Fertility Doctors Blog
Do you have questions about fertlity? Almost everyone does. On this page, RSC Dr. Mary Hinckley blogs about topics brought up by people suffering from infertility. If you have a question you'd like to ask Dr. Hinckley, please use the online contact form to submit your query to her.
What do you think about the octuplets?
In the wake of national media coverage of IVF patient Nadya Suleman and her octuplets born in January, we, at Reproductive Science Center of the Bay Area of San Francisco (RSC), say the issue is providing new opportunities to educate the public on avoiding perhaps the biggest risk of infertility treatments: multiple births.
Rapid medical advancements have reduced the need to take such risks. Now, in women younger than 36, we achieve high rates of successful pregnancies with the transfer of just one better-developed five-day-old embryo to the mother’s womb. High-order multiple births – triplets or more – are extremely uncommon.
In the first two decades since the first so-called “test-tube baby” was born in the United States, IVF pregnancy success rates were a fraction of the current levels, so numerous embryos were routinely transferred, and infertility patients accepted the possibility of giving birth to twins, triplets, or quadruplets in hopes of producing just one healthy baby.
We follow the medical guidelines established by American Society for Reproductive Medicine (ASRM) that recommend transferring no more than two embryos per procedure in women under 35 except in "extraordinary circumstances." We also do extensive statistical analyses on our own pregnancy rates to better advise women on the number of embryos to transfer, since our pregnancy rates are higher than the national average.
For appropriate patients, RSC physicians recommend transfer of a single embryo at blastocyst stage of development (usually 70 to 100 cells) as the best way of achieving a single pregnancy with a term delivery.
We are committed to reducing the number of multiple births associated with infertility treatment. Our policy is two good-quality embryos in women under the age of 40. Except in the rarest of circumstances, we’re not comfortable with the risk of high-order multiple births.
The major risk of high-order multiple pregnancies is preterm delivery, which occurs in more than 50 percent of twin pregnancies, 90 percent of triplet pregnancies, and all other higher order pregnancies.
The earlier a baby is born, the greater its risk of dying or facing significant lifelong problems. Many premature babies face greater risk of:
- lower birth weight
- bleeding in the brain
- ntestinal problems
- cerebral palsy
- respiratory distress syndrome,
- developmental delays
What do you think about the number of embryos she had transferred?
It is hard to understand why the doctor put such a large number of frozen embryos in a younger woman with a proven uterus. However, we don't know all the facts. What were the quality of the embryos? What were her previous fresh IVF cycles like? Did finances play into this decision (i.e. the patient couldn't afford to do 3 cycles of 2 embryos each over the next 3-5 years)? Did the patient claim a right to embryos and dictate what she wanted done, putting the doctor in a situation where he would have to "abandon" her if he did not agree with her reproductive choice? All of us as reproductive endocrinologists have faced situations where patients do not fully comprehend the implications of their reproductive choices and we need to guide them appropriately with the years of medical training we have received.
What do you think about the CDC/SART reporting statistics of participating clinics?
Reporting "some" of our statistics clearly puts clinics in competition if there are several in a geographic region and with the advent of reproductive tourism. Since the statistics are just a snapshot of patient age (not embryo quality, medical history, religious beliefs, etc) and outcome, they do not fully represent the quality of the clinic. There is however value in the reporting. It allows patients to see the volume a clinic has. A too-busy clinic or a too-small clinic may not be right for them. If the volume is low, statistics will be much less reliable. Using the donor egg pregnancy rates at clinics can also be helpful as a tool to evaluate the embryology laboratory; however, in some clinics, same sex partners and siblings who donate can adversely affect the success rate (if they are older). We still feel donor egg is a valuable service to those patients.
Why doesn’t everyone just get one to two embryos transferred back?
Physicians and patients are always fighting against the likelihood that no pregnancy will result from a given treatment. When IVF first started (about 30 years ago), pregnancy rates were 10-15 percent. Now they are closer to 40 percent per cycle. What this means is that more than half of the patients who need IVF may not conceive in a given cycle. With the cost of fertility treatment being high and few insurance companies covering it, not to mention the emotional toil of going through treatment, patients and doctors wish to maximize the success of each treatment. However, current technology has not allowed us to be able to know whether the embryo under the microscope that looks “good” can really make it to delivery of a healthy baby. By transferring more embryos we can increase the chance of AT LEAST one making it. Therefore, until we get smarter with embryo culture and selection, we will always be struggling between the two extremes: not getting a patient pregnant and getting her "too" pregnant.
Dr. Hinckley, what do you think about health care changes and insurance coverage for IVF?
I do believe that infertility is a disease with great treatment success and therefore should be covered by insurance like other illnesses. However, in states where insurance does cover infertility, there are often inappropriate guidelines for usage that can backfire against some patients, for example the 42 year old who just started trying to get pregnant and now must do several treatment cycles of insemination before IVF.
Is it common to see women over 40 in your clinic trying to get pregnant with their own eggs?
Approximately 20-30 percent of my patients are over 40. When you compare the number of women seeking IVF over age 40 in areas like the Bay area, it is considerably higher than in other parts of the country. NY and LA also see this, likely due to career women and societal influences on the time to start a family.
What can patients do who don’t want to freeze or discard extra embryos or donate them to research?
Many patients have to think long and hard about the ethical implications of pursuing assisted reproductive technology. However, the two are not always incompatible. Patients that have a faith-based philosophy preventing freezing of embryos would need all fertilized eggs (embryos) back in the fresh cycle. We can achieve this by choosing a low number of eggs to inseminate in order to obtain the optimal number of embryos for transfer based on ASRM guidelines. Patients that do not want to discard embryos may choose to freeze them for future attempts at pregnancy or for donation to another couple. Frozen embryos cycles at RSC have excellent pregnancy rates and high cryosurvival rates suggesting the freezing of embryos has very little impact on the embryo. In our center for 2008, the frozen clinical pregnancy rate for day 5 blastocysts was 59 percent and overall is was 48%. With these numbers, patients are very willing to have us freeze their extras for use or donation in the future.
I had my tubes tied but now I want another baby what are my options?
So long as you have your uterus and your ovaries you are in luck! You have two different options: One is to undergo a microsurgical tubal reversal. At RSC we have been doing this for over 20 years with a greater than 80 percent pregnancy rate in patients < 38 years old. If your FSH hormone level is normal and your partner has a normal semen analysis, this would be an excellent option. The surgery is an outpatient procedure with a 2-4 week recovery. The ectopic pregnancy rate at our center is <5 percent, and usually ectopic pregnancies after tubal reversal can be treated with medicine. The second option if IVF. For women over 38, or with a partner with a low sperm count, this is the best option. It expedites your time to pregnancy before the eggs are “too old”. IVF will allows for eggs to be surgically drained from the ovary and then combined with sperm and placed into the uterus (bypassing the tubes).
My husband had a vasectomy, what can we do to have children?
As is often the case, men with vasectomy have good sperm. The problem is that they cannot get from the testicles through the vas deferens to ultimately be ejaculated. There are 2 options in this situation. Option 1 is to reverse the vasectomy. A urologist would perform this outpatient procedure. It can be done in our facility. Sperm can be analyzed and cryopreserved on the spot for use in the future if the reversal is not successful. After a 3-6 month recovery, a semen analysis can be performed to check for healthy sperm. Conception can then occur naturally, or with a little help from inseminiations. Option 2 is to “harvest” the sperm through a simple needle procedure. The sperm (small in quantity) can then be frozen for later use in an IVF cycle. This is the quickest route to achieving a child. It is especially appropriate if the vasectomy was over 5 years ago or the female partner is over 38.
If I need to use a donor how do I find one that will be a good match for me?
If donor eggs are what you are looking for, RSC has its own donor list and team to help match you with the perfect donor. There are also outside agencies that solely specialize in donor recruiting, and the chosen donor could then be screened at RSC and undergo treatment with us. Usually, you and your partner (if applicable) should think of the genetic qualities that are most important to pass on to the next generation. This may include a healthy family line (free of medical diseases) and also may include ethnicity, eye and hair color, and physical size. You may care about academic achievement or musical/artistic abilities. Once you have generated this list, then searching the web site will help you decide which donor is best for you. A physician can help guide you if the donor has done a prior cycle and you wish to understand whether the response was appropriate.
How does my age affect my chance of getting pregnant?
We know that female fertility declines with age. Unlike men who continue to make new sperm throughout their lives, women are born with a finite number of eggs. Therefore, it follows that as the years go by, the number and quality of available eggs diminishes. Unfortunately there are no medications available that can increase the number or improve the quality of a woman’s eggs. Fertility treatments can, however, improve a woman’s monthly chance of achieving a pregnancy by increasing the number of eggs that are available for fertilization.
How do I know what fertility treatment would be appropriate for me?
Your doctor will take a detailed history and perform an ultrasound examination to begin to uncover the potential causes of your infertility. Diagnostic testing will be ordered to further determine any reasons that pregnancy is not occurring. Based on this evaluation, there are many treatment options available. Your doctor will sit down with you and review your specific findings and then review a treatment plan with you. Your treatment plan is always individualized to your particular infertility factors. Some patients benefit from oral medication or injections while other are aided by an insemination procedure. Some patients need in vitro fertilization to help them achieve a pregnancy. Your treatment plan is always created specifically for you to maximize your monthly chances of becoming pregnant.
My cycles are regular and my ovulation kit turns positive every month why am I not getting pregnant?
Monthly ovulation is only one piece of the puzzle in achieving a pregnancy. There are many other factors that come into play. During your evaluation, your doctor will confirm that your fallopian tubes are open because the egg needs to travel into the fallopian tube and the embryo has to travel through the fallopian tube. Your doctor will also check the sperm to measure the number of sperm, the percentage of swimming sperm, and the shape of the sperm. This information is important for making sure that enough sperm are reaching the egg every month to achieve fertilization. Your doctor will also make sure that the shape and size of the uterus is normal and that the lining of the uterus is adequate for implantation to occur. The quality of the egg that is ovulated each month is also a predictor of your monthly chance of achieving a pregnancy. Your doctor will most likely recommend an ultrasound and blood testing to assess the quality of the eggs. As you can see, there is so much more than ovulation that goes into making a pregnancy occur.
What’s the difference between an IVF cycle and a frozen embryo transfer?
When you do an in vitro fertilization (IVF) cycle, the eggs are fertilized in a laboratory and the resulting embryos are grown in culture. After three to five days of culturing, an embryo transfer is performed to release the embryo(s) into the uterus for implantation to occur. Your doctor will recommend transferring the fewest number of embryos that still gives you a good chance of pregnancy. For example, in women under 35 years old, it is most commonly recommended to transfer one to two embryos. Many couples will have more embryos available than they have transferred. Embryos that are high enough quality to potentially result in a pregnancy will be recommended for freezing. If pregnancy does not result from the fresh embryo transfer or if a second pregnancy is desired a few years after the first, the frozen embryos can be thawed for another embryo transfer. A frozen embryo transfer is much less expensive than an IVF cycle because only the uterine lining has to be prepared to receive the embryos.
My doctor told me I have PCOS, how does this affect my fertility?
Polycystic ovary syndrome (PCOS) is a syndrome that commonly affects reproductive age women. It is most often associated with irregular periods and excess male hormone levels. Most women with PCOS do not ovulate every month, making it more difficult for them to achieve a pregnancy. Treatment for women with PCOS focuses on helping ovulation occur with the assistance of oral medications or injections. Many women with PCOS are overweight, so additional attention is paid to improve a patient’s body mass index with diet and exercise guidelines. Decreasing a patient’s weight is also helps improve the safety of a pregnancy for the baby and the mom. If you have irregular periods or have noticed excess hair growth on your face, chest, or abdomen, you should see your doctor to determine if you may have polycystic ovary syndrome.
If I use a donor egg how long will it take for me to start my IVF cycle?
There are certain situations where a woman needs to select a younger egg donor to help her achieve a pregnancy. This happens when the quantity and quality of eggs decreases to a level that can no longer result in a healthy pregnancy. While this can be a difficult decision to make, pregnancy rates are very high using donor eggs because the quality of eggs that can be retrieved is so high. The first step in coordinating an IVF cycle using donor eggs is selecting a donor from a bank or agency. Talk with your doctor about your options for finding a donor. Once a donor is selected, the necessary testing is performed on both parties prior to initiating the cycle. Usually all of the necessary testing can be performed over the course of one menstrual cycle. After the testing is completed, your cycle and the donor’s cycle are synchronized so that your uterus will be ready for the embryos once the eggs are retrieved from the donor. The donor’s eggs are fertilized with your partner’s sperm and the embryo(s) are transferred into your uterus. You will work very closely with the donor team throughout the cycle to make sure that all of the coordinating goes smoothly.
– Dr. Mary Hinckley
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