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Archive for the ‘multiple pregnancies’ tag

Infertility Podcast Series: Journey to the Crib: Chapter 32: Octomom

By David Kreiner, MD

October 3rd, 2013 at 6:57 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-Two: Octomom. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=146

Octomom

 

A year ago, the Medical Board of California revoked the license of Dr. Michael Kamrava, finding he “did not exercise sound judgment” in transferring 12 embryos to Nadya Suleman, who already had six children at home. The ruling, while not surprising, was illuminating, and it’s worth reflecting on the five things we learned from Octomom:

 

1.      Know How to Say “No”: There is a point where physicians have to make a judgment call. Pregnancies with triplets – let alone eight infants – put the mother at high risk of serious medical complications and put unborn children at risk for developmental disabilities. Physicians need to rely on their professional expertise and experience to know when to turn down a patient request no matter how vehemently it is made.

 

2.      Beware the Patient with Tunnel Vision: Often when a patient comes to a fertility doctor, unsuccessful pregnancy attempts have made her anxious and determined. She might want to get pregnant regardless of the risks that pregnancy may present.

3.      Less is More: In 1999, 35 percent of all transfers involved four or more embryos. In 2009, only 10 percent had four or more. And those high-number transfers are generally reserved for patients with significant fertility challenges. In contrast, Octomom already underwent multiple successful IVF (in vitro fertilization) procedures and had given birth to six children when she had her 12-embryo transfer.

 

4.      Know When to Deviate: While Dr. Kamrava’s deviation from guidelines was an extreme departure, deviations do occur for specific reasons, such as repeated IVF failure, age-related infertility and poor egg quality. It is important to know when implanting several embryos is appropriate.

5.      “Reduce” Risk: Dr. Kamrava complained that Octomom refused to undergo “selective reduction,” which would have reduced the number of embryos she carried to term. Here, again, is an argument for fewer transfers. Had he transferred fewer embryos, Octomom would not have had to face such a difficult decision.

 

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Was this helpful in answering your questions about what could have been done differently to prevent the Octomom case? How much weight do you give your doctor’s recommendation on the number of embryos to transfer?

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

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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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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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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Infertility Podcast Series: Journey to the Crib: Chapter 3: What Are My Odds?

By David Kreiner MD

February 26th, 2013 at 4:59 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Three: What Are My Odds? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=24

 

What are my odds?

 

This chapter is dedicated to informing patients regarding the potential for success with fertility therapy.  Success, in particular with IVF has been increasing significantly over the years as physicians and embryologists became more experienced.   The tools we use are more accurate and effective today and the protocols, media and laboratory conditions are all far superior to that which was standard not so many years ago.

 

This improved efficiency of the process has allowed physicians to transfer fewer embryos thereby avoiding the higher risk multiple pregnancies that IVF was known for in the 1990’s.  Still pressure exists to transfer multiple embryos to minimize expenses for the patient and maximize success rates for the IVF programs.  I have instituted a single embryo transfer incentive (SET) program at Long Island IVF eliminating the cost of cryopreservation and storage for a year for patients transferring a single embryo.  These patients are also offered three frozen embryo transfers within a year of their retrieval for the cost of one in an effort to eliminate the financial motivation some patients express to put “all their eggs in one basket”.  Experience tells us that the take home baby rate for patients transferring a single embryo at the fresh transfer is equal to that for patients transferring multiple embryos when including the frozen embryo transfers. For information on the SET program, go to: http://bit.ly/WpzCvv

 

Since the merger of East Coast Fertility and Long Island IVF, we have seen clinical IVF pregnancy rates at 66% (35/53) for women <35, 60% (18/30) for women 35-37, 54.1% (20/37) for women 38-40 and 8/28 (28.6%) for women 41-42 from Oct 1- Dec 31, 2011.  MicroIVF has been running better than 40% for women <35.

 

Different factors are discussed that can affect pregnancy rates at different programs.  The use of Embryo Glue and co-culture at Long Island IVF are discussed as laboratory adjunctive treatments that appear to improve our success rates.

 

For the most recent success rates, speak to your Long Island IVF physician or visit our website at http://bit.ly/XYZrSC

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Please share your thoughts about this podcast or ask any questions of Dr. Kreiner here.

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Infertility Podcast Series: Journey to the Crib: Chapter 33: Fertility Treatment During This Economic Downturn

By David Kreiner, MD

November 8th, 2012 at 6:19 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers the final chapter, Chapter Thirty-Three: Fertility Treatment During This Economic Downturn. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=149 

 Fertility Treatment During This Economic Downturn 

Financial hardships have increased fertility challenges for many couples attempting to build their families.  In regions where patients do not have insurance coverage for their IVF procedures it is unlikely that they proceed with the treatment that is necessary for them to be able to complete their families. 

In places that do provide coverage for IVF, such as Massachusetts, 5% of all babies born are as a result of IVF.  Elsewhere in the U.S., IVF accounts for only 1% of births suggesting that the financial cost of IVF denies access for approximately 80% of couples in need.

The problem of the cost of IVF is compounded by the fact that patients are driven to transfer multiple embryos to limit the cost and avoid additional fees from cryopreservation, embryo storage and frozen embryo transfers.  These multiple transfers increase the risks of multiple pregnancy and preterm delivery with subsequent complications to the babies from preterm birth. 

We, at Long Island IVF, attempt to make IVF more accessible and safer by offering income based grants, free cryopreservation, storage and discounted frozen embryo transfers to patients electively transferring single embryos.  We have also offered free IVF cycles through best video/essay contests to a few needy patients over the past few years. 

It is our sincere wish and hope that a bill that is presently in front of Congress offering a tax credit to patients going through IVF is passed thereby making IVF that much more affordable to our patients in need. 

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Was this helpful in answering your questions about fertility treatment during this economic downturn? Are you aware of the pending proposed Family Act, which would offer a tax credit to infertile women wishing to undergo infertility treatment (similar to the current adoption credit for those wanting to pursue adoption)? Have you urged your legislators to support this important legislation?

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

 

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IVF Today: One Baby at a Time

By Tracey Minella and David Kreiner MD

August 26th, 2011 at 12:00 am

Single embryo transfers. What a concept!

Back when I was doing IVF in the mid-90’s, transferring FOUR embryos was the norm! Sometimes even more, depending on the patient’s history! After a few failed IVFs, I did a GIFT/ET in 1994 with 4 eggs for the GIFT plus a 3ET. Technically, I could have been the “Septomom”, though prior history didn’t make that seem possible. I did get pregnant that cycle but later miscarried that twin pregnancy.

Also back then, my best friend was doing IVF at a clinic upstate. She had elected on medical advice to reduce a triplet pregnancy to a twin pregnancy, but miscarried after the selective reduction. A few years later, she got pregnant with triplets again. She did not reduce and, despite many complications, has healthy 12 year old triplets now.

It’s refreshing to see that technology at some of the finest fertility clinics now enables couples to choose single embryo transfers (SETs) and avoid the expense and potential complications a high order, high risk multiple pregnancy brings.

Dr. Kreiner of East Coast Fertility believes so strongly in the success rates and safety of SETs that his practice offers an amazing financial incentive to patients undergoing traditional IVF. Read on for details:

I entered the field of IVF in 1985 when the pregnancy rate at the Jones Institute, the most successful program in the country, was 15 percent. This rate was achieved by transferring six embryos at a time. As a consequence, we experienced many high order multiple pregnancies. Unfortunately, these were often complicated and did not always end well. Aside from pregnancy and neonatal complications, many of the marriages also suffered.

Thankfully, today IVF is so much more successful and we can attain pregnancies in greater than 60 percent of retrievals for women under 40. These rates are accomplished while transferring one, two, or at most three embryos at a time. Cryopreservation, or freezing embryos, has also improved our pregnancy rates per retrieval giving us multiple opportunities to get a patient to conceive from a single IVF stimulation and retrieval.

In an effort to encourage safer single embryo transfer and avoid risky multiple pregnancies, we introduced a program in 2007 at East Coast Fertility for patients who transferred one embryo at a time. For these patients we offered free cryopreservation, storage and frozen embryo transfers until a live baby was born.

Still, patients don’t commonly choose single embryo transfer.

From our experience, similar to others’, there was no significant difference in pregnancy rates between patients who chose to transfer one embryo vs. those who chose to transfer two embryos. There was a trend, however, towards higher rates for the two-embryo transfer group that was practically eliminated when frozen embryo transfers were added. These groups were age matched with no difference except for a 40 percent twin rate and one triplet in the two-embryo transfer group compared to the single-embryo transfer group in which no twins were created.

It is hoped that these results will encourage a higher percentage of good prognosis patients to transfer a single embryo, which is the safer option.

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Would incentives and stats like those above make you consider SET for yourself? Why or why not?

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Octomom’s Fertility Doctor Loses License

By Tracey Minella and David Kreiner MD

June 7th, 2011 at 1:16 am

Eight small steps for mankind; one giant leap backwards for reproductive technology.

According to ABC News*, Dr. Michael Kamrava has had his license to practice medicine revoked. His name may not be familiar. But he’s notoriously well known as the fertility doctor responsible for transferring 12 embryos at one time into the uterus of Nadia Suleman, thereby creating the American phenomenon known as the Octomom. That’s 6 times more than the current national average.

Her delivery of eight IVF babies in January 2009 shocked the world on its own, but when the whole story came out, including her being a single, unemployed mother of six other young IVF children, it sent up red flags to anyone with half a mind. And its negative press set back the IVF movement by showcasing the sensational event.

Thankfully, he can no longer put the lives of mothers and babies at risk with his poor judgment and wanton disregard of the standards and procedures followed by responsible and ethical reproductive endocrinologists.

Only time will tell if those 14 kids grow up to kick his butt.

Read on for a flashback to Dr. Kreiner’s original post on the horror of the Octomom experience and why you’ll never be an Octomom at ECF:

The American public has been stunned by the news of a mother of six giving birth to octuplets. This shocking news is compounded by the stories broadcast by the mass media regarding the woman’s family situation and that she used IVF for these pregnancies.

Physicians have known for many years the dangers of multiple pregnancies and have worked steadily to formulate evidence‐based guidelines for the number of embryos to transfer in IVF cycles. The current rate of triplets in IVF cycles nationally has dropped in 2005 to only 2% of cycles. At East Coast Fertility our triplet rate has been below 1% since 2002 and not one of these occurred from transfer of more than 2 embryos. In fact a financial incentive is offered to patients to transfer a single embryo. Cryopreservation of embryos is offered for free as well as storage for up to 1 year. In addition, up to 3 frozen embryo transfers are offered for free until a baby is born. Patients are encouraged by this program not to put all their eggs in one basket. Unfortunately, this was not the case for this woman. Success rates with IVF, especially, in the good prognosis patients exceed 50% even when 1 or 2 embryos are transferred. It is hard to imagine a situation where it would make sense to take such an extraordinary risk like was done in this case in California.

We should keep this case in mind when considering how many embryos to transfer. It is rarely worth the risk to put more embryos back when one can alternatively keep the embryos in frozen storage until a patient is ready to conceive again.

* http://abcnews.go.com/Health/wireStory?id=13735735

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