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Dr. Natalie Crawford At Vivere Austin Publishes Study On Depression

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Infertile women who are depressed are less likely to proceed with fertility treatments, a small U.S. study suggests.

Fertility specialists should consider screening patients for depression, the authors write, to help these patients improve their quality of life and not miss out on the chance of pregnancy.

Of 416 women in the study, 41 percent screened positive for depression, researchers found.

“The relationship between depression and infertility is complex. Many women in our study screened positive for depression,” lead author Dr. Natalie Crawford told Reuters Health in an email.

Dr. Crawford, who is currently medical director of fertility preservation at Austin Fertility Institute in Texas, led the study while she was at the University of North Carolina (UNC) in Chapel Hill.

While she was at UNC, all patients were given questionnaires to screen for depression and providers noticed that many women tested positive.

“We suspected that women who did screen positive for depression were less likely to comply with infertility treatment recommendations,” Dr. Crawford said.

“Our study revealed that women who have a screening test correlating with depression were less likely to proceed with infertility treatments, likely making it harder to achieve the ultimate goal of pregnancy,” Dr. Crawford said.

The research team sent electronic questionnaires to 959 women. The surveys were designed to screen for mental health disorders and patients’ perception of mental health disorders and fertility.

Of the 416 women who answered the questionnaire, more than half had been trying to conceive for more than two years.

Although 41 percent actually tested positive for depression based on their questionnaire responses, 50 percent of the women with infertility said they felt depressed most or all of the time.

Only 36 percent of the women who screened positive for depression went ahead with fertility treatments compared to 64 percent of women who did not have depression, according to the results published January 9 in the journal Human Reproduction.

Dr. Crawford said that if people have friends or family members who are struggling with infertility, it is important to acknowledge their difficulty.

“I think simply starting the conversation is the hardest part. Couples who have infertility often report social isolation,” she said. “Thus, supporting friends and family who are suffering can be extremely helpful. Express your feelings clearly.”

Patients might not realize that their avoiding fertility treatment may be, in fact, a sign of the stress infertility is causing them, said Dr. Heather Shapiro, who wasn’t involved in the study.

Dr. Shapiro, vice chair of education in the Obstetrics and Gynecology department at the University of Toronto, said she thinks that fertility doctors are generally familiar with the problem of patients avoiding or delaying treatment due to depression or anxiety or some kind of emotional response to fertility.

It might help if family and friends recognize that when someone has started and then abandoned fertility treatment, there’s a good chance that there’s a major stress component to that, she said.

“If you’re in a position to address that stress component either as an informal family support member or professional support member, addressing the stress directly would probably in the long-term help their fertility,” Dr. Shapiro said.

By | January 25th, 2017|Industry News|0 Comments

Vivere Partners, Houston Fertility Institute, Named One of the Top Fertility Clinic by Forbes Magazine

By | April 21st, 2016|Industry News|Comments Off on Vivere Partners, Houston Fertility Institute, Named One of the Top Fertility Clinic by Forbes Magazine

‘Designer Babies:’ Patented Process Could Lead to Selection of Genes for Specific Traits

Wall Street Journal

A personal-genomics company in California has been awarded a broad U.S. patent for a technique that could be used in a fertility clinic to create babies with selected traits, as the frontiers of genetic enhancement continue to advance.

The patented process from 23andMe, whose main business is collecting DNA from customers and analyzing it to provide information about health and ancestry, could be employed to match the genetic profile of a would-be parent to that of donor sperm or eggs. In theory, this could lead to the advent of “designer babies,” a controversial idea where genes would be selected to boost the chances of a child having certain physical attributes, such as a particular eye or hair color.

The technique potentially could also be used to create healthier babies, by screening out donors with genes that are predisposed to disease, either on their own, or in combination with the recipient’s genes.

The awarding of the patent “is a massive addition to what is currently being done” in fertility clinics, said Sigrid Sterckx of the Bioethics Institute Ghent in Belgium, who co-wrote a commentary on the 23andMe patent in the journal Genetics in Medicine on Thursday. “It indicates a different attitude, not just about disease-related traits, but nondisease traits.”

23andMe, based in Mountain View, Calif., says that while its new patent encompasses trait selection in babies, through a tool called the Family Traits Inheritance Calculator, it has no plans to apply it to that end. Instead, 23andMe said, the tool offers customers “a fun way to look at such things as what eye color their child might have or if their child will be able to perceive bitter taste or be lactose tolerant.”

A spokeswoman for 23andMe, Catherine Afarian, said in an emailed response: “When the patent was first filed nearly five years ago, there was some thinking that this feature could have potential applications for fertility clinics where the donor selection process was typically based on photos, family history, and some limited genetic testing of donors—much of this has evolved in the past five years.” But 23andMe “never pursued the idea and has no plans to do so,” she said. 23andMe was co-founded in 2006 by Anne Wojcicki, who recently separated from her husband, Sergey Brin, co-founder of Google Inc.

The prospect of real designer babies—where it would be possible to reliably choose cosmetic traits such as complexion and hair color or even physical characteristics such as athleticism—remains a distant one. But that day may be drawing closer, thanks to advances in genetic technology.

Some people say it is unethical to bioengineer children because better-off parents could use it to give their children a competitive edge, widening societal divisions. Others worry about the “slippery slope” consequences: while it may relatively be harmless to choose a child’s hair or eye color, what if genetic breakthroughs allowed parents to enhance a child’s intelligence or athletic ability? But others say there is nothing wrong with genetic enhancement; parents, they argue, should be free to endow their kids with the best start in life.

One potential approach, unrelated to 23andMe’s patent, is known as pre-implantation genetic diagnosis, or PGD. It typically entails testing a three-day-old embryo, consisting of about six cells, to see if it carries a particular genetic disease. Only embryos free of that disease are implanted in the mother’s womb, to ensure the disease isn’t passed on.

However, some U.S. clinics have been using PGD not just to root out unwanted diseases, but also to allow customers to choose the gender of their child. That, some argue, is a step toward designer babies.

In principle, PGD could also be used to weed out—or specifically choose—physical traits such as eye or hair color, which are governed by relatively few genes. It will be much harder to select for other traits, such as height, athleticism or intelligence, because they are governed by multiple genetic factors as well as environmental effects.

23andMe’s patent describes a different technique. It explains how a patient would first specify certain traits that he or she wants in a child. Based on the patient’s own genetic profile, a computerized system then “performs inheritance calculations pertaining to the [traits] of interest and identifies one or more preferred donors for the recipient,” the patent states.

A chart accompanying the patent describes the outlines of such a system, whereby the recipient can choose a child with a low risk of colorectal cancer, say, along with a high probability of green eyes. For this to work, the genetic profiles of both recipient and donor (the provider of sperm or eggs) would have to be known. It isn’t clear whether any fertility clinic today asks donors for a genetic profile.

“Test tube babies were seen as an abomination [initially] but today they are routine and boring,” said Jacob Sherkow, an expert on biotechnology patents at Stanford University’s law school. In the same way, he added, 23andMe’s patent “is a shot across the bow—a signal to the world that this is what the future is going to look like.”

By | October 3rd, 2013|Industry News|Comments Off on ‘Designer Babies:’ Patented Process Could Lead to Selection of Genes for Specific Traits

New fertility treatment can induce egg growth in infertile women

Fox News

For women with primary ovarian insufficiency (POI), getting pregnant can feel like nothing more than a dream.  Characterized by entering menopause early before the age of 40, this kind of infertility has no current treatment options, and women cannot have a baby that shares their genetic information.

But now, there may be an answer for these women who want to have a child of their own.  Researchers from Stanford University School of Medicine have developed a brand new technique called in vitro activation, which involves inducing the ovaries to produce eggs.

The scientists tested their treatment on 27 women in Japan with POI and were able to collect viable eggs from five of them.  After going through the treatment, one woman gave birth to a healthy baby boy, and another is currently pregnant.

“Right now the main options people have for this diagnosis is to either do egg donation and fertilize with the intended father’s sperm, or they may adopt the child,” Dr. Valerie Baker, associate professor of obstetrics and gynecology at Stanford, told FoxNews.com. “Various fertility medications really don’t work well for this condition at all, which is why this is such a ray of hope.”

Awakening sleeping follicles

The key to developing their technique came when researchers discovered a signaling pathway responsible for controlling the growth of follicles in ovaries.

“The human ovary is a very interesting organ in that you have 800,000 follicles at birth,” senior author Dr. Aaron Hsueh, professor of obstetrics and gynecology at Stanford, told FoxNews.com. “…The follicles sit there, and they don’t grow, but then about 1,000 of this 800,000 begin to grow every month.”

Of those 1,000 follicles, only one matures into an egg that is released during ovulation each month.  During the course of her lifetime, a woman will ovulate only around 400 mature eggs.

It had previously not been known why one particular follicle became an egg and the others did not, but in 2010, Hsueh discovered that several proteins, including one called PTEN, regulate this growth process.  He showed that PTEN acts as a brake in the ovaries, keeping the small follicles from maturing fully.

“This is a system that’s found in a lot of organs in the body, and originally found in the fly,” Hsueh said.  “It is a very used signaling pathway that makes sure your heart or liver do not overgrow when they reach the right size.”

Hsueh found that by blocking this PTEN “brake” system, he could stimulate dormant follicles in the ovaries to grow and produce mature eggs.  He explained that although women with POI no longer have menstrual cycles, some of them still have unused small follicles in their ovaries.

In vitro activation

Utilizing this science, Hsueh and his colleague Yuan Cheng, a postdoctoral scholar in Hsueh’s lab, came up with a complex method called in vitro activation, which ultimately led to the successful birth in their study cohort.

First they removed the ovaries from their 27 participants, which were then cut into pieces – a process known as fragmenting.  Previous research has shown that mechanically disrupting the ovary through cutting or drilling small holes in it can help stimulate follicular development.

Once the ovaries were cut into small pieces, the scientists treated them with drugs to block the PTEN pathway, in order to further stimulate the smaller follicles to grow.  The ovary pieces were then transplanted through small incisions near the fallopian tubes of the women from which they were removed.

Of the 27 participants, five women went on to develop mature eggs – much more quickly than originally expected.

“This is where the interesting thing comes in,” Hsueh said. “This small sleeping follicle usually takes six months to grow” – based on pervious tests using mouse models.  “However, in his original study (Cheng) found that within three weeks, several of his patients had mature follicles and mature eggs.”

The mature eggs were then collected and fertilized with the intended husband’s sperm through in vitro fertilization.  The resulting embryos were then frozen and transferred back into the uterus.

Of these five women, one received her embryo but failed to become pregnant, one received the embryo and is currently pregnant, and one became pregnant, ultimately giving birth to a seemingly healthy baby boy.  The other two women are still preparing for their embryo transfer and undergoing further rounds of egg collection.

Providing hope

Hsueh and his team hope that in vitro activation will aid an entire group of women who previously thought they could never have a child of their own.  They noted that their technique can also be used to help women who have beaten cancer.

“A lot of people survive cancer, but because their chemotherapy damages the ovaries, they have fewer follicles,” Hsueh said.  “They’ll reach early menopause, but some of them still have smaller follicles and those baby follicles will be helped to wake up by this procedure.”

However, as shown in their study, only a fraction of women who reach early menopause will go on to successfully grow mature eggs.

“If they don’t have follicles left, there’s nothing you can do,” Hsueh said.  “So 25 to 30 percent of this type of patient can eventually have a baby.”

But according to Baker, who is working with Hsueh to continue investigating the treatment in Japan and at Stanford, these small odds are enough for these women.

“It’s so devastating for the women who have this,” Baker said. “For most people, the most important element in life is to have a family or have a child.  It can be devastating to a woman and her partner, not having a child genetically related…  So I’m incredibly excited.  It’s the first thing I’ve seen that looks like it could be hopeful.”

The research was published in the Proceedings of the National Academy of Sciences.

By | October 1st, 2013|Industry News|Comments Off on New fertility treatment can induce egg growth in infertile women

New Hope for Infertile Women: Healthy Eggs

Time Health & Family

About 6.7 million American women suffer from infertility, 1% of whom struggle to get pregnant because of poor-quality eggs.

Most of these women, whose ovaries don’t produce the regular amounts of estrogen needed to nurture and develop healthy eggs every month, will enter menopause before they turn 40. But researchers from Stanford University have developed a technique that could help them to overcome their ovarian insufficiency by supporting the follicles to produce healthy, mature eggs again.

Using a process called in vitro activation (IVA), the scientists take an ovary, or piece of ovarian tissue, and treat it outside the body with proteins and other factors that normally prompt immature follicles to mature into eggs. The recharged tissue is then reimplanted into the women’s ovaries. Among the 27 women who volunteered in the small study, five were able to produce viable eggs, one is pregnant, and another gave birth to a healthy baby.

The process, which the scientists described in the Proceedings of the National Academy of Sciences, is meant to “awaken” the follicles that failed to develop properly.

Although the study was small, the team is optimistic that it could be used to help infertile women who previously had to rely on egg donors to become pregnant, and that it might be expanded to aid women whose follicles were affected by chemotherapy treatments for cancer as well. Two of the women are waiting for an embryo transfer.

“The women and their partners come to me in tears. To suddenly learn at a young age that your childbearing potential is gone is very difficult,” said Dr. Valerie Baker, the director of Stanford’s Program for Primary Ovarian Insufficiency, in a statement. “This technique could potentially help women who have lost their egg supply for any reason.”

Andrew La Barbera, the American Society for Reproductive Medicine’s scientific director, says the research is exciting for women with ovarian insufficiency who want to conceive using their own eggs. Experts had previously thought that women with the condition did not have viable eggs, but the breakthrough suggests that it may be just a matter of stimulating them in the right way. “All of the patients had evidence of pre-existing follicles in the ovarian fragments that were harvested. That makes this paper all the more interesting scientifically because it suggests that primary ovarian insufficiency might not be due to simply ‘running out of follicles’ but rather might be due to inadequate stimulation,” he says. And this enhanced understanding of how human follicles develop and mature could also lead to other improvements in fertility treatments that could affect millions more women who struggle to start a family of their own.

By | September 30th, 2013|Industry News|Comments Off on New Hope for Infertile Women: Healthy Eggs

10 Things You’ve Always Wanted To Ask A Fertility Specialist

By Jessica Henderson | Forbes.com

You can’t bear to let anyone else hold your 6-month-old niece at family gatherings, the hat you’re absentmindedly knitting seems suspiciously small, and your Netflix queue is overrun with titles like “Baby Boom” and “What to Expect When You’re Expecting.”

If you’re ready for a baby, but not sure that your body is cooperating, it may be time to consult a fertility specialist.

Infertility—a disease of the reproductive system that impairs the body’s ability to conceive children—affects about 7.3 million women and their partners in the U.S. according to the CDC’s 2002 National Survey of Family Growth. And with the average cost of an IVF cycle coming in at a gulp-inducing $12,400, you’ll want to maximize your chances from the start.

To help you take those first, er, baby steps down the path to fertility, LearnVest spoke to Dr. Alan Copperman, director of infertility at Mount Sinai Medical Center in New York City, about the anxiety, misconceptions, key questions, and finally the triumph of today’s fertility treatment options to help get you started on diaper duty.

LearnVest: What does a fertility specialist do?

Dr. Alan Copperman: A reproductive endocrinologist practices all aspects of reproductive medicine, but in this day and age, we find ourselves really focusing on fertility preservation or curing infertility. There are animals that can simply look at each other from across a pond and get pregnant with quintuplets, but humans can be incredibly inefficient when it comes to reproduction. In humans, not all eggs are normal, they don’t always fertilize, they don’t always implant and they don’t always stick. And the major reason why there’s so much infertility is not because people aren’t eating right or are too stressed out—it’s because of reproductive aging.

For a woman in her twenties, about 90% of her eggs are normal, but by the time she’s in her forties, nearly 90% are abnormal. What we do is try to maximize fertility—and that starts with encouraging a woman to take her reproductive options seriously. If she’s in her thirties, and isn’t ready to conceive, egg freezing is an option that’s really come of age—it’s no longer considered experimental, and there have been thousands upon thousands of healthy babies born. If a woman is married, then we encourage her to conceive sooner than later because it doesn’t get easier over time.

What exactly is fertility preservation?

In general, fertility preservation is egg freezing, although it could also be embryo freezing. We’ve had many couples that aren’t at the right point in their lives or careers just yet, but they want to have children in the future, so we give them fertility medications, retrieve the eggs, fertilize them with the sperm and then freeze and hold them in liquid nitrogen. In a couple of years, the couple can thaw the embryos—and their fertility will essentially be preserved at the age that they are now, instead of the age that they will be.

How do you go about trying to locate the source of infertility?

When a couple comes in, it’s important to look at the basics: Are the eggs OK? Is the sperm OK? Is the uterus OK? Are the fallopian tubes normal? So we test the eggs through bloodwork and an ultrasound. We can see if a uterus is normal with an ultrasound. We can determine if the sperm is OK with a semen analysis. And we can tell if the fallopian tubes are open by doing an X-ray called an HSG, in which we inject dye through the cervix to tell whether or not it flows through the tubes.

Just by doing these basic tests, you’re usually going to pick up on a reason for infertility in almost all patients. So if you find a problem with the sperm, we can start with inseminations or in vitro fertilization, which involves implanting one normal embryo. If the fallopian tubes are blocked, we can unblock them surgically or do IVF and bypass them.

What should people take into consideration when they first start seeing a fertility specialist?

They should be prepared for physical, emotional and financial challenges. Walking into your specialist’s office empowered with questions to ask is my first piece of advice—and not necessary questions culled from random blogs or chatrooms that can sometimes heighten the hysteria surrounding infertility. Some questions to bring: What is your philosophy on twins? What is this going to cost? How has your practice performed compared to others? Are the technologies offered here the ones that I have the biggest need for? It’s OK to ask these questions. Cancer patients are certainly asking about their expected survival—and it’s only reasonable that a fertility patient know what are their chances for success.

What concern do you most often hear from patients who are just beginning treatments?

That they are going to wind up with twins or multiples. It can be unhealthy to carry twins—and certainly Octomom scared off a lot of patients—so I reassure couples that we’re striving for healthy, singleton births. We’ve tried to change treatments in recent years to minimize that risk by putting in one embryo, rather than two or three, because there’s more understanding that twin pregnancies can be complicated.

Fertility treatments are usually perceived as scary expensive. What financial considerations should you take into account?

This is such a complicated question. Different states have different mandates, and that might all be disappearing with the Affordable Healthcare Act. I would say that it’s important—upfront—for a patient to understand what the financial cost could be, and what their potential out-of-pocket expenses will be.

The practice should have a designated financial coordinator who understands their plan, and who will help them understand what it is to precertify treatments, what their pharmacy benefits are, and what the short- and long-term costs are going to be. It really is extremely variable—some people have very little covered, some people have almost everything covered, and most people have at least something covered.

I don’t usually like to speak to the financial side, but very generally speaking, the consultation and work-up can be in the hundreds, a cycle of fertility medications and inseminations can be in the thousands, in vitro can be $10,000 to $12,000, and getting pregnant using donated eggs can be over $20,000.

RelatedThe Latest Baby Trend: Crowdfunding Conception

Often, we’re finding that it’s more cost-effective to do a single, higher-tech treatment than multiple months of low-tech treatments—i.e., trying in vitro fertilization, which has a very high success rate, rather than doing multiple low-tech treatments, such as taking fertility pills and trying to time intercourse or intrauterine insemination, which involves injecting sperm directly into the uterus. This way, you can also take advantage of any financial caps that your insurance may have on treatments.

It’s clear that having as much information as possible upfront is key. But how else should a patient prepare?

If a woman wants to be a single mom by choice, she should definitely look at what her support systems are—and what the future looks like. If a couple comes in, they should have a good idea of each other’s thresholds and concerns.

We see men who don’t want to get a semen analysis because they’re afraid there’s something abnormal, and we have women who are afraid of gaining weight or that their emotions might change while on medication, so talking to each other about tolerance before walking into the visit is important. The answer to much of the stress that fertility treatments present is communication. Hopefully, articles like this will help empower patients to ask questions, control expectations and have some faith in the process—because most couples are successful.

Say a patient has decided to move forward with treatment. How do you go about finding a specialist who best fits your needs?

Most ob-gyns have relationships with specialists in the community, and they have a sense for who takes the best care of their patients, who might have a concierge environment, and who helps their patients come back to them pregnant quickly and with a healthy, singleton pregnancy.

The American Society of Reproductive Medicine can help you find a doctor who’s been board-certified. There’s also information available through sart.org, which profiles clinic-specific information to at least let you know what your realistic chances are at various clinics. Also, different clinics participate in different insurance plans, so a patient can call up their plan representative and ask if there’s a Center of Excellency close to them, based on their criteria. All of these are reasonable ways to do some homework.

How much of a role do family genes and history play in fertility?

I think it’s less reassuring than most couples would believe. In other words, it’s very common for a woman to come in and say, “My mom had kids into her forties, my grandma had them in her forties, and my sister is ultra-fertile. It’s unbelievable that I’m not getting pregnant!”

But it actually is believable—there isn’t really a fertility gene that goes around in families. Of course, there can be something causing miscarriages in families at a higher incidence or a history of premature menopause. But while there are negative predictors of fertility that can be familial, I would not be overly reassured by the super fertility of Grandma.

Speaking of, what’s the most common misconception about infertility?

That stress causes infertility—and that simply relaxing can cure it. By telling a woman to just relax, you’re really blaming her or saying she’s got control over something that she doesn’t. There really is no evidence that taking time off or meditating is going to make someone more fertile—as long as she’s having intercourse during ovulation, she has just as good a chance of getting pregnant than someone who’s feeling calm.

By | September 26th, 2013|Industry News|Comments Off on 10 Things You’ve Always Wanted To Ask A Fertility Specialist

Oncofertility offers new options for young women with cancer who want to have kids

The Washington Post

When Michele Foust received a diagnosis of Stage 2 breast cancer this spring, she typed out a list of questions about her treatment.At the top of the 26-year-old’s concerns was an unknown that haunts many young cancer patients: “If I survive, will I be able to have children?”
Foust’s breast surgeon was unsure and told her she thought it was likely that chemotherapy would impair her chances by damaging healthy eggs as fast as it killed other rapidly dividing healthy cells such as hair follicles.Indeed, says Neelima Denduluri, a breast medical oncologist at Virginia Hospital Center, “chemo is a real risk to fertility.” Certain regimens, she says, “are more likely to cause infertility and decreasing of sperm count,” with up to 80 percent of patients affected, with exact rates depending on the type of cancer treatment and age at diagnosis.Despite this, medicine has come a long way recently toward helping cancer patients — women especially — preserve fertility prior to treatment.The most common and successful option for a woman with cancer is freezing an egg or embryo before undergoing chemotherapy or radiation. Once the patient decides she is ready to get pregnant, she is given estrogen and progesterone to prepare the lining of the uterus. The embryo is then thawed (or the egg is inseminated) and transferred into the uterus. Success rates specifically for cancer patients have not yet been studied. But in vitro fertilization (IVF) rates are around 50 percent for women younger than 35.(For men with cancer, freezing sperm before treatment is far less invasive and less expensive.)

There are also experimental options such as ovarian tissue freezing, in which all or part of an ovary is removed and the outer area, which contains the eggs, is frozen in strips for later use. The ovary can be reimplanted when the patient is well. The procedure typically costs around $12,000; because it is experimental, research centers often provide funding, according to Teresa Woodruff, a professor of obstetrics and gynecology at the Feinberg School of Medicine at Northwestern University. Woodruff refers to such procedures as part of oncofertility, a new discipline that bridges oncology and reproductive medicine.

“I really appreciated there were so many advances in cancer therapy, yet so many young survivors were ending up sterilized,” Woodruff said. “There was a real need for a focus specifically in this field.”

Beginning the discussion

About 140,230 Americans younger than 45 will receive a cancer diagnosis this year, the American Cancer Society projects. The large majority of them are likely to survive for five years or more.

But only recently has fertility been factored into a patient’s treatment plan, according toMark Payson, a reproductive endocrinologist at Dominion Fertility, a practice based in Arlington. When he speaks to breast cancer support groups, patients say that “only half of their oncologists talk to them about fertility options.”

Last month, a study by researchers at the University of Sheffield in England found that only 40 percent of young female cancer patients were happy with the way their doctors discussed the options they had to preserve fertility.

Most doctors are typically more concerned with saving the patient’s life than with fertility options, Payson said.When Ilana Brunner’s breast cancer was discovered in 2009, she quickly embarked on fertility treatments in order to freeze some embryos before chemo began. But she was concerned others might not know to take the same steps.
“When I started chemo, they hooked me up to the machine and made me watch a video about cancer and chemo. But the video never mentioned fertility for women,” though it mentioned it for men, said Brunner, a 40-year-old lawyer who lives in Silver Spring. “I actually complained. To me, it was a travesty.”Foust’s fate was different. A few days after her initial conversation, she and her husband got an urgent phone call with a new plan for her treatment.Her breast surgeon at Virginia Hospital Center had set up a conference call with Stephen Lincoln, a reproductive endrocrinologist with the Genetics & IVF Institute’s fertility preservation center for cancer patients:She would be able to try to freeze her eggs or embryos before her treatment.Genetics & IVF, along with other well-known fertility centers including Shady Grove Fertility Center and Dominion Fertility, is part of a nationwide effort to encourage oncologists and their staffs to talk to cancer patients about their increasing fertility options.

“Everyone is recognizing now that talking about fertility is a part of dealing with cancer,” Lincoln said. “People aren’t just being rushed right into treatment anymore.”

Denduluri concurs. “The awareness is just much higher now, whereas before many were concerned with finding the so-called cure and saving the patient’s life,” she said. “It’s more a balancing act now, and there are more strident feelings about the importance of bringing up fertility issues at the beginning of treatment.”

‘It was amazing’

In late May, Foust went to the Genetics & IVF pharmacy near her home in Annandale and went home with a supply of vials of gonadotropins, hormones that stimulate the ovaries to produce eggs for retrieval.

She would have to give herself injections every day for the next two weeks. Then Lincoln and his team would extract her eggs, a procedure done with light sedation. (The process is typically the same one used for any woman who would like to have her eggs frozen to preserve her ability to have children.)

In breast cancer cases, doctors want to keep estrogen levels low because of concern that raising them might accelerate the growth of a tumor. Foust’s doctors combined a low dose of gonadotropin and a medication that promotes ovarian stimulation while keeping estrogen levels low.

“It was amazing that they could actually do this, safely. At the same time, you never think as a 26-year-old that the ability to bear children — something I was looking forward to — will be taken away from you,” said Foust, an emergency room nurse.

She decided to freeze eggs instead of embryos because she was concerned about having embryos she might not use. There was also a chance that she could have children naturally, depending on how much harm chemotherapy caused to her fertility.

“If I had children somewhere frozen, I would wonder what to do: Do you donate them? Do you send them to science?” she said.Just a few years ago, Foust wouldn’t have been able to consider this problem.
Back then, egg freezing had far lower success rates and was considered experimental by the American Society for Reproductive Medicine. That label was lifted in October, thanks to improved success rates with a new flash-freezing technology known as vitrification.“It’s been a massive leap forward,” said Frank Chang, a reproductive endocrinologist at Shady Grove Fertility Center.A growing number of oncologists reject the traditional view that the hormones used to stimulate eggs for retrieval — as well as pregnancy itself — might increase the risk of developing certain cancers. Today many doctors see both the freezing process and pregnancy as safe after three to five years of tamoxifen, a hormone drug used with breast cancer patients, according to Denduluri.And although large-scale data are still being collected about recurrence rates after pregnancy, tumor histories are also looked at on a case-by-case basis to see if carrying a baby is safe, according to Denduluri.There are also smaller studies showing that pregnancy after a breast cancer diagnosis does not carry a negative outcome as long as a patient waits two to three years after starting treatment with tamoxifen, Denduluri said.

For many patients, dealing with infertility treatments amid a cancer diagnosis is an emotional (and sometimes physical) encumbrance. It is also expensive.

Treatments are viewed as elective and are rarely covered by insurance. Fertility drugs can cost $6,000 a round or more; egg retrieval and freezing can be another $5,500. For freezing embryos, the process can run $6,500 and more.

A costly process

Many fertility centers help cancer patients find help with funding their drugs. TheLivestrong Foundation’s Fertile Hope program has helped close to 4,000 survivors since 2004, said Ashley Koenings, senior navigator for fertility services. Each month, the program helps about 80 people.

Shady Grove works with Walgreens, which donates drugs to patients whose insurance does not cover them. Shady Grove also has financial assistance for egg retrieval, depending on a patient’s income level.

But even with financial help, the emotional toll is often severe. Dealing with fertility issues is a roller coaster ride for anyone, but for cancer patients and survivors, it can feel even more burdensome.

“For once, could my body work with me instead of against me?” Brunner said of her efforts to retrieve her eggs. “During that time, a pregnant woman in a supermarket put me in tears.”

Brunner froze her eggs twice — once before her double mastectomy and another time before chemotherapy. “Someone said, ‘Are you sure you want to do this and start poking yourself with needles?’ And I said, ‘This is nothing compared to what I have to do with cancer.’ ”

After two unsuccessful embryo transfers, including with a gestational carrier (a woman who volunteered to carry the pregnancy for Brunner), she tried again, post chemo. She was able to get one viable egg the first round and one more the second. Both were fertilized with her husband’s sperm using IVF and were implanted in a new gestational carrier. Her positive outcome in retrieving viable eggs after chemo is uncommon, doctors said. Today, she has twins who are 9 months old.

At a recent Shady Grove Fertility’s Family Day, her twins wore onesies that said, “Made with love . . . and science.”

“Even when they are both crying and I’ve had no sleep, I am so thankful,” she said.

Meanwhile, Foust was able to freeze 15 eggs. When she is ready to become pregnant, the eggs can be thawed, fertilized and transferred to the uterus as embryos.

She is currently going through eight rounds of chemotherapy. Knowing that her eggs are frozen brings her comfort.

“I remember seeing a picture in my breast surgeon’s office that has a list of things that cancer cannot do,” she said. “And I wanted that to include that it couldn’t take a pregnancy away from us. Even if we never use the eggs or get pregnant on our own, it would be a blessing. I refer to my frozen eggs as my pocketful of sunshine.”

By | August 27th, 2013|Industry News|Comments Off on Oncofertility offers new options for young women with cancer who want to have kids

Not pregnant: Sometimes it’s the man

By Laura Hambleton, Washington Post

The couple married when they were 23 years old. For the next 10 years, they devoted themselves to their careers, moving around the country and earning doctorates. When they both secured jobs at a university, they decided it was time to start a family.Except they couldn’t.

When the couple sought out medical advice, a doctor showed the husband test results: He was not producing any sperm.The news sent him zigzagging across the country, searching for the right physician to help him with his infertility. In the meantime, he felt under a great deal of pressure and lost interest in sex.

Finally, the couple ended up at the office of Johns Hopkins University urologist Pravin Rao, who confirmed the problem: a case of mumps the man had contracted as a child in India had damaged his ability to produce sperm. Although he was infertile, a new technique might be able to help.

“For any man, it ultimately takes just one sperm to fertilize an egg,” Rao said. “However, he didn’t even have one sperm. He had azoospermia, meaning there were no sperm in the ejaculate. In this case, this was due to a factory or production problem, as opposed to a blockage.”

Couples are considered infertile if they are unable to conceive after having unprotected sex for one year, or six months if the woman is older than 35. According to the American Society for Reproductive Medicine, about 12 percent of couples in the United States, or 7.3 million couples, fall into this category. In about 40 percent of those cases, the problem is with the man.

Male infertility can be caused by such general health conditions as obesity and cancer as well as by problems including an obstruction in the ejaculatory ducts, a hormonal imbalance and genetic abnormalities. Also, childhood diseases such as the mumps, and sexually transmitted infections such as chlamydia and gonorrhea can cause genital-tract scarring that obstructs the flow of sperm.

There is an ongoing debate over whether sperm counts are going down worldwide. Somestudies suggest rates are declining, but others point to inconsistency in data collection and standards.

“Sperm counts do appear to be falling,” said Paul Turek, a San Francisco urologist who writes a popular blog that addresses male infertility. “But we are fully the men our grandfathers were. Women may be getting pregnant as efficiently as they did, but with fewer sperm.”

In the best of scenarios, a man deposits millions of sperm at the base of a woman’s cervix during ejaculation, and the sperm swim their way through her cervix, uterus and fallopian tubes just in time for one of them to fertilize an egg.

The production of sperm and testosterone begins when a boy reaches puberty and continues well into his 80s. Women, on the other hand, release the highest-quality eggs when they are young and stop altogether at menopause.

“Men always are producing sperm unless something happens in life,” said Stuart Moss, program director for male reproductive health at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, part of the National Institutes of Health. “Sperm are constantly being produced, a thousand sperm per second.”

What sperm look likeWhen doctors examine semen samples under a microscope, they look at the shape and size of sperm, counting them and assessing how many are swimming and how well. Normal sperm have oval heads and long tails. Normal sperm concentration is about 20 million per milliliter of semen. A low count is fewer than 15 to 20 million sperm in a milliliter of semen.

 

Motility — the ability to move proficiently — is key for sperm to reach their destination, an egg. As for sperm shape, scientists aren’t certain how that might affect fertility. “The scientific idea is that the sperm that look ‘perfect’ are the ones that contain the best genetic package and are best equipped to fertilize an egg and create an embryo,” said Juddson Chason, a urologist in Annapolis who specializes in male infertility. But, he said, data don’t consistently support that notion.Sperm are temperature-sensitive, and scientists believe testicles reside outside the body’s core to keep them cool, said Peter Schlegel, chair of the department of urology at the Weill Medical College of Cornell University in New York.

“Testicles move to adjust their temperature,” meaning they shrink in toward the body when they are cold and move away from the body when they are warm, he said. “The type of underwear you wear is not important,” he said.

Sitting in a sauna or exercising intensely for more than 90 minutes a day, on the other hand, may affect sperm production temporarily, though the disruption “may last months, as sperm production takes months,” Schlegel said.

Eating fruit and vegetables and taking vitamins such as folic acid and Vitamin E every day may help boost sperm production, though studies have been contradictory, he said.

“Human males have relatively lousy sperm production compared to other mammals,” he said, and they “are more sensitive to environmental influences.” Among those influences are smoking, drug use, significant weight issues, extreme exposure to toxins and childhood illnesses such as mumps.

“I ask about reproductive history, prior relationships and a history of conceiving,” said Robert Brannigan, an associate professor in urology at the Northwestern University Feinberg School of Medicine in Chicago. “If the man has had a fever or a systemic illness, that could lead to a sharp drop in sperm production. I want a good understanding of his medical background and any behaviors that could adversely affect sperm production, such as use of anabolic steroids or testosterone replacement therapy, both of which can suppress sperm production.”

According to some studies, sperm analysis can be a snapshot of the man’s overall health. “Men should have a biomarker of their health [in the way that] periods and cycles can be for women,” Turek said. “The semen analysis suffices as that male biomarker.”

For example, he said, a low sperm count might indicate testicular cancer or prostate cancer. “I diagnose these conditions daily in my practice as part of male fertility evaluations. Making sure that the man is healthy is paramount to being a doctor and, when a man is systemically ill, fertility is the first thing to go,” Turek said.

Structural and other problemsMale infertility also can be caused by structural deficiencies such as missing or deformed vas deferens, the tubes that carry sperm from the testes to the urethra during ejaculations. These are the tubes that are tied off during a vasectomy.

If the vas deferens are missing, the testicles continue to produce sperm, which eventually die off and are absorbed by the body. These tubes cannot be replaced. “You can’t make an artificial tube,” said Chason, and “these patients need assisted reproduction” using sperm that has been surgically removed.Diabetes can damage the nerves needed to produce an ejaculation. Sometimes, the ejaculatory ducts connecting to the vas deverens are blocked, though these sometimes can be opened surgically. If the testicles didn’t properly descend into the scrotum during fetal development, a man may not ejaculate large numbers of high-quality sperm, Chason said.

Some infertility is caused by a dilated vein that forces blood to pool or flow backward into the scrotum, raising the temperature inside the testicles, which can impede sperm production. Surgery can help here as well.

Insufficient testosterone production can also reduce sperm production. The pituitary gland regulates how much testosterone the testicles make. Anabolic steroids and testosterone replacement therapy can interrupt the natural production of sperm. The infertility drug Clomid can be effective in recalibrating the male’s testosterone level, Chason said.

For some men, genetics is the issue. A small percentage of men are born with an extra X chromosome. This is called Klinefelter syndrome, where a man “instead of XY, he is XXY,” which may result in his producing sperm early in life but then not later, said Moss, who has been researching male reproductive health for 30 years.

As much as doctors and scientists now understand about the causes of male infertility, in as many as 50 to 60 percent of cases there is no obvious explanation, he said.

Mumps in India

As for Rao’s patient at Johns Hopkins, mumps was the likeliest explanation since it is a known risk factor for sterility and he had not been vaccinated against the disease when he fell ill at age 11 in India. (In the United States, infants are routinely vaccinated against mumps.) About 25 percent of men who have had mumps experience swollen testicles because of the disease, and in 10 to 15 percent of these cases there may be some effect on fertility, according to Rao.

“As a child I had the mumps and then basically my testicles failed,” the man said, speaking on condition of anonymity to preserve his privacy. “It’s not reversible.”

But Roa told him surgery might help. “Men with azoospermia may still be producing small amounts of sperm,” Rao said, and it is now possible to extract some sperm from their testicles.

The two-hour surgery, called micro TESE, or micro-dissection testicular sperm extraction, has been used for more than 10 years and succeeds in about 50 to 60 percent of cases, depending on the issues involved.

The extracted sperm are united with eggs through in vitro fertilization and any resulting embryos are implanted in a woman’s womb.

“Once we had the first procedure done and the doctors found some sperm, that gave us hope,” Rao’s patient said. “Now we are a little stressed again with the IVF [which was performed in June]. There is limited amount of sperm, so if that doesn’t work, we are back to square one. My wife is emotionally attached to kids and wants her own.”

Rao was able to harvest four vials from the man, and each vial is usually enough for one IVF treatment. “Once we have obtained sperm . . . the success rate is largely related to the female partner’s age and reproductive health,” he said. “On average, most couples will have success after two to three cycles of IVF.”

By | August 26th, 2013|Industry News|Comments Off on Not pregnant: Sometimes it’s the man

Egg Freezing: A New Frontier in Fertility

US News & World Report

Even as a girl, Sarah Elizabeth Richards seemed maternal. The oldest of four, she was the most sought-after babysitter on her San Diego block. Her friends figured she’d be the first among them to have kids. And one day, she always assumed, she would. But at 36, Richards found herself single in New York City and consumed with the fear of that prospect dimming with each passing month.

After years of mounting worry about her biological clock, Richards found a way to free herself – and her fertility. Over the next two years, she spent $50,000 (her savings plus the wedding fund her parents set up for her) on eight rounds of egg freezing – a process that lets a woman use her younger, and ostensibly healthier, eggs when she’s ready to conceive.

“What else is there that I would want to spend money on that would be more important than this?” says Richards, now 42, who describes her experience and that of three others in her recently-released book, “Motherhood Rescheduled: The New Frontier of Egg Freezing and the Women Who Tried It.”

Richards is at the forefront of a crusade she hopes will spare women the heartache of fertility angst – and has sparked controversy for taking that stand. Her recent essay for The Wall Street Journal, “Why I Froze My Eggs (And You Should, Too),” generated hundreds of impassioned comments. But her voice reflects a shifting sensibility about the unprecedented opportunities afforded by egg freezing at a time when women are increasingly becoming mothers later in life.

“Today, there’s been an explosion” of interest and activity in the field, says Mitchell Rosen, director of the University of California San Francisco Fertility Preservation Program and Reproductive Laboratories. Rosen attributes the trend to more experience and success with the procedure (a new flash-freezing technique removes the ice crystals that can harm the egg) and the decision last fall by the American Society of Reproductive Medicine to remove the experimental label from egg freezing.

In 2006, a landmark trial at NYU Langone Medical Center found that frozen eggs could be used to achieve the same pregnancy rates as fresh eggs, used for in vitro fertilization, using egg and sperm to create an embryo in a lab that is then transferred into a woman’s uterus for pregnancy. “So all of a sudden now, it became an option,” says Jamie Grifo, lead author of the study and program director of the NYU Fertility Center. His team is now researching how to screen eggs for chromosomal normality to better achieve successful pregnancies.

Whether using fresh or frozen eggs, both procedures use IVF, which requires hormone injections that enable a woman to produce multiple eggs each month, which are extracted for fertilization. Frozen eggs require a process called intracytoplasmic sperm injection, in which a single sperm is injected into the egg.

The success rates of producing a baby from one round of IVF is about 60 percent at age 30, 27 percent at age 40 and drops to 6 percent between ages 40 and 44, says Grifo, attributing the declining success rates to the fact that a woman’s eggs develop abnormalities with age. And therein lies the hope of this new technology. “Egg freezing is a way to be your own egg donor,” Grifo says.

As to the cost of the process, the procedure plus doctor’s visits, medication and egg storage can run from $5,000 to $20,000, depending on the lab and the medical practice.

Egg freezing had been used in this country as a “semi-standard of care” when a woman’s medical condition would require treatment that could jeopardize her reproductive health, Rosen says. But even two or three years ago, offering the procedure purely to enhance a woman’s reproductive potential worried him. “I didn’t want to give an empty promise,” he says. Plus, he feared it would lead women to prolong getting pregnant and waste fertile years. But the stream of women who sought the procedure disabused him from that notion. “I was constantly told by patients, ‘Believe me, I want to get together. I want to be in a relationship … If it’s in front of me, I’m gonna get it.'”

In her research, Richards found that when a woman freezes her eggs, she becomes more committed to pursuing motherhood and more empowered on the path to get there. “You’re more relaxed, but at the same time, you’re more focused.” Or, as she puts it: “You’re not this sad 38-year-old whose options are dwindling” but someone who’s “got it going on.” With fertility fears out of the way, she says “you can talk about all the other stupid stuff you talk about on dates, flirt and drink martinis.”

For her part, the experience left Richards feeling more calm and confident. “If I could figure out how to stop my eggs from aging, I could figure out Match.com,” she says. These days, she’s settled into a 10-month relationship with a divorced dad who wants to have more kids. And, of course, she has her younger eggs in the bank, ready when she is.

“My whole idea of this has changed tremendously,” Rosen says. While most of the women who see him are pushing 40, “anyone is a candidate,” he says. And the younger the patient, the better the outcome – although most 20-year-olds likely aren’t worried yet about safeguarding their fertility, he notes. “If you’re thinking about it, I think you should see somebody for a consultation,” he says, explaining that women who ruminate about it for five years wish they had acted five years ago. A recent study by the Free University of Brussels in Europe found that among 86 women who had frozen their eggs, 96 percent said they would do it again, but 71 percent said they wish they’d done it sooner.

By 34, “if you know you’re not going to have children within a few years, find the money and freeze,” Richards says. “Let’s say you have a baby in your late 30s, you may want those frozen eggs for a second baby.” Although she bemoans the price tag for the procedure, she says that as you get older, “you’re gonna have to pay money for fertility at some point, so you might as well do it now when you have a good chance of lowering birth defects.”

“It feels like a shame, when women get together and they talk about it – the anxiety and the freak-out and the sadness of it. And I just want to say, ‘Let’s stop having those conversations. Let’s stop letting the panic control our lives.'” She draws from her own experience, in lambasting the years wasted on this worry – “especially when now we have something we can do about it … That’s where you can really ‘lean in,’ you know?”

By | July 1st, 2013|Industry News|Comments Off on Egg Freezing: A New Frontier in Fertility

Frontiers of Fertility

TIME Magazine

Making babies ought to be the easiest thing you’ll ever do—indeed, it ought to be a hard thing not to do. The evolutionary game is rigged so that it’s fun, the kind of fun you want to have even when offspring aren’t on your mind. Our body cycles make parenthood a constant possibility: women are ready to conceive every month, and men are pretty much ready to go any second. And the product of all that happy activity—a chubby, cuddly, cooing baby—is something we’re hardwired to find irresistible.

But things, of course, aren’t always so simple. The human reproductive system may be a prolific thing, but it’s also a very fragile thing, and there is a lot that can go wrong with it. In the U.S. alone, more than 7 million women have received treatment for infertility, spending more than an estimated $5 billion per year. For the past 10 years, the average billed cost for a single in vitro fertilization (IVF) cycle is $12,400—something infertile couples must pony up on their own since most insurance companies don’t cover infertility treatments—and just one cycle is usually not enough. According to the U.S. Centers for Disease Control and Prevention, only 42% of assisted-reproduction cycles lead to a live birth when the woman is younger than 35. The figure drops to 22% by age 40, 12% by 42 and just 5% by 44. Outside the U.S., the odds are no better, and the number of people who need help is far greater: an estimated 48.5 million couples worldwide are unable to conceive after five years of trying, according to figures released last year by the World Health Organization.

Given the powerful, primal hold baby-making has on us, the inability to perform so straightforward a genetic job can be deeply painful. “My husband and I would look around, and everyone we knew was having kids,” says Cindy Flynn, 35, an IT worker at a Sacramento nonprofit. “We struggled so hard to get pregnant. Building a family should not be so difficult.”

For now, it still is, but the outlook is getting decidedly brighter. Scientists are steadily refining and improving assisted-reproduction techniques. They’re harvesting better eggs, using fewer drugs to do it and selecting more vigorous sperm that have a better chance of producing a baby. They’re monitoring embryos while they’re still in the lab in ways that were impossible before. Perhaps most tantalizing, they are working to engineer human stem cells so that eggs and sperm can be produced in the lab using raw cellular material taken from the parents. This would lead to a baby that was entirely, genetically theirs, the product of an ordinary union of egg and sperm—nothing short of a last-ditch miracle for people who, without this help, might have been unable to produce any healthy egg or sperm at all.

“Twenty years ago I would often tell a patient, ‘I am sorry. There is nothing we can do,’” says Dr. Craig Niederberger, head of the department of urology at the University of Illinois at Chicago College of Medicine. “Fifteen years ago I would have been saying, ‘There is something I can do, but it’s very experimental.’ Today I can often say, ‘There is at least a 2-out-of-3 chance you are going to have a baby out of this process.’ It is becoming the most exciting field, with the most gratifying outcomes you can imagine.”

Boosting the Odds
Improving the outlook for fertility patients starts with improving the art of IVF, which is not just expensive and less than reliable but a true physical grind. Women must first endure a month’s worth of hormonal dosings, including two or three shots a day in the final stretch, all of which can lead to headaches, restlessness, irritability and hot flushing. The dosing pushes the ovaries to hyperovulate, producing up to a dozen ova at once, which are retrieved via laparoscope through an incision in the pelvis. Even after all that, there’s no guarantee the eggs will be viable; many immature ones that the ovaries would never have released on their own are shoved out prematurely by the drugs.

“Every time a patient goes through conventional IVF, the number of eggs designated as waste is about 90%,” says Dr. John Zhang, founder and director of the New Hope Fertility Center in New York City.

Not all sperm are created equal either. The average male produces 76 million sperm per ejaculation; the lower limit for conception is 18 million. For IVF, the quality of sperm is judged in the lowest-tech way possible: a lab technician looks at them through a microscope. This method has just the limitations you might expect.

“A sperm has a head, a midpiece and a tail,” says Niederberger, “and there’s a lot you can find that looks wrong. You would think if you can find the best-looking sperm, it would also be the healthiest one, but that is absolutely not correct. The vast majority of sperm—up to 96%—look abnormal, and the exact shape of a sperm doesn’t necessarily equate to its success.”

This is increasingly problematic as doctors turn away from the original IVF method of simply mixing an egg and a semen sample in a dish and adopt a more exacting approach known as intracytoplasmic sperm injection (ICSI), in which a single, especially handsome sperm is selected, lifted by the tail and injected directly into the egg. That practically guarantees fertilization, but if the technician was fooled by looks and rejected more viable candidates—what fertility experts dub “overcalling” sperm—it may doom a pregnancy before it can even get started.

All of this explains the growing interest in an approach called mini IVF, which Zhang’s and other clinics are promoting. As its name suggests, mini IVF strips the familiar in vitro regimen down in a way that makes it both less arduous and, its proponents say, more effective. Rather than endure a month of hormonal carpet bombing, women take a 12-day course of Clomid, an oral drug that blocks the body’s estrogen receptors and promotes egg maturation. This causes the ovaries to produce only three to five comparatively viable eggs rather than a dozen often immature ones. In the final day or two of the cycle, the women also use a nasal-spray version of Synarel, a drug that’s usually used to treat endometriosis but in this case helps trigger egg release. Eggs are then retrieved and fertilized as in traditional IVF.

“The physiologic changes the body experiences in mini IVF are close to the natural cycle, without excessive drugs,” says Zhang. Starting with fewer embryos can also help mitigate the ethical issues raised when unused ones are frozen and stored in clinics, with little or no prospect of ever being implanted but little or no appetite on the part of anyone involved to destroy them.

Not everyone is sold on the promise of mini IVF. Some critics suggest that the odds of producing a successful pregnancy with mini IVF are actually lower than with traditional IVF, but so far there have been few long-term studies to crunch the numbers. And though the drug regimen is less intensive, for some women Clomid brings on physical and emotional side effects similar to standard IVF hormone treatment. Zhang just completed a five-year look at mini-IVF success rates that he is submitting for publication and promises will be a “time bomb”—presumably the good kind—in the field. But he’s one of the method’s pioneers. Other, more disinterested experts may offer a more measured assessment when they see his data.

The job of selecting the best sperm for conception in any type of IVF is also seeing some advances. The trick is to look not just at the sperm cells but inside them to get a sense of how their DNA is packaged—and to do that without destroying them in the process. One method is to use something called Raman spectroscopy, which involves beaming laser energy of a particular frequency at the head of the sperm; the beam scatters back in readable patterns that reveal clues to the interior structure. The technique isn’t quite ready for wide use, but it’s getting close. “People are studying various frequencies along the electromagnetic spectrum to interrogate the sperm in a nondestructive way,” says Niederberger. “This holds a lot of promise.”

Even assuming the very best sperm can be matched with the very best egg, doctors still have to determine which of the several embryos that are often created in any one IVF cycle is the most viable one to transfer to the womb. That remains a highly subjective matter that depends, again, simply on which one looks the best. “Identifying the single best embryo for implantation is one of the challenges of the last decades in assisted reproduction,” says Dr. Zev Rosenwaks, director of the Center for Reproductive Medicine at New York–Presbyterian Hospital/Weill Cornell Medical Center.

At Rosenwaks’ clinic, doctors are addressing that challenge with a time-lapse-photography system that snaps pictures of growing embryos every 10 to 20 minutes for the first few days of incubation. Subtle differences in the way they divide can provide clues to which embryos are the strongest. Similar techniques were tried in the past, but the pictures were taken manually by lab technicians, which required opening the incubator several times a day, exposing the embryos to blasts of room-temperature air and contaminants. The new cameras peer through glass into the sealed incubator and fire off their pictures automatically. “We have increased pregnancy rates across the board while decreasing the likelihood of multiple [births],” says Rosenwaks. “Whether the woman is younger or older, in every category we have improved pregnancy rates by 15% to 20%.”

This process too faces some early challenges—principally ones of access. There are more than 400 fertility clinics in the U.S., but only a few dozen so far have a system like Rosenwaks’. Not only does that exclude an overwhelming share of patients; it also means the 15%-to-20% improvement rate could be a premature boast, depending on how other clinics fare if they adopt the new technology.

Further out on the developmental frontier are stem cells. For decades it was assumed that girls are born with all the eggs they will ever have and can produce no more during their lives. In 2012 that wisdom was overturned when Jonathan Tilly, director of reproductive biology at Massachusetts General Hospital, announced that the ovaries harbor stem cells that, with the right chemical coaxing, could be made to mature into eggs.

Tilly accomplished that egg-growing feat—after a fashion—by harvesting stem cells from ovaries removed during sex-reassignment surgery, growing them in a dish, repackaging them in a bit of the original ovarian tissue and transplanting the entire little bundle into a lab mouse so that it would receive a steady blood supply. (Implanting it in a woman would have raised ethical issues.) When Tilly extracted the cells, they had indeed matured into what at least appeared to be fully mature ova. Not even Tilly pretends that his method is safe or practical—at least not yet—but as a proof-of-concept study, it shows promise. The threshold requirement for parents conceiving via IVF, after all, is at least one healthy sperm meeting one healthy egg. If you don’t have that, all the improvements in the world in embryo monitoring and implantation do you no good.

Investigators at Newcastle University in England had similar success on the male side of the equation in 2009, using embryonic stem cells to create living, swimming, healthy-looking sperm—though the researchers have no idea if the sperm are viable, and British law prevents them from attempting fertilization and implantation to find out for sure. Since then, they have been working on ways to sidestep the use of embryonic stem cells and all the ethical issues they raise by creating stem cells from the skin cells of the infertile men, which could then develop into sperm.

Expanding the Choices?
The more the medical options expand, the more some doctors—and couples—wrestle with the implications. Fertility counselors, when framing patients’ choices, remind them that they can continue to try to conceive or they can choose to adopt or live child-free. That’s a word that’s carefully chosen with the intention of replacing the bleaker-sounding childless and capturing the notion of an upside for a loving couple living a free and relatively unencumbered life.

For those who decide to turn to science to boost their fertility, cost is no small issue. Assisted reproduction remains expensive and is typically not covered by insurance. Under the Affordable Care Act—a.k.a. Obamacare—basic gynecologic and obstetric care are covered, but infertility treatment isn’t. The law does increase the available deduction for those treatments from 7.5% of pretax income to 10%. (For people who adopt, there is a tax credit of $13,360.)

In a perfect world, money wouldn’t stand in the way of having a child, but in a perfect world, neither would fertility problems. Basic as the reproductive drive might be, a lot of things have to go just right for a healthy baby to be the result. For a growing number of parents-in-waiting, more is starting to go right than wrong.

By | May 30th, 2013|Industry News|Comments Off on Frontiers of Fertility