception?  Many women and men in their 20s do have infertility, mostly caused by endometriosis, prior STDs, and poor semen quality.  Thank you for your interest in the blog.

[invitrodoc]

Can Infertility Be Prevented?

Coupled with this, a study published earlier in 2012 from Johns Hopkins showed that about 1 in 5 young women ages 19 to 29 expressed significant concern about their future ability to conceive.  Although the study didn't delve into the specific reasons why these women believed they would have trouble getting pregnant, it's possible these women connected past or current problems with future fertility concerns.

What are common problems that can make getting pregnant difficult?  The most common diagnoses we address in our practice are endometriosis (either with active pain or silent symptoms), abnormal or irregular bleeding (often due to polyps or fibroids), very infrequent periods (often due to polycystic ovary syndrome and metabolic challenges), and ovarian aging issues (also known as diminished ovarian reserve).  A prior history of chlamydia or gonorrhea will often lead to infertility.  Male factor infertility, whether moderate or severe, is also quite common and is identified in 30 to 40% of male partners.

Infertility in the U.S. is estimated to affect 10 to 20% of reproductive age couples, with about 35% of women over age 34 having significant fertility challenges, according to the CDC.  That translates into millions of people who can't get pregnant when they want, leading to stress, depression, diminished work productivity, and an overall feeling of failure.  To make matters worse, millions of people in the U.S. aren't supported with the insurance coverage necessary to pursue successful treatments, such as IVF.

So can infertility be prevented?  Here's a 5-step proposal:

1) Aggressively seek answers.  If you are a woman with future pregnancy wishes and have problems such as chronic pelvic pain, severe menstrual cramps, pain with intercourse, and gastrointestinal and/or bladder problems, a diagnosis of endometriosis is a strong possibility.  Seek answers and care with an endometriosis specialist who is willing to tackle these symptoms honestly and directly.

2) Become wise about age and fertility.  Biological aging ('the ticking timeclock') of the ovaries is real.  Some of our patients are already facing significant challenges with egg quantity and quality in their 20s.  Many patients in their 30s and 40s wish they had known more about ovarian aging before attempting conception or finding out they were infertile.  Some simple hormone and ultrasound tests can give very helpful information.

3) Seek a healthy body mass index (BMI).  Both underweight and overweight women can have metabolic problems that interfere with ovarian health.  One major sign of a metabolic problem is when menstrual cycles become irregular or nonexistent.  Often, birth control pills are prescribed as a bandaid which doesn't correct the underlying disorder.  PCOS affects mostly overweight women, but can also impact women who have a normal or low BMI.  Metabolic problems can be significantly improved with lifestyle modification, including better nutrition, activity, and stress reduction.

4) Check out Fertility Wellness Centers.  This type of preconception program is growing around the U.S. as more people become aware of infertility and see their friends and family undergoing infertility treatments.  We opened a Fertility Wellness Center within our practice a few months ago, and it is already going strong.  Women and men can take charge of their health, and can anticipate potential fertility problems before attempting pregnancy.

5) Learn about preconception genetic testing.  Many problem pregnancies, including miscarriage and those affected by genetic diseases, can be completely prevented through careful assessment in conjunction with a trained Genetic Counselor.  Our Fertility Wellness Center has an experienced Genetic Counselor who is available to meet with every patient before, during, and after they conceive.

To peace and wellness in 2013!

[invitrodoc]

100,000 More Babies for America?

The birth rate in America has been declining — most recently an average 1.9 babies are born per woman — while economists and sociologists are trying to figure out why.  Esteemed publications such as The Economist and The Wall Street Journal have pointed out that "children are expensive" (brilliant!) and have suggested that delayed childbearing has become the new norm.  Curiously, infertility is not generally considered part of the equation.  Nor is the fact that as women (and men) delay having children, the chance of developing infertility rises dramatically.

All of this warrants further discussion, particularly as it relates to treating people who have infertility.  Data maintained by the CDC have indicated that about 12% of reproductive age women have sought fertility services, and that 35% of women ages 35 to 39 have impaired fertility.  See http://www.cdc.gov/nchs/nsfg/abc_list_i.htm#infertility for additional statistics regarding infertility in America.

IVF treatments are highly sought after in America, but are not readily available to the millions of infertile people who could benefit.  In 2010, according to published data by the Society for Assisted Reproductive Technology (SART; www.sart.org), over 37,000 live births occurred in the U.S. after successful IVF treatment with non-donor eggs.  Approximately 130,000 treatment cycles were performed in 2010, and about 28% of all treatment cycles resulted in a live birth across all ages of women.

Given the number of infertile people in America, especially amongst women over the age of 34, it could be argued that IVF is horribly underutilized in America.  And it might be reasonable to propose that greater utilization of IVF for infertile people might help turn around our national declining birth rate.

So how many infertile people would utilize IVF in America if cost barriers were removed?  One possible answer to this question might be by analyzing IVF utilization in Massachusetts, where a longstanding legislative mandate has permitted most citizens of that state to pursue multiple attempts of IVF if needed.  In 2010, the seven IVF facilities that reported to SART generated a total of 2,265 live births, or about 7% of all IVF births in the U.S.  Considering that Massachusetts has just 2.1% of the U.S. population, the state's IVF facilities generated 3.4 times more IVF births per capita than the rest of the country!

If the rest of the U.S. generated 3.4 times more births from IVF treatments, that would add about 117,000 more births annually throughout America.

What would this cost?  What if everyone in America had coverage for IVF if it was deemed medically necessary?  To generate 117,000 additional births would require, on average, about 463,000 additional treatment cycles.  If $15,000 per cycle was the assumed cost, the total bill would be about $7 billion dollars, or about $23/person annually.  This doesn't count the cost of pregnancy or neonatal care.

If we mandated single embryo transfer, we'd save $1-2 billion dollars annually and those funds could be used towards higher IVF utilization.  But that's a subject for a future blog.

[invitrodoc]

Fertility Care and The Golden Rule

Very often I am asked during patient consults: "Doc,  What would you recommend for me if I was your wife, sister, daughter, or dear friend?"

My answer is very simple: "I would recommend the same care for you as I would for any of my own loved ones."

When it comes to fertility care in America, there are many challenges, inequalities, and common threads of basic unfairness.  Many of these disruptions to The Golden Rule relate to how we treat one another in our society when it comes to infertility, how the healthcare system fully embraces many complex diseases but often ignores fertility care, and how our economy and communities encourage the notion in young women and men that family building can wait.  

Thus begins my foray into blogging about what I see and what I do.  My blogs on invitrodoc.org will be devoted to personal and professional perspectives on why infertility occurs in women and men, how different approaches to fertility care can yield very different outcomes and costs, and how we can all embrace the mantra of —  'A healthy baby for everyone who wants one.'  To me, how fertility care providers educate and advocate for their patients is also a key aspect of The Golden Rule.  

The year 2013 marks my 30th anniversary of becoming a physician, which has given me some pause for reflection and introspection.  During the year I finished medical school the first in vitro babies had just been born in the U.S. (two in my hometown of Philadelphia), and reproductive medicine was off and running as a truly exciting specialty.  It took me about 15 years after medical school to become a full fledged 'in vitro doc', which encompassed many personal inroads into research, patient care, and other academic endeavors.  

When I joined my partner Dr. Barbara McGuirk in practice in 1997, I was more committed and passionate than ever about my chosen field.  And I was able to harness all of my previous experiences to formulate sensible and fair treatment options for our patients.  Together, we implemented and lived The Golden Rule of fertility care.  Thousands of miracle babies followed.  

In the weeks and months ahead, and with the kind assistance of my terrific team, I hope to create a sounding board for many different topics and issues as they relate currently to fertility care and reproductive medicine.  I will draw on patient experiences, critique conventional wisdom and published papers, and advocate for improvements.  My comments going forward may irk a few people (including some of my mentors and previous professors), but I assure you it's not personal.  To fully encompass The Golden Rule, we must say what we believe, and do what we believe.  

Happy Holidays to All.  More to follow in 2013.