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Archive for the ‘diminished ovarian reserve’ tag

4 Hot Fertility Questions at ASRM 2016

By David Kreiner MD

November 7th, 2016 at 7:45 am

The theme for the 2016 ASRM (American Society for Reproductive Medicine) conference in Salt Lake City, Utah was “Scaling New Heights in Fertility”.  As one whose life on Long Island sheltered me from views of snow-capped mountain tops, the perspective of the attendees appeared to climb higher and perhaps to possibilities never previously conceived.

I summarize here 4 Hot Fertility Questions that were debated and discussed in the conference:

1)      Should PGS screening be routine for all IVF patients?

2)      Should all IVF transfers be restricted to blastocysts only?

3)      Should we freeze all embryos and transfer in an unstimulated cycle?

4)      What is the best treatment for the patient with diminished ovarian reserve?

Should PGS screening be routine for all IVF patients? 

The theoretical benefit of Pre-Implantation Genetic Screening, or“PGS”, testing is that it allows one to select a single “tested normal” embryo in the presence of multiple embryos which is more likely to implant and less likely to miscarry.  Absent testing the chromosome number of the embryos, to insure a similar chance of conception one might transfer two embryos– increasing the likelihood that twins would result in a pregnancy at greater risk for prematurity and complications affecting the health of the babies.  Most miscarriages are the result of abnormal chromosomes and if the embryos had normal chromosomes then there should be less of a chance the pregnancy would result in miscarriage.

The argument against routine PGS testing is based mainly on the fact that the test is not 100% accurate or predictive of either normalcy or abnormalcy in addition to not obtaining a result in some cases.  It is argued that the error rate is only 1% but there is a phenomenon called mosaicism where an embryo may have more than one cell line. It is not rare that an embryo which has an abnormal cell line in addition to a normal one can, during development, shed the abnormal cells and evolve normally.  However, PGS testing may pick up only the abnormal cell or detect both normal and abnormal and then there is the question of what to do with the mosaic embryos since there is no current way to predict whether these embryos will ultimately be normal.

Another argument against routine PGS testing is that most abnormal embryos never implant anyway and that perhaps the reduction in miscarriages with PGS is not as great as predicted.  Still another argument that holds true for younger patients in particular is that the pregnancy rate for a single blastocyst transfer is nearly as high without PGS testing and that one can achieve equal success without the risk of discarding potentially normal embryos.

Should all IVF transfers be restricted to blastocysts only?

In addition to improving the ability to select the best embryo, the proposed advantages of a blastocyst transfer (typically 5-6 days old) versus a cleaved embryo transfer (usually 3 days old) include the following:

  • an embryo transferred 5-6 days after ovulation is closer to the natural physiologic state
  • there are thought to be fewer uterine contractions 5-6 days post ovulation than 3 days;
  • blastocysts have a larger diameter and are thought to be less likely to be pushed into the fallopian tubes—which may lead to a lower ectopic pregnancy rate;
  • there is a shorter time to implantation and therefore less opportunity for a deleterious event to occur to an embryo in the uterus.

However, there are some patients, in particular older or those with more fragile embryos, which have been shown to fail to conceive on multiple occasions after a blast transfer but successfully get pregnant and deliver healthy babies after transfer of cleaved embryos.  Furthermore, there is evidence that in some of these cases embryos that may have been destined to otherwise result in a normal pregnancy may fail to develop to blast in the laboratory.

Should we freeze all embryos and transfer in an unstimulated cycle?

There is a growing consensus nationally among IVF programs that the endometrium is less receptive to embryo implantation during a stimulated cycle–especially one in which the estradiol and/or progesterone levels are high.  Although convincing patients to delay transfer to a subsequent unstimulated cycle is a challenge, growing evidence is pushing the field in this direction.

What is the best treatment for the patient with diminished ovarian reserve?

Optimal treatment of the patient with diminished ovarian reserve remains a challenge to the IVF program.  There is growing evidence that adjuvant therapy, including such things as acupuncture and Chinese herbs as well as supplements such as CoQ10 and DHEA, may improve a patient’s response to stimulation and improve pregnancy rates.  Other strategies include sensitizing follicles with estradiol and/or Growth Hormone pre-treatment and banking embryos from multiple cycles with transfer during an unstimulated cycle.  Still another strategy is milder stimulation in an attempt to improve the quality of the retrieved egg/s.

There were many heights achieved during this meeting and to this boy from Queens I was impressed not just with the science and the breathtaking vistas of the regal mountains forming a horseshoe around Salt Lake City but also with the most pleasing goodness of the people native to the city who genuinely offered their time to help make our experience a pleasant one.

 

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Age and Fertility

By David Kreiner MD

February 2nd, 2015 at 4:23 pm

 

credit: photostock/free digital photos.net


You’ve heard the “Reproductive Bell” toll and may question “Is it real?”…

You see celebrities getting pregnant well into their 40’s and think “Then why can’t I?” So, is your reproductive clock as critical as modern doctors say?

I have come across fertility advice from non-physician practitioners, such as acupuncturists and Chinese herbalists, who encourage their patients to “question the Western dogma” when it comes to age and fertility. They claim the effect of aging and fertility is “exaggerated by the Medical profession and can be overcome with a shift in an individual’s health and lifestyle”.

Unfortunately, this advice comes without any cited research or statistics in support of it.  According to the Society of Assisted Reproductive Technology, as published on SART.org, a review of the 2012 national statistics, those most recently published of IVF cycles started, the age breakdown for IVF live birth rates are the following:

 

Age <35= 40.2%

 

Age 35-37=31.3%

 

Age 38-40=22.2%

 

Age 41-42=11.8%

 

Age >42=3.2%

 

It is true that a woman’s health and physiology gets worse as she gets older.  Some of these non- physician practitioners argue that perhaps if this can be improved then the diminishing fertility commonly seen with aging can be reversed. But though improving a woman’s general health may help it is not sufficient in most cases.  Fertility rates decrease with increasing age in large part because there is an increase in genetic abnormalities found in gametes (eggs and sperm) as patients (women in particular) age.  This is the result of long-term environmental exposure to toxins, in addition to the increased likelihood of genetic damage over time.  Miscarriage rates increase with age for the same reason in large part due to the greater likelihood of embryos having chromosomal abnormalities.

Many women as they age also will experience a significant drop in their ovarian activity, referred to as diminished ovarian reserve.  This activity can be assessed by your physician with a blood level of Anti Mullerian Hormone (AMH) and day 3 FSH and estradiol levels.  Women with lower AMH levels and elevated FSH in the presence of a normal low estradiol have fewer ovarian follicles, and hence eggs, that will respond to ovarian stimulation.  Since the likelihood of these eggs being genetically normal is less, then fertility is reduced and the probability of IVF and other fertility treatments resulting in a live birth becomes significantly lower.

The challenge to any practitioner dealing with an aging patient attempting to conceive is to optimize their patient’s chance to have a healthy baby which optimally would include an integration of multiple modalities.  Therefore, ideally a physician specially trained in the fertility process (a Reproductive Endocrinologist), should implement state-of-the-art Western therapies with a complementary holistic approach that aims to shift their patient’s health and fertility.  These holistic approaches include diet and lifestyle changes as well as fertility-directed acupuncture and herbal therapy treatments.

Lifestyle changes that may improve fertility primarily include those that reduce stress and improve diet and activity.  Stress at work, at home, and with family and friends can create pathology from both Eastern and Western perspectives.  Diets that do not support adequate blood production or create Eastern patterns of cold or heat can affect fertility.  Excesses or deficiencies of particular foods…such as dairy, fat, or grains… can create imbalances or pathology that may affect fertility or result in obesity or malnutrition which also impact reproduction.

Inactivity may impair fertility. Therefore some level of exercise, combined with an improved diet directed at improving fertility, stress reduction techniques, acupuncture, and supplements (which may include Chinese Herbs as well as Western supplements) will optimize your chances of successfully building your family.

The first step is to seek help from a reproductive endocrinologist skilled in state-of-the-art fertility therapies who can coordinate a program which is ideal for you. But if you are hearing the “Reproductive Bell” tolling, it is important to take that first step soon, because, while these many complementary approaches can optimize your fertility, they may not be enough to overcome the reality of the negative effect of advanced age in fertility.

Long Island IVF offers complementary holistic approaches to achieving pregnancy (See our Mind-Body Program http://www.longislandivf.com/mind_body.cfm ) as well as a well-respected Donor Egg Program http://www.longislandivf.com/donor_programs.cfm  with no wait for pre-screened, multi-ethnic donor eggs, or Donor Embryos.

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Has the increased visibility of older celebrity moms getting pregnant made you think you have more time? Have you considered combining Western and Eastern medicine in your family-building treatment?

 

 

http://www.freedigitalphotos.net/images/Younger_Women_g57-Young_Woman_Holding_Clock_p49428.html

 

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Reasons to Consider Annual Fertility Screening

By David Kreiner MD

December 19th, 2014 at 8:01 pm

 

credit: akeeris/ freedigitalphotos.net


What Is Fertility Screening?

Fertility screening starts with a blood test to check the levels of FSH (follicle stimulating hormone), estradiol and AMH (antimullerian hormone). The FSH and estradiol must be measured on the second or third day of your period. The granulosa cells of the ovarian follicles produce estradiol and AMH. The fewer the follicles there are in the ovaries the lower the AMH level. It will also mean that less estradiol is produced as well as a protein called inhibin. Both inhibin and estradiol decrease FSH production. The lower the inhibin and estradiol the higher the FSH as is seen in diminished ovarian reserve. The higher the estradiol or inhibin levels are then the lower the FSH. Estradiol may be elevated especially in the presence of an ovarian cyst even with failing ovaries that are only able to produce minimal inhibin. However, the high estradiol reduces the FSH to deceptively normal appearing levels. If not for the cyst generating excess estradiol, the FSH would be high in failing ovaries due to low inhibin production. This is why it is important to get an estradiol level at the same time as the FSH and early in the cycle when it is likely that the estradiol level is low in order to get an accurate reading of FSH.

The next step is a vaginal ultrasound to count the number of antral follicles in both ovaries. Antral follicles are a good indicator of the reserve of eggs remaining in the ovary. In general, fertility specialists like to see at least a total of eight antral follicles for the two ovaries. Between nine and twelve might be considered a borderline antral follicle count.
As you start to screen annually for your fertility, what you and your doctor are looking for is a dramatic shift in values from one year to the next.

What Does the Screen Indicate?

A positive screen showing evidence of potentially diminishing fertility is an alarm that should produce a call to action. When a woman is aware that she may be running out of time to reproduce she can take the family-planning reins and make informed decisions. The goal of fertility screening is to help you and every woman of childbearing years make the choices that can help protect and optimize your fertility.

Although none of these tests is in and of themselves an absolute predictor of your ability to get pregnant, when one or more come back in the abnormal range, it is highly suggestive of ovarian compromise. It deserves further scrutiny. That’s when it makes sense to have a discussion with your gynecologist or fertility specialist. Bear in mind, the “normal” range is quite broad. But when an “abnormal” flare goes off, you want to check it out. It’s important to remember that fertility is more than your ovaries. If you have risk factors for blocked fallopian tubes such as a history of previous pelvic infection, or if your partner has potentially abnormal sperm, then other tests are in order.

Regardless of the nature or severity of the problems, today, with Assisted Reproductive Technology and the latest Egg-freezing technology, there is a highly effective treatment available for you.

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Have you had a fertility screening yet? Did you find it helpful? Do you have any questions for Dr. Kreiner?

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Infertility and The Greatest Gift

By Tracey Minella

April 12th, 2014 at 7:02 am

 

credit: artur84/freedigitalphotos.net


Ever wish you could make a real difference in someone’s life? A life-altering difference?  Well, you can, and you just may improve your own life in the process.

Egg donation is a gift you can give to a friend, family member, or stranger who desperately wants to conceive, but for any number of reasons, is unable to do so with her own eggs. She needs the eggs of a young, healthy, generous woman. Possibly you.

Donor egg recipients are often women who have struggled with infertility for years. Many have exhausted all other medical options to conceive using their own eggs or may have suffered the pain of repeated miscarriage along their journey. Sadly, some women battle cancer only to find that chemotherapy and/or radiation robbed them of the ability to use their own eggs to start a family afterwards.  

Egg donors are special, empathetic people.

Although they are financially compensated in the sum of $8,000, most women donate their eggs simply because they want to help someone else.

Some donors have had children and know how much motherhood means. Others may be students who aren’t ready to have their own families just yet, but want to help someone else do so. Most healthy, young women under the age of 31 can be candidates.

Long Island IVF gave Long Island its first donor egg baby. For more than two decades our Donor Egg Program has been helping donor egg recipients find the right egg donor and build their families.

If you’re interested in giving someone the ultimate gift…the chance to become a mother…and want to learn more about becoming an egg donor, including details regarding compensation for participation in the program, please contact the Donor Egg Coordinator, Vicky Loveland, RN, at (631) 752-0606 and view our website at http://www.longislandivf.com/egg_donor.cfm

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Are you, or do you know anyone who would be, interested in this opportunity? If so, please call or forward this information to others.

If you have donated… or received… eggs would you share your experience?           

 

Photo credit: http://www.freedigitalphotos.net/images/agree-terms.php?id=100169597 artur84

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Is Your Biological Clock Running Out?

By David Kreiner, MD

January 10th, 2014 at 10:35 pm

 

image courtesy of photo stock/freedigital photos.net

Tears start to course down the cheeks of my patient, her immediate response to the message I just conveyed to her. Minutes before, with great angst anticipating the depressing effect my words will have on her, I proceeded to explain how her FSH was slightly elevated and her antral follicle count was a disappointing 3-6 follicles. I was careful to say that though this is a screen that correlates with a woman’s fertility, sometimes a woman may be more fertile than suspected based on the hormone tests and ovarian ultrasound. I also said that even when the tests accurately show diminishing ovarian reserve (follicle number), we are often successful in achieving a pregnancy and obtaining a baby through in vitro fertilization especially when age is not a significant factor.

These encounters I have with patients are more frequent than they should be. Unfortunately, many women delay seeking help in their efforts to conceive until their age has become significant both because they have fewer healthy genetically normal eggs and because their ability to respond to fertility drugs with numerous mature eggs is depressed. Women often do not realize that fertility drops as they age starting in their 20s but at an increasing rate in their 30s and to a point that may often be barely treatable in their 40s.

A common reason women delay seeking help is the trend in society to have children at an older age. In the 1960’s it was much less common that women would go to college and seek a career as is typical of women today. The delayed childbearing increases the exposure of women to more sexual partners and a consequent increased risk of developing pelvic inflammatory disease with resulting fallopian tube adhesions.

When patients have endometriosis, delaying pregnancy allows the endometriosis to develop further and cause damage to a woman’s ovaries and fallopian tubes. They are more likely to develop diminished ovarian reserve at a younger age due to the destruction of normal ovarian tissue by the endometriosis.

Even more important is that aging results in natural depletion of the number of follicles and eggs with an increase in the percentage of these residual eggs that are unhealthy and/or genetically abnormal.

Diminished ovarian reserve is associated with decreased inhibin levels which decreases the negative feedback on the pituitary gland. FSH produced by the pituitary is elevated in response to the diminished ovarian reserve and inhibin levels unless a woman has a cyst producing high estradiol levels which also lowers FSH. This is why we assess estradiol levels at the same time as FSH. Anti-Mullerian Hormone (AMH) can be tested throughout a woman’s menstrual cycle and levels correlate with ovarian reserve. Early follicular ultrasound can be performed to evaluate a woman’s antral follicle count. The antral follicle count also correlates with ovarian reserve.

By screening women annually with hormone tests and ultrasounds a physician may assess whether a woman is at high risk of developing diminished ovarian reserve in the subsequent year. Alerting a woman to her individual fertility status would allow women to adjust their family planning to fit their individual needs.

Aggressive fertility therapy may be the best option when it appears that one is running out of time. Ovulation induction with intrauterine insemination, MicroIVF and IVF are all considerations that speed up the process and allow a patient to take advantage of her residual fertility.

With fertility screening of day 3 estradiol and FSH, AMH and early follicular ultrasound antral follicle counts, the biological clock may still be ticking but at least one may keep an eye on it and know what time it is and act accordingly.

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Did you realize that aging is not the only factor in the biological clock race? Did you know that certain conditions, like endometriosis, can play a part, too?

 

Photo credit: http://www.freedigitalphotos.net/images/agree-terms.php?id=10049499

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Infertility Podcast Series: Journey to the Crib: Chapter 31: When Are You Too Old to be a Mother?

By David Kreiner MD

November 24th, 2013 at 9:44 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Thirty-One: When Are You Too Old to be a Mother? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=143

When Are You Too Old to be a Mother?

 

Over the years, there have been reports of women as old as in their 70′s having babies as a result of In Vitro Fertilization (IVF) performed using donated eggs from a young fertile donor.  Immediately after these reports appear, I am bombarded with questions and criticisms about how wrong it is that we (somehow I am included as part of the responsible party as an IVF practitioner) allow women to have children beyond that which is not just natural but also reasonable. Those of us in IVF have had many experiences with making the news as this medical technology pushes to the edges of what society views as acceptable.

 

We are often put in the position of making decisions with our patients that have even larger implications to society than the individual patient.  I do my best to look at each patient and each situation as unique and treat them accordingly.  Regarding the age of a prospective egg recipient however we are dependent on the patient’s honestly reporting such to us.  Unfortunately, there are circumstances where patients have misled their doctors and in the case of one 70 year old mother, she had reported to the clinic that she was in fact 53.

 

Even so, it is the responsibility of the IVF provider to ensure that a woman is healthy and capable of bearing the pregnancy, giving birth and being a mother.  There is not an absolute age cutoff at which point a woman is universally unfit to undergo IVF and become pregnant.

 

My personal oldest woman I helped achieve a pregnancy was a 53 year old who delivered at age 54.  She had a normal stress test, EKG and was cleared by an internist, perinatologist and psychologist.

 

Some point out that beyond a certain age, it is unnatural to become a mother and that it puts the family at risk that she may not be around to help raise the child or that perhaps the woman lacks the energy and stamina to raise the child properly.  I personally struggle to separate my own feelings about the proper age to have a child which may be inappropriate for others who have a different perspective.  My responsibility as the physician is to the health of my patients, the well-being of the child and for the good of society.

 

Many women in their 50′s have the health and energy to carry a pregnancy and bear a child with no more risk than many women 10-20 years younger.  That being said, what about the risk that the mother may not be around to raise the child to maturity?   There is no question that a young healthy couple with sufficient financial support and emotional maturity is ideal to raise a family.  But, happy, successful families can take on many different faces.  Single parent families exist, survive and often thrive.  One can never be certain that the condition of the couple at the time of conception will continue through the child’s birth or for that matter until the child has reached maturity.  In addition, at least 50% of couples in the U.S. become divorced.  One can argue that couples at risk of divorce should not get pregnant.

 

I apologize that I cannot offer an answer to this question, when are you too old to be a mother.  For me personally, it is more a question of health …for the mother and baby… which needs to be evaluated individually for each case utilizing testing and experts to make the best assessment.  Otherwise, I feel it is an individual’s right to choose as long as society is unaffected or supports the individual in those cases where the pregnancy has a significant impact beyond the immediate family.

 

 

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Was this helpful in answering your questions about what fertility doctors might consider when questioning if an older woman may be able to conceive and carry a pregnancy?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them.

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Infertility Podcast Series: Journey to the Crib: Chapter 29: Why the Wyden Bill Does Not Support Fertility Patients

By David Kreiner MD

November 3rd, 2013 at 11:20 am

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Nine: Why the Wyden Bill Does Not Support Fertility Patients. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=138

Why “The Wyden Bill” Does Not Support Infertility Patients

 

IVF results subjected to government audit were mandated to be reported with the passage of the “Wyden bill”.   The intent of the CDC and national reproductive society (SART) was to assist infertility patients by informing them of the relative success of all IVF programs in the country. 

 

Unfortunately, what sometimes creates the best statistical results is not always in the best interest of the mother, child, family and society.  Now that prospective parents are comparing pregnancy rates between programs there is a competitive pressure on these programs to reports the best possible rates.   Sounds good…unfortunately it doesn’t always work out that way for the following reasons.

 

Patients with diminished ovarian reserve, who are older or for any number of reasons have a reduced chance for success, have a hard time convincing some programs to let them go for a retrieval.  In 2008, we reported our success, 15% with patients who stimulated with three or fewer follicles.  Sounds low and in fact many of these patients were turned away by other IVF programs in our area.  However, for those families created as a result of their IVF, these “miracle” babies are a treasure that they otherwise… if not for our program giving them their chance… would never have been born.

 

Another unfortunate circumstance of featuring live birth rate per transfer as the gold standard for comparison is that it pressures programs to transfer multiple embryos thereby increasing the number of high risk multiple pregnancies created.  This is not just a burden placed on the patient for their own medical and social reasons but these multiple pregnancies add additional financial costs that are covered by society by increasing costs of health insurance as well as the cost of raising an increased number of handicapped children.

 

William Petok, the Chair of the American Fertility Association’s Education Committee reported on the alternative Single-Embryo Transfer (SET) “Single Embryo Transfer:  Why Not Put All of Your Eggs in One Basket?”.  He stated in November 2008, that although multiple rather than single-embryo transfer for IVF is less expensive in the short run, the risk of costly complications is much greater.  Universal adaptation of SET cost patients an extra $100 million to achieve the same pregnancy rates as multiple transfers, but this approach would save a total of $1 billion in healthcare costs.

 

We have offered SET since 2006 with the incentive of free cryopreservation, storage for a year and now a three for one deal for the frozen embryo transfers within the year in an effort to drive patients to the safer SET alternative. 

 

If we are going to report pregnancy rates with IVF as is required by the Wyden Bill, let us put all programs on the same playing field by enforcing the number of embryos to be transferred and even promoting minimal stimulation IVF for good prognosis patients.  The Wyden Bill without the teeth to regulate such things as the number of embryos transferred and reporting success per embryo transfer does more harm than good.  Let us promote safer alternatives and report in terms of live birth rate per stimulation and retrieval, including frozen embryo transfers, so that there is a better understanding of the success of a cycle without increasing risks and costs from multiples.

 

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Was this helpful in answering your questions about the Wyden Bill, IVF success rates and reporting requirements, and SET?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them.

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Choosing a Fertility Clinic: The Importance of Being an Educated Consumer

By David Kreiner MD and Eva Schenkman MS CLT TS

September 9th, 2013 at 9:16 am

 

image courtesy of Ambro/free digital photos.net

In-Vitro Fertilization (“IVF”) offers the highest chance for success of any fertility treatment.

Pregnancy rates for IVF have improved dramatically over the years. In 1989, the national delivery rate was only 14%… by 2011, it had increased to 30%. To put this in perspective, the pregnancy rate of couples with proven fertility is approximately 20% per cycle. So while 30% nationally may sound low, it is greater than the average fertile couple will have in any given cycle.

In 2011, Long Island IVF had a 40% live birth rate per retrieval for the 303 patients under 43 years of age.

There have been many advances in IVF technologies over the years, including embryo culture media and environment, improved laboratory air quality, improvements in embryo transfer technique and ultrasound visualization of transfer catheter placement, and advances in fertility medication.  The skills and experience of reproductive endocrinologists and their cycle management, coupled with the highly-skilled and experienced embryologists, have improved IVF success rates significantly.

When investigating prospective IVF clinics, the delivery rate or “take home baby” rate as it is known, is really the only true measure of success. As a patient, you should be aware that many clinics define success in different ways. This may include defining success as a positive pregnancy test or any pregnancy, even miscarriages and ectopic pregnancies. While to a clinic, these numbers may serve as important quality indicators to the patient desiring a baby these successes are irrelevant.

Pregnancy and birth rates from IVF procedures are subject to influences that may vary significantly from clinic to clinic, making success rate comparisons between clinics very troublesome for consumers. These differences between clinics may be explained by a variety of factors that impact a patient’s fertility potential.  Such variables as infertility diagnosis, age of patients, rejecting patients with prior failed cycles and a program’s threshold for performing IVF on patients with diminished ovarian reserve will impact reported success rates..  Cycle cancellation policies and the number of embryos the clinic is willing to transfer likewise will significantly affect reported success rates.

In most cases, these differences reflect the philosophies and clinical practices of the physicians, and are not sinister or purposefully deceptive manipulations. Nonetheless, consumers need to be aware of these differences when comparing success rates, and also, put success rates in perspective when choosing a clinic. Success rates among clinics can vary greatly, so consumers must be careful when investigating prospective programs. Even the Society for Assisted Reproductive Technologies (“SART”), the organization to which IVF practices report their pregnancy rates, cautions consumers that IVF success rate data should “not be used for comparing clinics.”

Given this complexity to interpreting pregnancy rates, how should patients choose a clinic?  Most important, and potentially evident to the prospective patient, is the level of experience and expertise of the physicians and embryologists in the program.  Furthermore, IVF labs that rely on per diem staff that is unable to monitor and manage the embryology laboratory on a daily basis may lead to deficiencies in quality and consistency which may be another potential cause of lower success rates.  

It is important to look at several years’ worth of data rather than just how a clinic performed in one year. If a clinic consistently under- performs, patients need to think strongly before entrusting their eggs in its care.

While IVF success can vary with many factors, the biggest determining factor of success is maternal age. Success rates will decline with a woman’s age, and they drop off dramatically after about age 37. Age can affect both egg quantity and egg quality. While there is no test to assess egg quality, there are tests that can be performed to assess egg quantity. These include:

·                     Day 3 FSH testing

·                     AMH Levels

·                     Antral follicle counts.

The following table shows pregnancy rate, live birth and singleton rates nationally for 2010. This data clearly shows the impact of advancing maternal age on IVF success. As you can see, the curve starts to drop about age 28. It drops faster at about age 34 and even more startling drop after age 38.


*   The dark blue line (triangles) shows pregnancy rates per cycle by age

*   The red line (circles) shows live birth rates per cycle by age

*   The rate of singleton live births per cycle is shown by the green line
*   The difference between “pregnancy” rate and “live birth” rate is due to miscarriages

In this table, the IVF live birth rates per cycle started for different age groups (circled in red). Percent of IVF cycles resulting in egg retrieval, an embryo transfer & a pregnancy are also shown.

              At Long Island IVF, the total combined years of experience of our Senior Embryology team is over 100 years. Most of our Senior Embryologists hold advanced degrees in their field. Our Laboratory Director holds a PhD degree and is certified by both NYS and the American Board of Bioanalysts as a High Complexity Laboratory Director.

             Long Island IVF achieved Long Island’s first successful IVF leading to the birth of a baby in 1988.  Since then, with advances in technology and experience, success rates have skyrocketed.

            At Long Island IVF, from the most recent birth rates available (IVF performed in 2011), patients under 35 had a 51% live birth rate (59 live births/116 retrievals).  As of the summer of 2013 an additional 20 patients achieved live births as a result of 50 transfers from embryos frozen at the time of their 2011 retrieval (40%).  This cumulative success rate from 2011 retrievals as of August 2011 was 68.1% (79 live births/116 retrievals).           

            Not all clinics are created equal and as the consumer you really need to do your homework to find the clinic with excellent success rates that offers the expertise needed to give you the best chance of achieving your dream and bringing that baby home. Do not be too shy to ask the tough questions about not only the physician but the lab.

            The message here is to do your research on all clinics in your area, schedule a consult with several different clinics, and pick the clinic that best fits your needs.

 

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What is/was the most important factor to you when choosing a fertility clinic?

 

Photos credit: Ambro http://www.freedigitalphotos.net/images/agree-terms.php?id=10029569

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Infertility Podcast Series: Journey to the Crib: Chapter 29: Why the Wyden Bill Does Not Support Fertility Patients

By David Kreiner MD

August 28th, 2013 at 2:18 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Nine: Why the Wyden Bill Does Not Support Fertility Patients. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=138

Why “The Wyden Bill” Does Not Support Infertility Patients

 

IVF results subjected to government audit were mandated to be reported with the passage of the “Wyden bill”.   The intent of the CDC and national reproductive society (SART) was to assist infertility patients by informing them of the relative success of all IVF programs in the country. 

 

Unfortunately, what sometimes creates the best statistical results is not always in the best interest of the mother, child, family and society.  Now that prospective parents are comparing pregnancy rates between programs there is a competitive pressure on these programs to reports the best possible rates.   Sounds good…unfortunately it doesn’t always work out that way for the following reasons.

 

Patients with diminished ovarian reserve, who are older or for any number of reasons have a reduced chance for success, have a hard time convincing some programs to let them go for a retrieval.  In 2008, we reported our success, 15% with patients who stimulated with three or fewer follicles.  Sounds low and in fact many of these patients were turned away by other IVF programs in our area.  However, for those families created as a result of their IVF, these “miracle” babies are a treasure that they otherwise… if not for our program giving them their chance… would never have been born.

 

Another unfortunate circumstance of featuring live birth rate per transfer as the gold standard for comparison is that it pressures programs to transfer multiple embryos thereby increasing the number of high risk multiple pregnancies created.  This is not just a burden placed on the patient for their own medical and social reasons but these multiple pregnancies add additional financial costs that are covered by society by increasing costs of health insurance as well as the cost of raising an increased number of handicapped children.

 

William Petok, the Chair of the American Fertility Association’s Education Committee reported on the alternative Single-Embryo Transfer (SET) “Single Embryo Transfer:  Why Not Put All of Your Eggs in One Basket?”.  He stated in November 2008, that although multiple rather than single-embryo transfer for IVF is less expensive in the short run, the risk of costly complications is much greater.  Universal adaptation of SET cost patients an extra $100 million to achieve the same pregnancy rates as multiple transfers, but this approach would save a total of $1 billion in healthcare costs.

 

We have offered SET since 2006 with the incentive of free cryopreservation, storage for a year and now a three for one deal for the frozen embryo transfers within the year in an effort to drive patients to the safer SET alternative. 

 

If we are going to report pregnancy rates with IVF as is required by the Wyden Bill, let us put all programs on the same playing field by enforcing the number of embryos to be transferred and even promoting minimal stimulation IVF for good prognosis patients.  The Wyden Bill without the teeth to regulate such things as the number of embryos transferred and reporting success per embryo transfer does more harm than good.  Let us promote safer alternatives and report in terms of live birth rate per stimulation and retrieval, including frozen embryo transfers, so that there is a better understanding of the success of a cycle without increasing risks and costs from multiples.

 

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Infertility Podcast Series: Journey to the Crib: Chapter 12 What Do You Know About Your Fertility?

By David Kreiner MD

May 13th, 2013 at 8:16 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twelve: What Do You Know About Your Fertility? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=74

What do you know about your fertility?

Women have a biological clock.  Everyone knows that.  However, life seems to get in the way sometimes; whether it be school, career or failure to find Mr. Right.  Most people assume that if they are healthy then there should not be a problem conceiving.  Unfortunately, general health and fertility are not always related.

Women are born with their reproductive lifetime supply of eggs.  That means the body doesn’t produce new ones.  With each menstrual cycle one egg is released and an additional thousand eggs simply are lost in the body’s natural process of selecting one for ovulation.  As a woman approaches 50, she typically runs out of her store of eggs.

Additionally, there is the issue of the effect of aging on the eggs.  Older eggs are more likely to have chromosomal abnormalities making them unlikely to become viable embryos.  Fertilized eggs with abnormal chromosomes are the most common cause of miscarriages, running about 40% by age 40.

Furthermore, not everyone’s ovaries/eggs age at the same rate and again it is not necessarily reflective of how old you look either.  Often very young looking women have very old acting ovaries and eggs.  You can be screened to evaluate your fertility status with an ultrasound examination of your ovaries performed by an experienced reproductive endocrinologist as well as by blood hormone screening looking at your FSH, estradiol and AntiMullerian Hormone levels.

I urge every woman of reproductive age who has not completed her childbearing to be evaluated and make plans based on knowledge about her own fertility.  Aggressive fertility treatment might be needed depending on your age, how long you have been trying to conceive, and your fertility screening.  Women who do not have a partner should explore the possibility of freezing their eggs while the likelihood of them still being healthy is high.  Remember, fertility treatment has a high success rate that decreases significantly as time passes on the biological clock.

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Was this helpful in answering your questions about your fertility?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them personally.

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