What Is Fertility Preservation?
Fertility preservation is a fairly new concept in reproductive medicine. The idea of preserving a patient’s current fertility status for future use is rapidly gaining exposure in the media, resulting in growing public interest in its utilization. Initially developed primarily for young patients of cancer and other diseases undergoing life-saving treatments that can cause irrevocable damage to reproductive function (medical fertility preservation), fertility preservation is a concept of “safeguarding” current reproductive abilities into the future by storing reproductive cells or tissues “out of harm’s way.”
In recent years, so-called social fertility preservation, especially utilizing egg freezing, has rapidly gained popularity. In this application of fertility preservation, women delaying childbirth are trying to preserve their fertility of younger years into the future by freezing their eggs when they are young but not ready to start a family.
Medically indicated and social fertility preservation, however, constitute distinctively different ethical and practical concepts of fertility preservation, with their own distinct risk-benefit considerations. We need to discuss the two separately.
Medically Indicated Fertility Preservation
Here, patients face medical conditions or life-saving medical treatments which with great likelihood will “wipe out” gonadal functions of ovaries in women and of testes in men. Chemotherapy and radiotherapy are good examples. While potentially life-saving, they are also toxic to reproductive cells (eggs and sperm). With modern cancer therapies, more and more young patients overcome cancer and eventually return to a normal life. To maintain options of having biological children once cured of cancer, patients are now encouraged pursue fertility preservation. Whether the patient is female or male, the idea of fertility preservation in these cases is to store reproductive cells (or tissue) “away” from the harm of toxic treatments.
The alternative to medically indicated fertility preservation is life-long sterility with no way to have biological children, a devastating consequence for many. For this reason, medically indicated fertility preservation is no longer considered experimental, even though success is not guaranteed, and outcome statistics for the procedure are still insufficient. The ethical consideration behind this designation is that, whatever the results from fertility preservation, even if only minimally successful, it will be superior to virtually guaranteed life-long sterility.
Different methods of fertility preservation may be appropriate, depending on medical conditions and/or gonado-toxic treatments needed, as well as the patient’s personal circumstances. In some cases of gynecological cancers, use of specific surgical and medical treatment techniques can be used to avoid damage to vital reproductive organs.
What medical conditions are involved, which treatments must be started, and how soon, whether the patient has a committed life partner, how many children the patient might want to have in the future are all important questions to be considered. Open communications and close collaboration between patients, treating physicians and reproductive endocrinologists offering fertility preservation are, therefore, crucial.
Social Fertility Preservation
In many countries, women are increasingly delaying childbearing as they pursue higher education and career goals. With growing public awareness of female fertility declining with advancing age, especially after age 35, social fertility preservation has become an increasingly popular solution. By freezing eggs or freezing embryos when still young, women assure access to their youthful reproductive potential later in life, when they are ready to start a family.
Many women are single when pursuing social fertility preservation. They, therefore, usually prefer to freeze eggs . Increasingly, however, there are married couples who want to preserve their fertility. They frequently freeze embryos because embryo freezing can more predictable than egg freezing.
Considerations surrounding social fertility preservation differ from those of medical fertility preservation. Here, the certainty of sterility later in life does not exist. Therefore, the still limited amount of published data about the procedure and its outcomes, as well as the resulting uncertainties in risk-benefit analysis, mandate that social fertility preservation via egg freezing be considered still experimental. Embryo freezing, however, has for many years been considered a more “established” procedure.
Fertility Preservation Centers
Fertility preservation centers have been available for a few years. These centers were established when fertility preservation, whether for medical or social indications, was still in its infancy. Today, there are a number of IVF centers licensed to cryopreserve (freeze) not only eggs but also ovarian tissue for this purpose.
Some centers offer a comprehensive array of fertility preservation options for both medical and social reasons, for women, men and pre-pubescent children:
- Embryo banking (freezing)
- Egg banking (freezing)
- Ovarian tissue banking (freezing)
- Sperm banking (freezing)
- Fertility preservation for children
Fertility Preservation by Embryo Banking (Embryo Freezing). Overview.
Embryo banking (embryo freezing) is the most well established method of fertility preservation with the largest amount of outcome data published in the literature. Successfully used for decades, embryo freezing has been responsible for births of hundreds of thousands of babies worldwide.
Embryo freezing requires a woman to undergo ovarian stimulation. In a natural menstrual cycle, only one mature egg is usually released from the ovary for possible fertilization. In embryo freezing, the patient takes daily hormonal injections that encourage the ovaries to develop multiple mature eggs. When these eggs are ready, they are retrieved with a thin needle inserted into the ovary under ultrasound control via the vagina. The patient is usually asleep for this procedure under intravenous sedation given by an anesthesiologist, which takes only a few minutes.
Retrieved eggs are mixed with partner’s (or donor’s) sperm for fertilization, and embryos are created. The embryos are cultured for a few days, and then frozen for future use.
Who May Benefit from Embryo Freezing
Embryo freezing is a procedure for both medical and social fertility preservation (unlike egg freezing, which can be considered experimental if performed for social reasons). Because embryo freezing requires sperm, embryo freezing may not be a good option for women who do not have a committed partner. Many single women, for this reason, choose egg freezing instead. Embryo freezing, however, is still the more established method of social fertility preservation for couples in stable relationships.
Embryo freezing takes a few weeks to complete. Some newly diagnosed cancer patients may not have enough time before they are scheduled to undergo chemotherapy or radiation to freeze embryos (or eggs). Even when patients have enough time for an embryo freezing cycle, a single embryo freezing cycle may not suffice to freeze enough embryos.
The literature suggests that cancer patients typically produce only approximately eight embryos per cycle, which may not be enough to offer a high probability of future pregnancy. Other fertility preservation methods such as ovarian tissue cryopreservation might be a better option, depending on the treatment time frame.
How Many Embryos to Freeze
With a decades-long history, embryo freezing has considerable outcome data to determine how many embryos should be frozen in order to have a reasonable chance of future pregnancy. How many embryos a patient should freeze will depend on her age and ovarian reserve status. For younger women with normal ovarian reserve, some clinicians may recommend freezing of at least 20 embryos. As embryos frozen later in life have a lower potential of leading to a pregnancy, women in their 30s and 40s should consider freezing significantly more. Consult your physician for counseling based on your individual circumstances.
Fertility Preservation by Egg Banking (Egg Freezing). Overview.
Compared to embryo freezing, egg freezing (oocyte cryopreservation) is a relatively new technique of fertility preservation. Like an embryo freezing cycle, an egg freezing cycle resembles an IVF cycle for the most part. An egg freezing cycle starts with ovarian stimulation and ends with egg retrieval.
During the ovarian stimulation phase, the patient self-administers daily hormone injections to stimulate her ovaries – sometimes the administration of injections is helped by a friend, significant other or family member. While only one mature egg is ovulated for possible fertilization in a natural menstrual cycle, ovarian stimulation encourages the ovaries to produce multiple mature eggs. Once mature, those eggs are retrieved from the ovaries with a thin needle, which is inserted through the vagina under ultrasound control, while the patient is asleep under intravenous sedation administered by an anesthesiologist. The egg retrieval takes only a few minutes.
Here, the retrieved eggs are not fertilized with sperm, but immediately cryopreserved (frozen).
Egg freezing is technically more challenging than embryo freezing. One reason is the large size of a mature egg cell, which is the largest cell in the human body. Oocytes (eggs) are more difficult to freeze and thaw compared to embryos, which are made up of much smaller cells. These technical complexities add to the uncertainties surrounding future pregnancy chances after egg freezing.
Risk-Benefit Considerations of Egg Freezing.
If performed for cancer patients, egg freezing is no longer considered experimental by professional organizations in the field, including the American Society for Reproductive Medicine (ASRM). This designation may require some explanation: Adequate outcome data on egg freezing are still lacking. However, the alternative for cancer patients is loss of ovarian function with no chance of future pregnancy with use of their own eggs. The risk-benefit consideration under such circumstances, therefore, clearly favors egg freezing in young cancer patients, whatever future pregnancy chances may be, because even a small chance of pregnancy that egg freezing might offer is better than no chances at all.
Egg freezing for social reasons, on the other hand, is considered still experimental. For women who want to freeze eggs so that they can focus on life’s other priorities while safeguarding their current fertility, the risk-benefit analysis is still unclear, because the lack of long-term outcome data makes it difficult for even expert physicians to offer guidance on how many eggs should be cryopreserved.
Mass and social media recently “discovered” the subject after some highly visible tech companies announced that they would offer to their employees insurance coverage for egg freezing. Unfortunately, coverage of this highly complex issue by the media has been superficial, often driven by talking points provided by public relations firms for a rapidly developing “industry” around fertility preservation.
Emborrow strongly objects to the rapid commercialization of social egg freezing, characterized by excesses like “egg-freezing parties.” We consider social egg freezing to be an excellent option for well informed women. Egg freezing, however, could be a second-best option after spontaneous conception at younger years, and given the still-experimental nature of the procedure, thorough counseling by a qualified physician is crucial.
Emborrow also strongly believes that the current status of egg freezing as an experimental procedure is appropriate, and that this fact should be openly communicated to all women considering this procedure.
Who May Benefit from Egg Freezing.
Egg freezing may be a good option for medically indicated and social fertility preservation. Who may benefit directly depends on the pros and cons of egg freezing:
- Unlike embryo freezing, egg freezing does not require sperm;
- Egg freezing usually takes a few weeks to complete;
- Most women will need more than one egg freezing cycle in order to accumulate enough eggs to have a reasonable chance of future pregnancy.
Because egg freezing does not require sperm, egg freezing is a good option for women who do not have a committed life partner to produce embryos with. Because of time limitations, egg freezing may not be possible in cancer patients who must immediately start life-saving treatments. For these patients, ovarian tissue freezing, either alone or in combination with limited egg freezing, might be a better choice, since ovarian tissue freezing, a surgical procedure, can be performed on a very short notice.
Egg freezing may also be an attractive option to young women who discover that they may be at risk of premature ovarian aging (POA). Approximately 10 % of all women develop POA when their ovaries prematurely lose the ability to produce healthy eggs.
Losing fertility potential with advancing age is normal. However, in women with POA this loss happens earlier than it is normal. The younger women could be diagnosed with risk toward POA, women gain new options: They can either decide to have children at a younger age or, when this is not possible or desirable, freeze eggs (or ovarian tissue) when they are still young. In general terms, the younger the patient when her eggs are frozen, the more “fertile” they are.
How Many Eggs to Freeze.
How many eggs a woman should freeze in order to achieve a reasonable chance of future pregnancy is not well established yet, and will depend on her age and ovarian function. Some clinicians recommend freezing of at least 20-25 eggs for young women for every future pregnancy they are planning for. Because an egg’s potential to fertilize, develop normally and lead to a healthy pregnancy declines precipitously with age, the older a woman at the time of egg freezing, the more eggs she will have to freeze. Therefore, older women may need more than 25 eggs to achieve a pregnancy in the future.
This means that most women will need more than one egg freezing cycle. Since older women produce fewer eggs per egg freezing cycle, they might need many more cycles. Recognizing this fact, Emborrow can offer financing options when Multiple Egg Freezing Cycle Program, which offers a discounted package when the woman’s physician is recommending three (3) or more egg freezing cycles. A specialized physician should counsel women based on their specific circumstances and needs.
Ovarian Tissue Freezing
Fertility Preservation by Ovarian Tissue Banking (Ovarian Tissue Freezing).
Ovarian tissue cryopreservation (freezing) is an experimental method of fertility preservation in which the outer layer of an ovary, which contains a large number of immature eggs, is taken out of the body and frozen for future use. In ovarian tissue freezing process, a part of an ovary or a whole ovary is surgically removed, usually by laparoscopy. In the laboratory, the ovary’s outer layer (called ovarian cortex) is cut into small strips and frozen. An experimental procedure, ovarian tissue freezing is for the most part performed for medically indicated fertility preservation in cancer patients.
When the patient is cured of the primary disease and ready to have children, the ovarian strips are thawed and transplanted back into her body, either on the remaining ovary or elsewhere. In most cases reported in the literature, transplanted ovarian strips regain normal function of producing hormones and eggs. So far, several live births have been reported worldwide after ovarian tissue freezing and re-transplantation.
Benefits of Ovarian Tissue Freezing.
A major advantage of ovarian tissue freezing is the number of eggs that can be frozen in “one shot.” Embryo freezing and egg freezing typically result in approximately 10 eggs or embryos per freezing attempt. In contrast, ovarian tissue freezing lets women freeze a vastly larger number of immature eggs—hundreds to thousands—for future use. When frozen ovarian tissue is re-implanted into the body and regains its functions, immature eggs that were frozen within the tissue start developing normally, and become retrievable in an IVF procedure.
Unlike egg and embryo freezing, where just one cycle can take a few weeks to complete, ovarian tissue freezing can be performed on very short notice. Even women who must undergo chemotherapy or radiation almost immediately after diagnosis may be able to preserve their fertility using this method.
Ovarian tissue freezing is also an important method of fertility preservation for young girls. When a young girl is diagnosed with cancer or other conditions requiring life-saving, ovary-toxic treatments, the option of egg freezing may not yet be feasible because her eggs have not started the maturation process, which starts with menarche (first menstrual period). While still considered an “experimental” procedure, ovarian tissue freezing is utilized for young prepubescent girls.
Counseling and Informed Consent.
Patients considering ovarian tissue freezing should be thoroughly informed about risk-benefit considerations, the procedure’s experimental nature and available alternative treatments. Since ovarian tissue freezing is typically performed for patients facing life-threatening illnesses and ovary-toxic therapies, close communication and coordination among patients, physicians treating the primary disease (oncologists, oncologic surgeons, etc.), fertility specialists performing the fertility preservation procedure and family members is essential.
The Potential of Ovarian Tissue Freezing with In Vitro Maturation.
Reproductive medicine is rapidly evolving, and one of the possibilities in this area is to in vitro mature the primordial follicles (very immature eggs) contained in the cryopreserved ovarian tissue. If successful, in vitro maturation (IVM) of primordial follicles would eliminate the need to surgically re-transplant the ovarian tissue back into the body. While IVM is currently not able to mature eggs in such an early stage of development, successful IVM of primordial follicles would make hundreds to thousands of eggs in each small strip of frozen ovary available to cancer survivors later in life, rather than the few dozens currently banked from egg or embryo banking cycles.
Understanding My Fertility
Tests for female infertility and a semen analysis are frequently how fertility is assessed. Because male factors account for approximately 50% of all infertility cases, it is important to examine both partners for possible infertility issues.
Female Fertility Testing Process
What is the process for female fertility testing?
The first step in diagnosing an issue relating to fertility is a comprehensive appointment with your fertility physician. During this appointment, your medical history and lifestyle will be discussed extensively. Topics such as birth control use, menstrual and pregnancy history, current and past sexual practices, medications used, surgical history, other health issues and what your lifestyle is like as well as your work/living environment will potentially be discussed.
A thorough physical exam will also probably be done. Areas such as your thyroid, breasts, and hair growth will be looked at. A pelvic exam is also an important part of evaluating fertility, along with a pap smear.
After a first appointment, your physician may want to proceed with some initial testing. This initial testing will evaluate things such as if ovulation is occurring, when it should be occurring, ovarian function, and uterine function during the ovulation process.
Ideally, you will have already begun tracking your ovulation. This will provide your reproductive specialists with valuable information about your ovulation. Usually one of the first questions regarding female fertility is whether you are ovulating or not.
Ovulation evaluation may be broken down into types:
- Ovulation testing— to confirm if ovulation is occurring by looking through your temperature charts, using ovulation predictor kits and blood tests and ultrasound.
- Ovarian function tests–These tests are looking to see how the hormones are functioning and working during your ovulation cycle. Tests include the Day 3 FSH (measuring follicle stimulating hormone), Day 3 Estradiol (measuring estrogen), ultrasound (to confirm ovulation occurred) and blood tests to determine the levels of inhibin B.
- Luteal Phase testing– Testing will evaluate progesterone levels, more extensive hormone testing, and possibly a endometrial biopsy ( see below for more info on this procedure.)
- Hormone tests: Most all of this testing will revolve around thorough hormone tests.
These hormone tests include the following:
- Luteinizing Hormone
- Follicle Stimulating Hormone
- Free T3
- Total Testosterone
- Free Testosterone
The following tests are also commonly used in the first evaluated cycle:
- Cervical mucus tests: This involves a post coital test (PCT) which determines if the sperm is able to penetrate and survive in the cervical mucus. It also involves a bacterial screening.
- Ultrasound tests: This is used to assess the thickness of the lining of the uterus (endometrium), to monitor follicle development and to check the condition of the uterus and ovaries. An ultrasound may be conducted two to three days later to confirm that an egg has been released.
If both the semen analysis and the above testing return normal results, there are also additional tests that your fertility physician may recommend.
These tests include any of the following:
- Hysterosalpingogram (HSG): This is an x-ray of your uterus and fallopian tubes. A dye is injected through the cervix into the uterus and fallopian tubes. The dye enables the radiologist to see if there is blockage or some other problem.
- Hysteroscopy: This is a procedure that may be used if the HSG indicates the possible presence of abnormalities. The hysteroscope is inserted through the cervix into the uterus, which allows your fertility specialist to see any abnormalities, growths, or scarring in the uterus. The hysteroscope allows the physician to take pictures which can be used for future reference.
- Laparoscopy: This is a procedure done under general anesthesia that involves the use of a narrow fiber optic telescope. The laparoscope is inserted into a woman’s abdomen to provide a view of the uterus, fallopian tubes, and ovaries. If any abnormalities such as endometriosis, scar tissue or other adhesions are found, they can be removed by a laser. It is important to confirm that you are not pregnant before this test is performed.
- Endometrial biopsy: This is a procedure that involves scraping a small amount of tissue from the endometrium just prior to menstruation. This procedure is performed to determine if the lining is thick enough for a fertilized egg to implant in and grow. It is important to confirm that you are not pregnant before this test is performed.
These tests are not mandatory and your fertility specialists will know which tests to recommend in your situation.
You’re making big decisions regarding your health and fertility, and having an in-depth understanding of your personal fertility could be vital in choosing a treatment that is right for you.
Female Fertility Testing Process
Below is an overview list of potential infertility conditions and treatments, with links to more information about each topic.
- Infertility? When to see a specialist
- Infertility diagnosis and treatment
- Major causes of infertility
- Infertility diagnosis
- Treating endometriosis infertility
- Tubal infertility
- PCOS and infertility
- Should I get surgery to treat infertility?
- Male infertility
- What is In Vitro Fertilization (IVF)?
- How IVF works – step by step
- Fertility medications for IVF and ovarian stimulation
- How to interpret IVF success rates
- Mini IVF: Are they really economical?
- IUI vs IVF
- IVF vs tubal reversal
1. Infertility? When to see a specialist.
Affecting about 15% of couples, infertility is defined as the inability to conceive or maintain a pregnancy within a certain period of time. For couples under the age of 35, infertility is diagnosed when they fail to conceive after 1 year of regular, unprotected sexual intercourse. In addition, couples who are able to conceive but experience repeat miscarriages may also be considered infertile.
2. Infertility diagnosis and treatment.
What are the major causes of infertility?
Reproduction is a complex function involving many factors that can affect a couple’s ability to become pregnant. About 15% of couples of reproductive age suffer from infertility. In both men and women, most causes of infertility can generally be attributed to either anatomical, hormonal, environmental, or genetic factors that prevent normal reproductive functions.
Causes of Female Infertility
- Polycystic ovarian syndrome (PCOS)
- Damage to fallopian tubes
- Premature ovarian failure (POF) and premature ovarian aging (POA)
- Hormonal problems
- Autoimmune diseases
- Ovulatory dysfunction
- Luteal Phase Defect
- Sexually transmitted diseases
Causes of Male Infertility
- Structural abnormalities or damage to the reproductive organs
- Abnormal or low sperm production
- Sexually transmitted diseases
- Environmental exposures
- Autoimmune disease
3. How is infertility diagnosed?
Couples under 35 years of age who have been having regular unprotected sexual intercourse for more than 1 year are typically diagnosed with infertility. In older couples, it may take longer to conceive. However, older couples also may not have the luxury to “wait and see,” since the female reproductive time frame is limited. Older couples, therefore, should consider seeking professional counsel even before a full year of unsuccessful unprotected sexual intercourse. Further testing is needed to determine the specific underlying cause.
Typical diagnostic tests that are prescribed may include:
- Health, social and sexual
- Pelvic examinations
- Hormone evaluations
- Sexually transmitted diseases
- Ovulation testing
- Hysterosalpingogram (HSG)
- Hysterosonogram (HSN)
- Semen analysis
- Genetic testing
4. Health, social and sexual history interview
Identifies contributing risk factors such as medications, history of sexually transmitted disease, prior ectopic pregnancies, weight, or other health conditions that may impact fertility. Significant family history of infertility, autoimmune problems, etc. can also be discovered in this process. This is the most basic but possibly important diagnostic process for fertility patients.
5. Treating endometriosis infertility
Endometriosis infertility is a problem that affects many women with endometriosis. However, with proper treatment and reproductive technology many women may be able to overcome this disease.
What is endometriosis?
Endometriosis is a gynecological disease in which cells from the inside lining of the uterus (endometrium) grows outside of the uterus. In a normal menstrual cycle these cells on the inside of the uterus are affected by hormones, first thickening and then shedding through menstrual bleeding. In a woman with endometriosis, the endometrial cells that are growing outside of the uterus also thicken and shed during the monthly cycle. However, once they shed, they have no place to go. The body sees this bleeding as “wound” and rushes to heal it. This process creates scar tissue and adhesions.
How does endometriosis cause infertility?
Unfortunately, when endometriosis spreads in a woman’s reproductive organs, it often affects the fallopian tubes, ovaries, and pelvic floor, leading to endometriosis infertility. Depending on the extent of the disease, the scar tissue or adhesions can prevent normal egg maturation and release, prevent an egg from passing through the fallopian tubes, or a fertilized egg from implanting inside the woman’s uterus. In some cases, endometriosis can also release toxic substances causing harm to eggs or embryos.
How is endometriosis infertility treated?
Depending on the extent of the disease, there are several different ways that endometriosis infertility can be treated. Medications to control hormones along with surgery are two ways that physicians can help reverse the effects of endometriosis in addition to the use of assisted reproductive technology such as IVF. When evaluating the possibility of surgery for endometriosis, however, it is important to discuss with your physician how such a surgery may affect your fertility prospects. It’s possible that after an endometriosis surgery especially involving the ovaries, the patients could experience a sudden drop in their ovarian reserve.
6. Tubal Infertility
The term “tubal infertility” refers to the inability to become pregnant due to a problem in the fallopian tubes.
What are fallopian tubes?
The fallopian tubes are the two long hollow appendages on either side of the uterus that connect the uterus to the ovaries. Each month, the ovaries release a mature egg into the fallopian tubes, where they can be fertilized by sperm. Once fertilized, tiny hairs inside the fallopian tubes move the embryo (fertilized egg) down the tubes and into the uterus for implantation and pregnancy.
What Causes Tubal Infertility?
Tubal infertility is most often caused by either damage or blockage in these tiny tubes. This can be due to past infections, sexually transmitted diseases, pelvic inflammatory disease, history of an ectopic pregnancy or endometriosis. Tubal infertility is a mechanical problem that prevents either the fertilization or implantation.
How Common is Tubal Infertility?
It is estimated that approximately 20-25% of all infertility cases involve tubal infertility. However, damage to the fallopian tubes is often missed due to limitations in diagnostic screenings. This statistic might under-represent the real prevalence of tubal infertility.
How is Tubal Infertility Diagnosed?
A good way to diagnose tubal infertility is through a procedure known as a hysterosalpingography (HSG), in which contrast dye is inserted through vagina to the uterus and fallopian tubes. X-ray images are then taken while the dye is flowing through the structures in order to illuminate any area that may be blocked or partially occluded. It sometimes takes an experienced physician, preferably a fertility expert (not a regular radiologist) to diagnose subtle cases of tubal infertility.
How is Tubal Infertility Treated?
Treatment for tubal infertility depends on the type of damage that is present. In some cases the dye from a HSG exam is enough to clear a blockage whereas in many other cases IVF could offer the best hope for pregnancy.
7. PCOS and infertility.
Polycystic ovarian syndrome (PCOS), also known as polycystic ovary disease (PCOD), is another cause of female infertility. PCOS is characterized by many small cysts that develop inside of the ovaries and interfere with normal reproductive function.
What Causes PCOS Infertility?
Approximately 30-40% of women with PCOS could experience difficulty becoming pregnant. Women who have PCOS develop a lot of eggs in the ovaries, but these eggs are not released from the ovaries when time for ovulation comes. This means that sperm cannot “meet” a mature egg. Each month, when the egg matures, it becomes trapped inside the ovaries, forming a cyst.
How is PCOS Infertility Treated?
In some cases, PCOS infertility can be treated with medications that regulate hormones. However, in other cases, when the cysts interfere with proper ovulation, assisted reproductive techniques such as in vitro fertilization (IVF) or surgery may be considered. When considering surgical interventions for PCOS, you should discuss your fertility prospects with your physician.
8. Should I get surgery to treat infertility?
Unfortunately, surgery as an infertility treatment could potentially be over-used and in many cases can actually cause more harm than good. For example, there is little point in using laparoscopy to open a blocked tube for a patient who is 45. At that age, she would most likely need IVF, which makes her tubal status irrelevant. In addition, surgical intervention for endometriomas (“chocolate cysts,” cysts that develop in the ovary due to endometriosis) and certain other conditions could potentially lead to loss of fertility. It is important to fully consider with your physician all other less invasive treatment options available before determining whether or not surgery is truly an appropriate choice.
9. Male infertility
Contrary to traditional belief, many cases of infertility are due to male factors. These factors may include varicoceles, low sperm count, sexually transmitted diseases, structural anomalies, age, or medications.
Male infertility can be diagnosed through a semen analysis or other diagnostic procedure such as a physical evaluation or ultrasound. The type of treatment needed depends on the exact diagnosis and might include medications, surgery or testicular biopsy. However, in many cases of male infertility, treatment does not restore fertility enough for patients to father children “naturally.” However, in many cases of male infertility, there are assisted reproductive techniques, such as IUI and IVF, to help patients become fathers.
10. What is In Vitro Fertilization (IVF)?
In the IVF process, eggs are collected from the woman’s ovaries and mixed with the man’s sperm outside the body, usually in a glass dish in a laboratory. “In vitro” comes from Latin and literally means “in glass,” a reference to the glass container where fertilization of the egg oocyte takes place. The fertilized eggs are then cultivated for a few days in the laboratory and transferred to the woman’s uterus.
IVF treatment allows women and men to circumvent a variety of fertility problems, from tubal infertility and diminished ovarian reserve to problems with sperm. With several years of history since the birth of the first “test-tube baby,” in vitro fertilization has helped millions of couples build and expand their families.
Who might need in vitro fertilization (IVF)?
Couples may benefit from in vitro fertilization (IVF) treatment if the any one of the following factors are present:
11. IVF Basics – How does IVF work?
In vitro fertilization is the process by which a woman’s egg is fertilized with sperm outside of her body in a lab setting. This fertilized egg, now called an embryo, is then transferred back into her uterus for pregnancy.
This procedure is a common infertility treatment for women who have viable eggs, but have damage to their fallopian tubes or another fertility factor which prevents the possibility of pregnancy without assistance. IVF is also used when other infertility treatments have been unsuccessful.
The IVF procedure has five different parts: hormone suppression, ovarian stimulation, egg retrieval, fertilization, and transfer.
Step 1: Hormone Suppression
Regulation of hormones is a key part of a successful IVF procedure. In order to achieve this, a woman’s own hormone cycle must be suppressed. Suppression is necessary to prevent premature ovulation (release of eggs), ensuring that mature eggs are available for egg retrieval.
Step 2: Ovarian Stimulation
Once a woman’s own hormonal cycle is suppressed, medications are given to help stimulate the ovaries to encourage the development of multiple eggs. In a normal reproductive cycle, a woman typically matures one egg. However, for an IVF procedure, multiple eggs are created in order to increase the chances of a successful pregnancy. Once the eggs are almost mature, a second medication is administered to help give a final “push” in preparation for retrieval and to trigger ovulation.
Step 3: Egg Retrieval
In egg retrieval, eggs are aspirated from the ovaries. In this procedure, a thin needle is guided by ultrasound through the vagina and to the ovaries where eggs are retrieved. This procedure is usually done under light sedation, and takes only 10 to 15 minutes.
Step 4: Fertilization
Using the partner’s sperm or donor sperm, the retrieved eggs are fertilized in a lab setting either by mixing the eggs with the sperm or by injecting a single healthy sperm directly into each mature egg (this procedure is called ICSI). Once the eggs are fertilized, they become embryos. These embryos are allowed to mature for some days. The fertility expert will then decide which embryos are the healthiest and select those to be transferred back into the uterus for pregnancy.
Step 5: Transfer
A few days after the egg retrieval occurs, the female patient will come back to the center for the embryo transfer. The embryos are suspended in fluid and inserted directly into the uterus through a long flexible tube. The process is generally quick and painless; however, the woman will be advised or rest for a short period of time.
Once the IVF procedure is complete a woman will need to wait approximately 2 weeks before taking a pregnancy test.
How likely am I to become pregnant with IVF?
The success rate of IVF depends on multiple factors, including age and endometrial lining. However, the Society for Assisted Reproductive Technology reported that the average successful live birth rate after IVF in the US was 41% (for women under the age of 35).
12. Fertility medications for IVF and ovarian stimulation
Many fertility medications are used in fertility treatment. The list below contains some of the typical fertility medications used. Although many fertility centers use a same small set of medications, the protocols that the fertility experts prescribe to each patient can be very different (and can make all the difference between a successful IVF cycle and a failed one). There are exceptions, of course, such as the use of dehydroepiandrosterone (DHEA) supplementation in women with diminished ovarian reserve. When taking fertility medications, follow your fertility doctor’s instruction carefully, as timing can be very important for some medications, such as hCG.
13. How to interpret IVF success rates
IVF success rates represent the number of times a fertility clinic achieves a favorable outcome from a in vitro fertilization procedure. Success rates are published by individual clinics, and CDC/SART provides this information to the public. For patients, it is important to know that there are two different types of IVF success rates: “clinical pregnancy rate” and “live birth rate.” Knowing the difference between the two can help you understand major variations in success rates between different fertility clinics.
Clinical Pregnancy Rate
A clinical pregnancy rate is the percentage of women that have a positive pregnancy test following an IVF treatment, regardless of whether or not the pregnancy results in a live birth. Because miscarriage rates are often high among women seeking fertility treatment (25% or more), the clinical pregnancy rate is usually higher than the live birth rate. However, in many cases, clinical pregnancy rates are the only available success rates for fertility clinics.
Live Birth Rate
The live birth rate is the percentage of IVF procedures at a fertility clinic that result in a live birth of a baby. Since this is the desired outcome, this is the type of success rate that is often sought by patients. For many reasons, however, live birth rates are often not available (one difficulty that fertility centers face is the length of time it takes for a pregnancy to reach full term).
In addition, patients should be cautioned that there are many factors that may influence an IVF center’s IVF success rate, including their practice specialty or if there are exclusion criteria for IVF patients. For example, clinics that specialized in IVF for the older women will have a lower IVF success rate than clinics that treat a younger patient population. In addition, it could be possible that some clinics might artificially keep their IVF success rates high by excluding patients who are less likely to have a successful IVF treatment (criteria includes age, FHS levels, number of follicles, etc.).
14. Mini IVF: Are they really economical?
Low-cost IVF, also often called “Mini IVF,” has gained some popularity as an attractive alternative to regular IVF. These programs might run at a huge savings compared to standard IVF programs. However, this does not make them cheap. Unlike regular IVF, low-cost IVF cycles have significantly reduced success rates and on average require more cycles to achieve a pregnancy. In other words, couples may wind up spending much more than they would have had they invested in a regular IVF program. In addition, needing more cycles to get pregnant means that you’ll have to spend more time trying – a stressful proposition for many. Unless your primary motivation is to use as little medication as possible for ovarian stimulation, Mini IVF may not be the best option. As always, Emborrow strongly encourages you to discuss your options thoroughly with your IVF physician.
15. IUI vs IVF
Intrauterine insemination (IUI) and in vitro fertilization (IVF) are two of the most common infertility procedures prescribed.
Intrauterine Insemination (IUI)
Sometimes considered a first-line treatment, IUI is one of the least complicated and cost-effective option available for some fertility patients. In an IUI procedure, the male partner’s sperm is “washed” in a lab setting to create a highly concentrated sample of healthy sperm. Then, a woman’s cycle is monitored to determine when she is most likely to ovulate and become pregnant. At the time of ovulation, the sperm sample is inserted directly into the uterus through a long thin catheter.
The success rates for IUI depend on the couples’ individual factors such as infertility diagnosis, age, etc. Typically, IUI success rates are lower than IVF; however, the cost of the procedure is much less and therefore younger couples who can afford to “wait and see” may undergo more rounds before deciding whether or not to advance to a more complex and expensive treatment options. IUI is generally a good option for couples with regular ovulation, open tubes and mild male factor infertility, who can afford to “wait and see.”
In Vitro Fertilization
In vitro fertilization (IVF) is the process by which a woman’s egg is fertilized with sperm outside of her body in a lab setting. This fertilized egg, or an embryo, is then transferred back into her uterus for pregnancy.
This procedure is a common infertility treatment for women who have viable eggs, but have damage to their fallopian tubes or another fertility factor which prevents the possibility of pregnancy without assistance. IVF is also used when other infertility treatments have been unsuccessful, or when patients’ reproductive time frame doesn’t allow for trying less costly but less reliable treatments like IUI.
16. Tubal Reversal vs IVF
One reason a couple may need fertility treatment is the past use of tubal ligation as a form of permanent birth control. When life circumstances change, some of those who had tubal ligation realize that they want more children. Without permeable fallopian tubes, a fertilized egg cannot travel to the uterus and therefore pregnancy cannot occur.
Pregnancy After Tubal Ligation
Women who have undergone a tubal ligation but later decide they desire more children have options to try and become pregnant again: tubal reversal and IVF.
Tubal reversal is an attempt to surgically repair the fallopian tubes. However, the availability of this option depends on the amount of healthy tubes left. When surgery is not possible or the likelihood of a natural pregnancy after tubal reversal is low, IVF is an alternative, potentially more reliable, option. In an IVF procedure, the need for healthy fallopian tubes is bypassed by extracting mature eggs out of the ovaries, fertilizing them in a lab setting, then implanting them back into the uterus for pregnancy.
Some considerations in deciding which procedure is right for you may include financial factors (many health insurances do not cover the cost of this surgery, which could be very expensive), methods used for tubal ligation, or the likelihood of a natural pregnancy after a tubal reversal.
Causes of Infertility
Some of the causes of infertility are:
- Anti-Müllerian Hormone (AMH)
Anti-Müllerian Hormone (AMH) is a hormone secreted by the cells of the developing antral and pre-antral follicles (or egg sacks) in the ovaries. Once secreted from these growing follicles, AMH stops more immature ones from getting recruited into the maturation process, so that not all the eggs mature all at the same time. Because AMH reflects the number of eggs maturing in the ovaries on their way to ovulation, AMH is a strong indicator of a woman’s ovarian reserve (OR) – the ovaries’ ability to produce good-quality eggs.
- Autoimmunity & Infertility
The term autoimmune disease refers to a varied group of more than 80 serious, chronic illnesses that involve almost every human organ system. In all of these diseases, the body’s immune system becomes misdirected, and attacks the very organs it was designed to protect. About 75% of autoimmune diseases occur in women, most frequently during the childbearing years.Autoimmune diseases can affect connective tissue, the tissue that binds together various tissues and organs. It can also affect the nerves, muscles, endocrine system, and gastrointestinal system. There are a large number of autoimmune diseases, with multiple sclerosis, Hashimoto’s thyroiditis, rheumatoid arthritis being some of the most common.
- Diminished Ovarian Reserve
The ability of a woman’s ovaries to produce high-quality eggs (and ultimately good-quality embryos) is known as ovarian reserve (OR). One of the major conditions leading to infertility in women, diminished ovarian reserve (DOR) is characterized by a low number of eggs in a woman’s ovaries and/or impaired development of the existing eggs. CHR has special expertise in treating women with DOR, born out of our decade-long research on the condition.
- Premature Ovarian Failure
The average age at which women typically experience menopause is around age 51. Premature ovarian failure occurs when a woman experiences menopause prior to turning age 40. It can occur as a result of genetic abnormalities that affect the ovaries, with family history playing a role; certain medical conditions can also cause early menopause.
- Egg Quality
When women have a failed IVF cycle or are considering undergoing IVF at an advanced maternal age, they are often told that they might have poor-quality eggs. But what does it mean, and why is egg quality so important for success in infertility treatment? The answer comes down to that high-quality eggs produce high-quality embryos: 95 percent of embryo quality comes from the egg. Embryos must be strong enough to survive the early stages of development in order to result in a successful pregnancy, and that’s why egg quality is crucial in the success of fertility treatments.
Endometriosis is a common gynecological condition affecting women in their reproductive years. The cause of endometriosis is still mostly undetermined, and the condition involves the endometrium (cells making up the internal lining of the uterine cavity) growing outside the uterus, most commonly on fallopian tubes, ovaries, bowel, and the pelvic tissue linings.
- High FSH
FSH (follicle stimulating hormone) is a hormone released by the pituitary gland. FSH stimulates the growth of follicles and has a role in the maturation of oocytes. The measurement of FSH levels in the blood is one of the most widely used tests to assess a woman’s ovarian function and is typically taken on day 2 or 3 of a woman’s menstrual cycle. If a woman’s FSH levels are above what is expected for her age, then she is considered to have “High FSH”.
- Male Infertility
Male infertility refers to the inability of a male to contribute to conception with a fertile female. With modern treatment tools, in a majority of cases, men with male infertility can become fathers.
- Ovulatory Dysfunction
Ovulatory problems account some infertility cases. A normal adult women ovulates every 25 to 32 days. Ovulation is actually a process of maturing eggs that have been “resting” in the ovaries since birth. Each day throughout a woman’s life until she reaches menopause, a few eggs move from the “resting” state into an “active” state.
Polycystic ovary syndrome (PCOS) is a “basket” of different medical conditions, with one finding in common: polycystic ovaries (PCO). In polycystic ovaries, multiple small cysts appear along the outer capsule of the ovaries on ultrasound imaging. PCOS is often associated with infertility, because of anovulation (lack of ovulation) and amenorrhea (lack of menstruation).
- Poor Response
Many women who struggle to get pregnant, even with IVF, are diagnosed as poor responders. This label means that their ovaries respond poorly to ovarian stimulation.
- Repeated Miscarriages
Any unwanted, spontaneous pregnancy loss prior to the 20th week of pregnancy is considered a miscarriage. Miscarriages are a relatively common occurrence. However, repeat miscarriages, defined by either three consecutive first-trimester losses or two with one in the first trimester and one in the second trimester, suggests that there may be an underlying medical condition. Women experiencing repeat miscarriages should consult a recurrent miscarriage specialist to avoid further losses.
- Unexplained Infertility
Unexplained infertility (UI) is one of the most frequent infertility diagnoses given to women. A couple is given the diagnosis of unexplained infertility when they suffer from infertility, and undergo a diagnostic workup that fails to reveal a credible underlying cause for their condition. In other words, the diagnosis of UI is reached by default; it is a negative diagnosis, suggesting that a clinical problem exists somewhere but the likely cause for this problem has remained elusive.
Premature Ovarian Failure
Premature ovarian failure occurs when a woman’s ovaries, which store and release eggs, stop working before age 40. In these cases, there may be no or few eggs. Depending on the cause, primary ovarian insufficiency may develop as early as the teen years, or the problem may have been present from birth.
A woman who has primary ovarian insufficiency is very likely to have irregular or no periods, infertility problems, and menopause-like symptoms. It is difficult, though not impossible, for women who have primary ovarian insufficiency to become pregnant.
What causes primary ovarian insufficiency?
Although the exact cause of primary ovarian insufficiency may be unknown, a genetic factor or a problem with the body’s immune system might play a role in some women. In an immune system disorder, the body may attack its own tissues-in this case, the ovaries.
Primary ovarian insufficiency may develop after a hysterectomy or other pelvic surgery or from radiation or chemotherapy treatment for cancer. In some of these cases, the condition may be temporary, with the ovaries starting to work again some years later.
What are the symptoms?
The symptoms of primary ovarian insufficiency are similar to those of menopause. Your menstrual periods may become irregular-you have a period one month but not the next-or they may stop. You also may have some or all of the symptoms of menopause, such as hot flashes, night sweats, irritability, vaginal dryness, low sex drive, or trouble sleeping.
How is primary ovarian insufficiency diagnosed?
If your periods become irregular or stop, your doctor will give you a physical exam and ask you questions about your general health and whether you have other symptoms of primary ovarian insufficiency. You will also have a pregnancy test. And your blood will be tested for other possible causes of irregular periods.
To check for possible ovarian failure, your blood level of follicle-stimulating hormone (FSH) will be checked. FSH signals your body to release an egg every month. If the amount of FSH in your blood is higher than normal on more than one day, you may have primary ovarian insufficiency. Another blood test also may be done to measure the amount of estradiol (or estrogen) in your blood. Very low estrogen with a high FSH is a sign of primary ovarian insufficiency.
Some women find out they have primary ovarian insufficiency when they see a doctor because they are having trouble getting pregnant.
How is it treated?
Treatment for primary ovarian insufficiency will help you manage your symptoms. But there is currently no treatment that will make the ovaries start to work properly again. Your doctor may prescribe hormone therapy or other medicines to help with hot flashes. Hormone therapy can also help prevent early bone loss in women who have this condition. Talk to your doctors about which treatments may be right for you.
Some women with primary ovarian insufficiency may choose to try to become pregnant using donor eggs and in vitro fertilization.
Finding out you have primary ovarian insufficiency can be extremely upsetting, especially for a woman who hopes to become pregnant. You may want to get support through counseling.
Can primary ovarian insufficiency be prevented?
At this time, there is no way to prevent primary ovarian insufficiency. But you can take steps to protect your overall health. Women with this condition have a higher risk of bone thinning and fractures (osteoporosis), diabetes, and heart disease. A balanced and low-fat diet, regular exercise, and not smoking can help protect your bones and heart. Getting enough calcium and vitamin D may help slow bone loss. Talk to your doctor about other steps you can take. As every piece of information in this site, this information is not intended to replace the advice of a physician.
National Center for Health Statistics
The National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC). In its May 2014 Data Brief, the NCHS reported.
- Percent of women aged 15-44 with impaired fecundity: 12.1%
- Percent of married women aged 15-44 that are infertile: 6.7%
- Number of women aged 15-44 who have ever used infertility services: 7.3 million
- Percent of women aged 15-44 who have ever used infertility services: 12.0%
First birth rates for women 35–39 generally increased from the mid-1970s to 2012, while steady increases for women 40–44 began later in the early-1980s
Burden of Infertility
For Millennials and Generation X, knowledge is power. Millennials greatly benefit from knowing that if they experience infertility, there are treatment options that are available, some of which – like cryopreservation, In Vitro Fertilization (IVF), Single Embryo Transfer (SET), Comprehensive Chromosome Screening (CCS) and others – can help ensure they will be able to have a family when they are ready. Businesses must also beware. As Millennials embark on their careers, many of them will be looking to employers to offer insurance that includes fertility coverage and will be more willing to change jobs for one that caters to their needs. We believe that businesses forgoing or offering minimal fertility coverage will see this impact their ability to retain talent.
With more dialogue about infertility, there will be better understanding that infertility treatment methods are ever evolving and paving the way for those currently struggling with infertility to experience the joys of parenthood – one healthy baby at a time.
In 2015, nearly seven million men and women in the U.S. experienced infertility and will need help through some sort of assisted fertility treatment, such as in vitro fertilization (IVF). According to the Society for Assisted Reproductive Technology (SART), nearly 175,000 cycles of IVF were conducted in 2013, a six percent increase since 2012. And while advances in research and science will help many of these individuals grow their families, some will find they may have waited too long.
There has been a 65% increase in IVF since 2003.
Facing the challenges associated with infertility can be extremely stressful, even competitive with more commonly discussed stresses. In fact, many individuals who have experienced infertility believe it is more stressful than unemployment, and many of those believe it is more stressful than divorce. Clearly, more attention needs to be given to those individuals facing infertility and more education needs to be provided to help overcome current misconceptions about IVF and infertility. That’s why Emborrow was born!
Americans are overly confident in their ability to conceive. Those most confident in their ability to have their first or next child when ready can be those individuals actively trying or expecting to try within five years. However, we know that even a healthy, fertile 30-year old woman only has approximately 20 percent chance of conceiving naturally each month. Individuals must be prepared – or at least more aware – about what their options are if they are unable to get pregnant on their own.
In 2006, the average age of a mother at the birth of her first child was 25 (up from 21.4 in 1970). In a survey run by Reproductive Medicine Associates of New Jersey, Millennials reported that they plan to wait to have children until after they turn 30. While individuals may be planning on starting a family later than previous generations, having a family is still a priority for those who have never had children. For those planning to try within the next five years, 92 percent reported in that survey that having children was important. The top reasons cited among those as to why they have not had children include focusing on their career first (48%) and an inability to afford it (33%). Interestingly, 27 percent of the survey respondents who are actively trying to get pregnant reported that they are facing infertility issues – this figure is more than double what the CDC has estimated (12%), showing that infertility, as a whole, could be underreported. It is important to take the time to learn about your options. While you don’t have to start your family when you are younger, you should, at the very least, start planning your path to parenthood and consider options that can increase your chances of having a child later.
For many individuals (58%) in that survey, cost remained a leading cause for why they would forgo fertility treatments. IVF cycles may not always be covered by employer insurance or categorized as an Essential Health Benefit (EHB), which varies on a state-by-state level. Concerns around stress of the process (34%), physical and psychological, followed by the potential health impact (30%) were the second and third most common responses among those surveyed by the Reproductive Medicine Associates of New Jersey. The rules and stipulations (or “fine print”) in many insurance plans often make it difficult to understand and/or obtain fertility benefits.
High costs can cause individuals to take misinformed or unhealthy risks when it comes to seeking treatment – such as using multiple embryos. However, recent research has shown a 40 percent savings when patients rely on the right treatment paradigm: a paradigm that includes a combination of comprehensive chromosome screening (CCS) with single embryo transfer (SET) resulting in higher birth weights, less time in the NICU and greater savings when it comes to downstream costs.
Reference: RMANJ. (2015). Infertility in America 2015 Survey and Report. Retrieved November 4, 2017.
Most women and couples have no fertility coverages and pay for treatments out-of-pocket. Even for women with infertility coverage, it is not comprehensive and is capped at a fixed dollar benefit that is often exhausted mid-treatment. Women and couples are often compelled to transfer multiple embryos, which results in twins. In each case, because decision making is driven by financial considerations and not the best science, multiple births are common and employers have to pick up the bill for high-risk prenatal care, pregnancy complications, preterm delivery and NICU stays.
In this first prospective study to examine costs across the full range of infertility treatments, treatment costs ranged from a median cost per successful outcome of $5,894 for MEDS, to $61,377 for IVF, and $72,642 for IVF-DE. While costs for IVF and IVF-DE were highest, per-successful-outcome costs for some of the lower intensity treatments were not insignificant: $5,894 for MEDS, $10,696 for IUI-C and $19,566 for IUI-FSH.
Reference: Katz, P et al. Costs of infertility treatment: Results from an 18-month prospective cohort study. Fertil Steril. 2011 Mar 1; 95(3): 915–921. Published online 2010 Dec 4.
Impact on the workplace
Infertility is not an issue that stays at home, as it has the potential to profoundly impact the workplace. As people start to plan families later in life, there will be an increasing need for fertility coverage and benefits. The Reproductive Medicine Associates of New Jersey survey found that more than two-thirds (68%) of respondents were willing to change jobs to ensure they had infertility coverage. This number jumps to 90 percent among those who have experienced fertility issues.
In the current business climate, where organizations are already struggling to retain top talent, offering fertility coverage can be a unique benefit that may help close the talent gap. And it’s not just women who said they would leave their jobs.
- Among those who have experienced fertility issues, this figure increases to 90 percent.
- 70 percent of Millennials reported they would switch jobs to gain fertility benefits if they have difficulty getting pregnant.
Businesses can benefit in the long run by offering coverage that encourages one healthy baby at a time, instead of leaving it to the employees to select treatment options that may result in twins or other high-risk pregnancies. Employers spend 12 times as much on healthcare costs for premature or low-weight babies as they do for babies without complications.
Reference: RMANJ. (2015). Infertility in America 2015 Survey and Report. Retrieved November 4, 2017.
SART’s Fertility Success Rates
SART’s (Society for Assisted Reproductive Technologies) mission is to establish and maintain standards for assisted reproductive technologies. The goal being that patients receive the best level of care possible. As a requirement for membership, SART-member fertility clinics must adhere to standards for quality, safety, advertising and patient care. Outcomes are required to be reported in a strictly defined and standardized fashion. SART member clinics are subject to routine auditing to assure that they are in compliance.
Approximately 5% of programs in the U.S. who do not report to SART send data directly to the CDC. Thus these clinics are not obligated to adhere to SART’s guidelines – the guidelines offer a standardized control over how their data are presented in clinic generated publications or websites.
SART Success Rates – Visit SART.ORG
ART’s Data Fertility Success Rates
Although various definitions have been used for the CDC’s Assisted Reproductive Technology – ART, the definition used by CDC is based on the 1992 Fertility Clinic Success Rate and Certification Act that requires CDC to publish the annual ART Success Rates Report. According to this definition, ART includes all fertility treatments in which both eggs and embryos are handled. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. They do NOT include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved.
Fertility clinics that are operating in your state and explore clinic services and ART success rates based on the latest data from the National ART Surveillance System. To begin, go to the link below and then select a state from the drop-down menu or simply click on a state within the map to see all clinics within the selected state, or enter a zip code to find all clinics within a specified radius.
CDC Statistics https://nccd.cdc.gov/drh_art/rdPage.aspx?rdReport=DRH_ART.FindAClinic
Embryology is the study of development of an embryo from the stage of ovum fertilization through to the fetal stage.
The ball of dividing cells that results after fertilization is termed an “embryo” for eight weeks and from nine weeks after fertilization, the term used is “fetus.”
An Overview of Conception
Once an egg is released from the ovary during ovulation, it meets with a sperm cell that was carried to it via the semen. These two gametes combine to form a zygote and this process is called fertilization. The zygote then begins to divide and becomes a blastula.
The blastula develops in one of two ways, which actually divides the whole animal kingdom in half. The blastula develops a pore at one end, called a blastopore. If that blastopore becomes the mouth of the animal, the animal is a protostome, and if it forms an anus, the animal is a deuterostome.
Protosomes are invertebrate animals such as worms, insects and molluscs while deuterostomes are vertebrates such as birds, reptiles, and humans.
The blastula continues to develop, eventually forming a structure called the gastrula. The gastrula then forms three germ cell layers, from which all of the body’s organs and tissues are eventually derived. From the innermost layer or endoderm, the digestive organs, lungs and bladder develop; the skeleton, blood vessels and muscles are derived from the middle layer or mesoderm and the outer layer or ectoderm gives rise to the nervous system, skin and hair.
Preimplantation Genetic Diagnosis – PGD
Preimplantation genetic diagnosis (PGD) is a procedure used prior to implantation to help identify genetic defects within embryos. This serves to prevent certain genetic diseases or disorders from being passed on to the child. The embryos used in PGD are usually created during the process of in vitro fertilization (IVF).
How is the PGD performed?
Preimplantation genetic diagnosis begins with the normal process of in vitro fertilization that includes egg retrieval and fertilization in a laboratory. Over the next three to five days, the embryos will divide into multiple cells.
Preimplantation genetic diagnosis involves at least the following steps:
- A few cells are micro surgically removed from the embryos, which are about 5 days developed. After this cell collection, the embryos are safely frozen.
- The DNA of the cells is then evaluated to determine if the inheritance of a problematic gene is present in each embryo. This process takes at least one full week.
- Once PGD has identified embryos free of genetic problems, the embryo(s) will be placed in the uterus (usually by an IVF procedure), and the wait for implantation and a positive pregnancy test begins.
- Any additional embryos that are free of genetic problems are kept frozen for possible later use. This testing process may take weeks.
Getting from the egg retrieval process to the final results of PGD can take several weeks. This process includes collection, fertilization, 3-5 days of development, 1-2 weeks of testing, and scheduling an appointment to discuss results with your physician. It is important to keep this in mind if you plan to pursue IVF with PGD so that you know what to expect.
Who can benefit from PGD?
Preimplantation genetic diagnosis may benefit couples at risk for passing on a genetic disease or condition.
The following is a list of the type of individuals who are possible candidates for PGD:
- Carriers of sex-linked genetic disorders
- Carriers of single gene disorders
- Those with chromosomal disorders
- Women age 35 and over
- Women experiencing recurrent pregnancy loss
- Women with more than one failed fertility treatment
PGD has also been used for the purpose of gender selection. However, discarding embryos based only on gender considerations is an ethical concern for many people.
What are the benefits of PGD?
The following are considered benefits of PGD:
- PGD can test for more than 100 different genetic conditions.
- The procedure is performed before implantation thus allowing the couple to decide if they wish to continue with the pregnancy.
- The procedure enables couples to pursue biological children who might not have done so otherwise.
What are the concerns of PGD?
The following are considered concerns or disadvantages associated with the use of PGD:
- Many people believe that because life begins at conception, the destruction of an embryo is the destruction of a person.
- While PGD helps reduce the chances of conceiving a child with a genetic disorder, it cannot completely eliminate this risk. In some cases, further testing is needed during pregnancy to ascertain if a genetic factor is still possible.
- Although genetically present, some diseases only generate symptoms when carriers reach middle age. The probability of disorder development should be a topic of discussion with the healthcare provider.
- Keep in mind that preimplantation genetic diagnosis does not replace the recommendation for prenatal testing.
If you are interested in PGD, talk with your fertility physician, genetic counselor, or a fertility specialist to discuss your options.
Preimplantation Genetic Screening – PGS
Preimplantation Genetic Screening (PGS) is the testing of an embryo’s overall chromosomal normality prior to being transferred to the patient’s uterus in conjunction with In Vitro Fertilization (IVF). Specifically, PGS identifies the most suitable and healthiest embryo to transfer by detecting chromosomal deficiencies – aneuploidy – an extra or missing chromosome.
PGS Can Increase Pregnancy Success Rates
Some studies show that PGS could increase a woman’s chance of conception. This is because her physician has the skill and expertise to identify the most suitable and healthiest embryo(s) to transfer.
PGS VS. PGD
PGS differs from Preimplantation Genetic Diagnosis (PGD) because the procedure does not diagnose an inherited genetic defect in the embryo. PGS searches for aneuploidy – extra or missing chromosomes.
In comparison, PGD diagnoses genetic defects such as:
- Cystic Fibrosis
- Sickle Cell Anemia
Then, what’s the difference between PGS and PGD?
If a fertility physician is doing both tests to diagnose genetic disease, say a couple carries a genetic disease, the physician will use PGD to diagnose whether or not this gene has been passed onto the embryo. For example, both parents may be carriers for Cystic Fibrosis, a recessive disease, which means there is a 1/3 likelihood that their baby will have it, and we can diagnose it using PGD.
PGS will be used to screen out abnormalities that may exist in anyone but aren’t specifically known to exist and thus aren’t easily predictable through one of the parent’s genetic dispositions. This is more commonly used in a patient who is trying to get pregnant and who might have age-related issues or age-related miscarriages. For example, a woman who is 39-years old might have a 30% chance of miscarriage due to chromosomal abnormality. But screening out these problems could increase the chance of pregnancy.
Thus, the difference between PGS and PGD is that with PGD a physician already knows there is a potential for abnormality; but with PGS you are unaware of any particular deficiency and so are screening for chromosomal age-related problems.
Candidates For Preimplantation Genetic Screening – PGS
Some fertility doctors might recommend PGS for every IVF patient. The pros of PGS are that you learn a lot about the health of your embryo and then can make more informed decisions about your fertility treatment. The cons of PGS are cost and an approximate 1.5 percent error rate. PGS finding are not infallible.
Other Candidates for PGS
- Women that have a history of recurrent miscarriages (2 or more)
- Women that have failed IVF cycles
- Gender Selection – Family Balancing
PGS Can Detect Low Quality Embryos
By extracting a cell from an embryo and analyzing it, poor quality embryos are detected. Biopsy of this cell will not damage the embryo.
Low quality embryos result in:
- Low pregnancy success rates
- High miscarriage rates
- High chance for birth defects
Next Generation Sequencing – NGS
NGS (Next Generation Sequencing) is a newer method of PGS. NGS is a genetic screening test for primary candidates undergoing IVF. NGS is used for comprehensive chromosome testing of embryos created through IVF. NGS is on the horizon to replacing PGS because of the procedure’s lower cost and reduced errors.
NGS allows embryologists to screen for defects on the chromosomal level with higher accuracy and more detail than ever before. PGS results are comprehensive and a higher resolution than any other genetic testing method because it detects more translocations.
NGS may be run as a standalone test – or in conjunction with PGD – at a faster completion rate. NGS also detects mosaicism – when the embryo’s cells exhibit different chromosomal content.
Primary Potential Benefits of NGS
- Reduce the number of miscarriages
- Reduce the number of IVF cycles
- Reduce the risk of multiple pregnancy with a single embryo transfer
- Increase ongoing pregnancy rates
- Increase live births
Importance of NGS
As a woman reaches an advanced maternal age (35 and older), there is a greater chance that her low quality eggs will create chromosomally abnormal embryos. The primary goal of NGS is to transfer embryos that have been found to have a normal chromosomal number – euploid.
Embryo morphology – how the embryo looks – alone as a means of selection for transfer is not the best tool. It might be potentially better to couple PGS with NGS to eliminate the chance of good looking embryos being abnormal.
Here is a list of books that offer additional perspectives when dealing with infertility. For further information you could connect with the American Society for Reproductive Medicine at www.ASRM.org and the National Infertility Association at www.Resolve.org. Readings are not a substitute for professional counseling and/or medical treatment.
Infertility and Assisted Reproductive Technology
- Aronson, D. & Resolve (1999). Resolving infertility: Understanding the options and choosing solutions when you want to have a baby. Harper Collins.
- Berger, G. S., Goldstein, M., & Fuerst, M. (2001). The couples guide to fertility: Third edition. New York: Random House.
- Fry, S. (2014). The IVF (In Vitro Fertilization) Journal: The Solution for Managing Practitioners, Tests, Medications, Appointments, Procedures, Finances, and the Emotional Aspects of Your Journey. Hatherleigh Press.
- Domar, A. D., & Dreher, H. (1996). Healing mind, healthy woman: Using the mind-body connection to manage stress and take control of your life. New York: Dell Publishing.
- Fett, R. (2014). It Starts with the Egg: How the Science of Egg Quality Can Help You Get Pregnant Naturally, Prevent Miscarriage, and Improve Your Odds in IVF. Franklin Fox Publishing LLC.
- Domar, A. D., & Kelly, A. L. (2002). Conquering infertility: Dr. Alice Domar’s mind/body guide to enhancing fertility and coping with infertility. New York: Viking.
- Friedeman, J. S. (1995). How to become your own best infertility counselor: Helping you understand your struggle; deciding what’s best for you and educating others to accept your choice. Fort Thomas, KY: Jolance Press.
- Johnston, P. I. (1994). Taking charge of infertility. Indianapolis: Perspectives Press.
- Peoples, D. & Rovner Ferguson, H. (1998). What to expect when you’re experiencing infertility: How to cope with the emotional crisis and survive. New York: W. W. Norton.
- Schover, L. R. & Thomas, A. J., Jr. (2000). Overcoming male infertility: Understanding its causes and treatments. New York: John Wiley & Sons.
- Swire-Falker, E. (2004). The infertility survival handbook: Everything you never thought you’d need to know. New York: Berkley Publishing Group.
- Vargo, J. & Regan, M. (2005) A Few Good Eggs. New York: HarperCollins Books.
- Jaffe, Janet, Diamond, Martha Ourieff, Diamond, David (2005) Unsung Lullabies. New York: St. Martin’s Press.
- Schover, Leslie, & Thomas, Anothony J. (2000) Overcoming Male Infertility: Understanding Its Causes and Treatments. New York: John Wiley and Sons.
- Third Party Reproduction (egg donation, sperm donation, gestational surrogacy)
- Glazer, E. S. & Sterling, E. W. (2005). Having your baby through egg donation. Indianapolis: Perspectives Press.
- Ehrensaft, D (2005) Mommies, Daddies, Donors, Surrogates. Answering touch questions and building strong families. New York: Guilford Press.
- Erickson, T. M. (2005). Assisted reproduction: The complete guide to having a baby with the help of a third party. New York: iUniverse.
- Friedeman, J. S. (1996). Building your family through egg donation: What you will want to know about the emotional aspects, bonding and disclosure issues. Fort Thomas, KY: Jolance Press.
Explaining Third Party Reproduction to Children
- Stamm, L. (2003). Phoebe’s family: A story about egg donation. New Jersey: Tapestry Books.
- Bourne, K. (2002). Sometimes it takes three to make a baby: Explaining egg donor conception to young children. Victoria, Australia: Melbourne IVF.
- Nadel, Carolina (2006). Mommy Was Your Tummy Big? USA: Lulu Press.
- Pellet, S. (2006) The Kangaroo Pouch: A story about gestational surrogacy for young children. Victoria, BC Canada: Trafford Publishing.
Miscarriage and Loss of Child
- Douglas, Ann & sussman, John R. (2000) Trying Again: A Guide to Pregnancy after Miscarriage, stillbirth and infant loss. Dallas, Texas: Taylor Trade Publishing.
- Dubois, Ellen (2006) I never held you: A book about miscarriage, healing and recovery. DLSIJ Press.