Not too long ago there weren’t many options when it came to making a baby, but times have changed. Here’s some news from the front lines of fertility: new approaches, new treatments, and new techniques that everyone should be aware of.
1. In Vitro Maturation (IVM)
What it is: In this relatively new procedure, immature eggs are collected from minimally or non-stimulated ovaries and then hormonally stimulated and matured in the lab for 24 to 48 hours. The eggs are then injected with sperm in the procedure known as intracytoplasmic sperm injection (ICSI). Because fewer (or no) drugs are required, IVM is considered an alternative to egg freezing for women undergoing chemotherapy or for those with polycystic ovary syndrome (PCOS).
The key issues: There have only been about 400 births worldwide with IVM, and most experts consider the procedure experimental. “The few studies published suggest it may have roughly half the success rate of IVF,” notes Glenn Schattman, M.D., associate professor of obstetrics and gynecology at New York-Presbyterian Hospital, Weill Cornell Medical College in New York City. But as with all new technologies, these rates may improve with time.
2. Single-Embryo Transfer (SET)
What it is: As the name implies, this is the transfer of just a single embryo during in vitro fertilization (IVF) rather than two or more, as has been the custom. Two studies published in 2009 in the European journal Human Reproduction showed that SET is both a successful and cost-effective way to produce the outcome that most people want: a single, live, healthy baby. One study compared a decade’s worth of results among 1,510 women younger than 40. About 90 percent of their deliveries occurred within four cycles of IVF/ICSI regardless of whether one or two embryos were transferred. But with SET, the total treatment cost per woman averaged 5 percent less. And, of course, there was a much lower rate of multiple pregnancies.
The key issues: Elective single-embryo transfer is much more common outside the United States, explains Suheil J. Muasher, M.D., associate professor of obstetrics and gynecology at Johns Hopkins University School of Medicine in Baltimore. In fact, the average number of embryos transferred per cycle in this country ranges from two to three, according to data from the Society for Assisted Reproductive Technology. “Single-embryo transfer probably makes sense for 30 to 40 percent of patients, especially those younger than 40,” Dr. Muasher says, adding that of course it depends on the individual situation. “What these studies also emphasize is that the percentage of twin and triplet births would drop dramatically as a result.” The reason SET has been slow to catch on in this country has as much to do with finance as medicine. Because so few health insurers are providing coverage for high-tech fertility treatments, women or couples undergoing IVF want to give each attempt the best chance of success so they won’t have to pay for another try. And in spite of rising success rates with single-embryo transfer, many doctors and their patients still believe that transferring multiple embryos gives a better chance of success.
3. Procreation Vacations
What it is: Travel with the express purpose of reproducing (the old-fashioned way). Some romantic getaway spots and hotels are now offering “conception-moon” packages. And many spas are ramping up their couples’ offerings to include alternative medicine options said to boost fertility and enhance “reproductive readiness.”
The key issues: Experts, including Alice Domar, Ph.D., of Harvard Medical School, and Robert A. Greene, M.D., medical director of the Sher Institutes for Reproductive Medicine, have long posited that de-stressing can enhance fertility. So if a vacation spot or spa helps take the stress off you and your partner, it’s worth a visit. The only caveat: Don’t get your hopes up and expect such a trip to be a guarantee of success. Focus on where you want to travel and enjoy your time there; if you wind up pregnant afterward, it’s a wonderful bonus!
4. “All-in-One” Genetic Testing
What it is: The new “Universal Genetic Test” from Counsyl (counsyl.com) is a completely noninvasive saliva-based screening test that checks for more than 100 potential diseases that can be “carried” by potential parents’ genes. According to its manufacturer, it’s aimed at identifying disease genes in men and women, and is both comprehensive and cost-effective, since it doesn’t require drawing blood or performing multiple tests for multiple diseases. Invented by scientists from Stanford, Harvard, and Yale, the new test has been enthusiastically welcomed by many general ob/gyns as well as reproductive health specialists. If testing shows a couple may pass on a genetic disease to their offspring, they can take preventive measures like preimplantation genetic diagnosis (PGD, which tests an embryo’s genes before IVF transfer) or even use donor egg or sperm.
The key issues: Some experts are urging that all adults of reproductive age have this testing done before they start trying to conceive. If testing shows that a couple may pass a genetic disease to their offspring, they can take preventive measures such as those described above (PGD and IVF). But while the all-in-one genetic test may not itself be too pricey, having a baby through IVF is, and may not be an option for many people who test positive as carriers for genetic diseases. Genetics counselors at leading medical institutions have long emphasized that patients should consider not just whether or not they want to go through with a specific test, but how they will respond to the test results. A growing number of physicians are urging their colleagues to bear these factors in mind as they treat infertility patients as well. “Genetic testing is highly ethically complex. The technology could relieve a lot of stress but raises an enormous number of questions as well,” explains Anne Drapkin Lyerly, M.D., associate professor of obstetrics and gynecology at Duke University Medical Center in Durham, North Carolina.
5. Natural and Mini-Stim IVF
What it is: An IVF technique that relies on a woman’s natural cycle, using either no or fewer medications than traditional IVF. Proponents claim these less aggressive treatments can save thousands of dollars on medication costs alone without—at least in the case of mini-stim IVF—compromising success rates.
The key issues: The use of fewer medications for IVF is, in a sense, a return to the past, when doctors administered lower doses of drugs and retrieved fewer eggs. Over the years, IVF evolved to include higher drug doses, more eggs produced, and more embryos transferred. Unfortunately, though, this “more is better” approach carries with it a higher risk of ovarian hyperstimulation, miscarriage, premature labor, and multiple births. For women who are uncomfortable taking high-dose hormones and for those who simply can’t—because of a history of cancer, for instance—natural and mini-stim IVF provide options.
6. Fertility Consultants
What it is: These new service specialists aim to guide people through the complex process of infertility diagnosis and treatment. The consultants help their clients compare medical options and choose experts to carry out their treatments. Some also offer advice on financing, by checking and following up on insurance coverage (where available) or locating loans and payment plans. Some of these consultants are women capitalizing on their own research and experiences with infertility treatment, while others are professional life coaches who add fertility “coaching” to their services. Fees can range from a few hundred to thousands of dollars.
The key issues: There are no formal training requirements for these positions; virtually anyone can hang out a shingle as a fertility consultant. Some doctors welcome any move to provide patients with more sources of support, while others find the trend disconcerting. “The field of infertility treatment is one of profound emotion. When a woman has expected to have a baby her whole life and it doesn’t happen, she can feel as if she doesn’t have a sense of control,” says Dr. Lyerly of Duke. Fertility consultants can help give women a sense of control over their treatments. But, as with any consultant, their value depends entirely on the skill and knowledge of the individual.
7. “Fast Track” IVF
What it is: Conventional infertility treatment often begins with several cycles of pills (usually clomiphene citrate) to stimulate ovulation. If pregnancy doesn’t occur, the next step is often more powerful injectable drugs along with intrauterine insemination (IUI). When that treatment doesn’t produce a pregnancy, then it’s time to move on to IVF. Increasingly, top experts in the field have urged their colleagues to reexamine this whole process. One much-respected study confirmed what many have expected: Streamlining the procedure by eliminating IUI and in many cases going straight to IVF, can offer the quickest, lowest-cost route to pregnancy and lower the risk of both ovarian hyperstimulation (a painful and sometimes dangerous condition that results from the ovaries producing too many follicles) and multiple births.
The key issues: For many couples, the financial and emotional costs of infertility treatments have spiraled beyond their control, explains Richard Reindollar, M.D., professor and chair of obstetrics and gynecology at Dartmouth-Hitchcock Medical Center/Dartmouth Medical School in Lebanon, New Hampshire. And injections can be the most-dreaded part of the process due to the unpleasantness of the whole procedure, the hormonal side effects, the sky-high cost of the drugs themselves, and the increasing risk of multiple births. In 2009, a major study co-authored by Dr. Reindollar and published in Fertility and Sterility found that “skipping” straight to IVF after trying oral medications with IUI first can shorten the time to pregnancy, lower the risk of multiple births, and save as much as $10,000 per pregnancy. “Our data show that, for women up to age 39, adding an injection/IUI stage does not raise the chances of having a successful pregnancy,” explains Dr. Reindollar. Next up: studies of fast-track IVF for women ages 38 to 43. Again, it may be finance that’s standing in the way of this practice catching on, even though studies show it is cost-effective. IUI cycles are much less expensive than IVF, so people paying out of pocket may be more likely to try the lower-tech procedure first.
8. Egg Freezing and Fertility Preservation
What it is: Egg preservation has primarily been used for young women exposed to chemotherapy that would negatively affect egg follicles, explains Dr. Schattman of Weill Cornell. But as egg freezing techniques have improved, the procedure is increasingly being offered to any woman who’s worried about reproductive aging but is not yet ready to have a baby. Since egg freezing is still considered experimental (although many experts urge that it should no longer be), it should be performed at a medical center with an institutional review board. (Women who are already involved in a relationship can, as an alternative, choose to have their eggs removed and fertilized with their partner’s sperm, and the resulting embryos frozen.)
The key issues: Traditionally, the rationale for egg freezing is that “chemotherapy has been shown to literally ‘age’ the ovaries by anywhere from six to eight years, depending on the type of chemotherapy given. Egg freezing basically stops the clock; there is then a 2 to 5 percent chance of a successful pregnancy resulting from IVF for each egg that is frozen, depending on the age of the woman,” explains Dr. Schattman. But with many women postponing motherhood until their 30s and beyond, the appeal of freezing eggs and being able to start a pregnancy with a younger—and therefore better-quality—egg is obvious. Other new fertility preservation techniques that are still experimental (and still primarily used for cancer patients, but with the potential for wider use someday) include freezing ovarian tissue or whole ovaries that can be re-implanted later, and transplanting ovarian tissue, whole ovaries, and even uteruses. For men, sperm banking has been a reliable method of fertility preservation for decades, but researchers are now investigating the feasibility of preserving testicular tissue as well.
9. Third Party Reproduction
What it is: Also called “collaborative reproduction,” this category includes the use of donor egg, donor sperm, donor embryo, surrogates, or gestational carriers. Sometimes the third party is someone known to the intended parents, such as a friend or relative, and sometimes the arrangement is made between strangers through agencies, clinics, or attorneys.
The key issues: Third-party arrangements always have the potential to be ethically, emotionally, and financially fraught. Current discussion in this field centers on embryo donation. Many couples who’ve done IVF now have “leftover” embryos in frozen storage. For those who can’t use the embryos themselves, can’t or won’t donate them to research, and can’t bear the idea of having them destroyed, donating the embryos to another couple is a fourth option. . . although not a very popular one. In a study published earlier this year in Fertility and Sterility, only 7 percent of couples said they would be very likely to consider donating their unused embryos to another couple. Notes Dr. Schattman, “Most couples are not comfortable with the idea of a child that has their exact genetic material being raised by others.”
10. Fertility Tourism
What it is: Traveling abroad for medical care has been growing as U.S. costs rise and insurance coverage doesn’t keep pace; infertility treatment is the latest medical field to be “outsourced.” A small number of overseas fertility clinics are run in conjunction with U.S. hospitals, but the majority are “home-grown.”
The key issues: Costs are often considerably lower overseas, but not all countries have state-of-the-art fertility centers. Also, even health insurance companies that do cover fertility treatments may not automatically reimburse for treatments done abroad (although some will still cover what they would have for any other “out of network” care). Be careful in evaluating foreign success rates, cautions Johns Hopkins’ Dr. Muasher. “The average infertility patient in the U.S. is 35 to 36 years old. In Europe, the average patient is only 30 or 31, while Southeast Asian women average in their 20s. The younger women are, the higher their pregnancy success rate, so don’t be misled into thinking doctors are automatically getting better results overseas.”
