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Archive for the ‘history of IVF’ tag

ASRM Retrospective 30 Years Later

By David Kreiner MD

October 17th, 2013 at 1:48 pm

image courtesy of renjith krishnan/freedigital photos.net

 

Flying into Boston this week it occurred to me that this was the 30 year anniversary of the first ASRM meeting I ever attended.  In 1983, the American Fertility Society “AFS” meeting (as it was called then) was held in San Francisco and I attended as a third year ob-gyn resident. I was in awe attending this huge conference of about 3-5,000 held at the Hyatt Hotel as I recall.


Though I was required to man the Ovcon 35 birth control pill exhibit (since Ovcon’s manufacturer was paying my way), I was drawn to the microsurgery and in vitro fertilization exhibits and presentations.  

In the ballroom, the presenters presided over a few thousand of us eager to hear about the most recent successes in IVF.  Already, Norfolk had achieved dozens of births through this new scientific process which brought gynecological surgeons (laparoscopists) together with embryo biologists, endocrinologists, andrologists and numerous nurses, technicians and office staff.  For me, hearing Dr. Howard Jones, American IVF pioneer, and others speak about their experiences with this life creating technique was exhilarating.

Years later, as a Jones Institute reproductive endocrinology fellow, I would hear Dr. Howard proclaim that a chain is only as strong as its weakest link.  IVF required every link to maintain its integrity for the process to work.

In 1985, I presented my own paper at the AFS meeting in Phoenix, Arizona.  My wife and two sons joined me.  My presentation on endometrial immunofluorescence in front of hundreds of experts and specialists in the field remains one of the strongest memories in my life.

Today, the ASRM must be held in mega convention centers like the one in Boston where it could accommodate tens of thousands of attendees.  One presentation estimated the number of IVF births worldwide at over five million. Interestingly, per capita, the US performs one fifth the number of IVFs as Europe–where IVF is much more accessible and typically covered by government insurance.

Today, success in the US is better than fifty per cent for most people, thereby making single embryo transfer (“SET”) for good prognosis patients a viable option to avoid the risk of multiple pregnancy. Minimal stimulation IVF (“Micro-IVF”) is a viable alternative for many patients, offering a lower cost and lower risk option.  Egg freezing offers a means of fertility preservation, especially valuable to women anticipating cancer therapy.  Pre-embryo genetic screening (“PGS”) is an option that allows patients to screen for and eliminate genetically undesirable embryos that may otherwise lead to miscarriage or termination.

Looking back at the past thirty years, I am amazed at the progress and achievements made by my colleagues in IVF and happy that I was able to participate in this most rewarding field that has brought so much joy to millions of people.

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photo credit: renjith krishnan http://www.freedigitalphotos.net/images/agree-terms.php?id=10058384

 

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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 28: No More “Jon and Kate” Casualties

By David Kreiner, MD

August 23rd, 2013 at 5:12 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-Eight: No More “Jon and Kate” Casualties. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=136

No More “Jon and Kate” Casualties

 

A few years ago when I wrote this chapter, the Jon and Kate makes eight story was still hot in the press.  It brought to the national limelight the potentially tragic risk of the high order multiple pregnancy for women undergoing fertility therapy.  It is one I was all too familiar with from my early days in the field, during the mid-1980′s when the success with IVF was poor and we consequently ran into occasional high order multiple pregnancies with transfer of four or more embryos or with the alternative gonadotropin injection treatment with intrauterine insemination (IUI).

 

Today, IVF is an efficient process that, combined with the ability to cryopreserve excess embryos, allows us to avoid almost all high order multiple pregnancies.  In fact the IVF triplet pregnancy rate for Long Island IVF docs has been under 1% for several years now.  There has not been a quadruplet pregnancy in over 20 years.  Such a claim cannot be made for gonadotropin injection/IUI therapy where as many eggs that ovulate may implant.

 

You may ask then why would we provide a service that is both less successful and more risky and was the reason Jon and Kate made eight.

 

Not surprisingly, the impetus for this unfortunate treatment choice is financial.  Insurance companies, looking to minimize their cost, refuse to cover fertility treatment unless they are forced to do so.  In New York State, there is a law that requires insurance companies based in NY State that cover companies with over 50 employees that is not an HMO to cover IUI.  The insurance companies battled in Albany to prevent a mandate to cover IVF as has been passed in New Jersey, Massachusetts and Illinois among a few others.  As a result, many patients are covered for IUI but not IVF.  This short-sighted policy ignores the costs that the insurance companies, and ultimately society, incurs as a result of high order multiple pregnancies, hospital and long-term care for the babies.

 

The answer is simple.  Encourage patients to practice safer, more effective fertility.  This can be accomplished with insurance coverage for IVF, wider use of minimal stimulation IVF especially the younger patients who have had great success with it and minimizing the number of embryos transferred. 

 

At Long Island IVF we encourage single embryo transfer by eliminating the cost of cryopreservation and embryo storage for one year for patients who transfer one fresh embryo.  In addition, we offer those patients up to three frozen embryo transfers for the price of one within a year of their retrieval or until they have a live birth.

 

It is my sincere wish that the government can step in to enforce a policy that will never again allow for the possibility of another Jon and Kate debacle.

 

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Was this helpful in answering your questions about multiple pregnancies, IVF, IUI, and Micro-IVF?

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

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IVF Throwback Thursday

By Tracey Minella

March 7th, 2013 at 11:22 pm

Just for kicks, I thought I’d be nostalgic today…and show my age…by telling those still on their infertility journeys what infertility treatment and IVF was like “back in the day”.

“The day” being the early 1990’s.

All patient charts were folders with paper in them. Computers were still the size of a Volkswagen and were only used by the medical billers.

There were no apps to keep track of anything. Girls had a paper calendar and a mercury basal body thermometer to track their cycles or ovulation. That’s because there were no smart phones. In fact, there weren’t cell phones at all yet. The high tech communications device of that time was the pager. Important folks…or those who wanted to look that way…wore them clipped to their belts and when someone was looking for them, it’d vibrate—which sent them running to find the nearest payphone. Yes, payphone. Anyone have a quarter?

We watched injection teaching videos on VHS tapes and then practiced on an orange. Once. If the husband wanted to be involved, that was his only job back then. Well, besides the major genetic contribution. Husbands were not present in the transfer room.

Except for Lupron, every needle needed for IVF was a twelve inch 2-1/2 inch IM syringe. Well, it felt like it was twelve inches…

Retrievals and transfers were only done hospitals, so hours of waiting and paperwork were added to the experience. No convenient, private on-site facilities were available. Blood work was drawn at the hospital on Sunday mornings. So after your sonogram, off you went with a prescription to the lab.

All transfers were Day 3. There were no Blastocyst transfers yet in the early 90’s. Transfers were done without ultrasound guidance and with an empty bladder. You laid there perfectly still in Ambulatory surgery with butt propped up on pillows and your legs elevated for an hour or more as the feeling of pins and needles ate at your feet. You tried not to hit any bumps on the car ride home.

And that was the kind of transfer the lucky ones got. The ones with the easily navigable cervixes.  The unlucky ones had something called a “Jones” transfer, named after America’s famous founding couple of IVF, Drs. Howard and Georgianna Jones, of the Jones Institute in Norfolk, VA. In a Jones transfer, you didn’t lay on your back. Instead, you’d kneel on the gurney with your face mushed into the pillow… and your butt in the air. Can there possibly be another position of greater humiliation?

There was little or no insurance coverage for anything related to infertility, much less IVF. (Some things never change.)

 

The success rates were low compared to today. With IVF, my odds of conceiving, at under 35, were only 17%. In 2011, the live birth rate per transfer at LIIVF was nearly 60%! See success rates here: http://www.longislandivf.com/ And transferring four (4) embryos back was routine. No surprise that there was more high-order multiple births back then.

There were no 3D baby sonograms. And no Facebook to post them on. You had to pick up the corded phone and actually call people to tell them the good news!

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Hearing all this, do you think it’s harder or easier to go through IVF now than it used to be?

 

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=6563&picture=volkswagen-van

 

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Infertility Podcast Series: Journey to the Crib Chapter 1

By David Kreiner MD

March 22nd, 2012 at 3:45 pm

Welcome to the Journey To the Crib Podcast.  We will have a blog discussion each week with each chapter.  You, the viewer, are invited to ask questions and make comments.  You can access the podcast here:http://www.longislandivf.com/podcast/Chapter_1-ThroughMyEyes-AnHistoricalPerspectiveOnIVF.mp3

 The first chapter introduces the reader to the writer, me, and my early experiences in the field of reproductive endocrinology, infertility and IVF.  This was during the early years of IVF and I was a new doctor driven by a passion for fertility; the science, the surgery and the new technology of in vitro fertilization.

 

I dedicated the book to my parents who were both still alive when it was published.  They taught me the importance of family as it was the most precious commodity they owned.  My father recently passed but he was excited and proud of the work his son did even if he suggested making more revisions to my original drafts than I wanted to hear.  My mother, who suffered a ruptured cerebral aneurysm twenty five years ago and as a result has significant cognitive issues, remains my biggest fan.

 

It was with great anticipation that I sent to my mentor, Dr. Howard W. Jones Jr., this first chapter as much of it describes my impressions of him and his wife, Georgeanna Seegar Jones, the American pioneers in In vitro fertilization.  Today, he is 101 years old and remains the sharpest individual I have ever met.  I am proud to say that he was touched and impressed with my memories as I recorded them. 

 

If you have not had the opportunity to hear him speak, please do yourself a favor and listen to any one of many videos recorded of him.  “Dr. Howard” describes how he initiated his efforts to develop the first IVF program in the U.S. on http://vimeo.com/asrm/howardjones

I have a YouTube video discussing this pioneering couple at: http://www.youtube.com/watch?v=b790aiFLzJI&feature=related

If you have time, Dr. Howard gives an exceptional speech on the future of fertility on http://vimeo.com/17418251 .  He starts speaking about 19 minutes into the video.

 

The reproductive endocrinologist who had the greatest impact on my career was Dr. Zev Rosenwaks.  I unfortunately did not sufficiently credit him with the huge influence he had on my career and in shaping the physician that I have become.  As Zev was a fellow of both Joneses at Johns Hopkins and I was a fellow of his, it is this family of Reproductive Endocrinology from which my career was born.  There is not a thing that I do in practice today that cannot be traced back to Zev or Drs. Howard and Georgeanna or to any of the other fertility giants that were in Norfolk in those days including Suheil Muasher, Mason Andrews, Annibal Acosta, Gary Hodgen, Sergio Oehninger and Richard Scott.

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Please let us know what you think of the podcast.

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