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The American Fertility Association Blog

Minimal Stimulation

July 28, 2009 - Tuesday
Posted by admin

By:  Dr. Fred Licciardi

I have been practicing infertility at NYU for 16 years. Basic infertility, reproductive surgery, ovulation induction, IVF, and egg donation are all areas of my expertise. Most of my patients are from New York , but people come to see me from other states and other countries.

Reprinted From Monday, January 21, 2008

Does taking a lower dose of fertility drugs improve your chances of becoming pregnant with IVF? I think not, but I can tell you of some exceptions. Mostly I have had some very good experiences with patients confirming that lower is not better.

How do I know?

Well, as it turns out over the past few years I have been seeing more patients from Europe. There are a few things that have contributed to this. One is the blog. It’s been fun getting e-mails and seeing patients from around the world. The second is the exchange rate: for some, New York is now a “reproductive tourism” destination. The third has to do with laws in Italy, Germany and other countries that restrict IVF and donor egg.

Anyway, the European doctors give their patients a much lower dose of drug that we do in the US. Part of this is due to the fact that they may not be allowed to fertilize more than a few eggs, so they don’t bother trying to get more. Another reason may just be due to a general philosophy that less drug is better.

So the typical European woman that sees me has done IVF many times, usually making just a few eggs on a lower dose of drug. Unless she has had a fantastic response, I increase the dose for her IVF cycle with me. In most cases, the egg yield is much higher (still in a safe range) and the pregnancy rate in these women is very high. So the point is that in these women, a higher dose is better because it increases the number of eggs, and therefore there are more embryos available for selection.

Do some women make more eggs with a lower dose? I have seen a few cases of this. This is typically the woman who was given a lower dose for IUI and develops more follicles than she did with her higher dose IVF cycle. Should we go back to the lower dose for the next IVF cycle? It’s a gamble and it takes a little courage. It is really hard emotionally to go into an “experimental” IVF cycle.

Many patients considering this have had many attempts and may not be ready to give up a couple months for a “let’s see” cycle. If you and your doctor can stomach it, you can give it a try. I can tell you I have one woman, who had been through many cycles, who wanted to give it a go, and she did better with less. Was that her month to make more, regardless of drug dose? Who knows, but let’s give her the credit.

But I do think starting on a minimal dose, just because your doctor thinks it’s more homeopathic and will result in better quality embryos, is not correct. To return to our common theme, if one of the self proclaimed experts in minimal stimulation wants to take 100 women and give them minimal stimulation, and take another 100 and give them regular stimulation, and then show us that minimal is better, great. But until this happens we have to say that it’s not better, and may be worse for most people. I know some of you can tell me that you did minimal and got pregnant. I just feel that my experience has shown that overall, regular may be better.

Categories
Donor Egg • Egg Donation • Fertility • Fertility Drugs • IUI • IVF • Pregnancy

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Oh Bitch Please!

July 16, 2009 - Thursday
Posted by admin

By:  Dr. Daniel Shapiro

Today, Maria del Carmen Bousada, the Spaniard who three years ago became the oldest woman on record to conceive through IVF, died of cancer.  She left behind twins and no known biological father to care for them. On seeing the news of her passing on CNN, my 16 year old daughter reflexively yelled out ‘Oh Bitch Please!!” at the TV. Being a conscientious father (and an IVF doctor) I castigated my scion to be respectful of the dead. I further cautioned her against use of the ‘B” word in describing women.

My eldest, who suffers fools lightly, explained that she was not in any way criticizing poor Maria, but making a general comment about the absurdity of the situation. She went on to say that ‘Oh Bitch Please!” means the same as ‘Tcha, as if!?’ which she was sure I would understand since I am old and from the 80’s.

In fact, I do understand exactly what she means.

To date, there are fewer than 20 reported pregnancies ever in women over 60. ALL of the recent cases occurred as a result of IVF and donor eggs. These pregnancies occurred solely by choice and with great effort on the part of many players. The press has gleefully shown every sexagenarian pregnancy that they can and in every case the debate about whether we should do this or not rages back and forth both in print and between wonkish talking heads on the tube.

The American Society for Reproductive Medicine says plainly that we should not do this. The ASRM guidelines suggest that egg donation services be limited to women at the natural age of menopause (51+) or less.

Proponents of individual rights correctly point out that men are under no such limitation and that it is inherently sexist to apply age limits to women who wish to be parents.

So what’s a society or an IVF clinic to do?

The debate really boils down to competition between the rights of the individual and the best interests of society as a whole. Though I do not pretend to know the right answer to this one, I think I can make a logical argument as to why the rights of the individual here should be secondary to societal norms.

The desire to parent is essentially an accepted form of narcissism. Though childbearing serves a social need by bringing joy to family units and creating a new generation of workers, consumers and thinkers we are all deluding ourselves into thinking that we are individually capable of parenting well. Of course no one person has the right to criticize the parenting style of any other person as long as we stay within legal boundaries and keep our children housed, fed, clothed, schooled and reasonably safe. At the same time we do have the right as members of a larger social group to limit parenting arrangements that put a child or a parent at risk.

In cases such as these the benefit to the individual is narrow and particular and does not serve the greater good. We now see in painful strokes of pointillist realism why this is so. Who now will care for Maria’s twins? Aside from the inherent benefit to the children by being born, who else benefited from this arrangement beside the doctor and those who write about this for the tabloids?

Though Maria’s death is tragic at many levels, the real tragedy is that this happened at all.  Saying this usually elicits an uncomfortable ‘utz’ in the stomachs of reasonable people: criticizing the birth of any child after that child is born goes against our natural wiring. Yet this story represents failure at many levels.

Let’s start with Maria herself. Ms. Del Carmen Bousada just wanted to have a baby. Fair enough. But at age 66, she should have asked herself how being 83 teaching her twins to drive would work. Or maybe she should have asked who would manage the house if she broke her hip at 77. Maria sadly was only thinking of herself and succumbed to narcissistic rationalization.

Now let’s consider her doctor. The clinic’s cut-off was age 55. This is outside ASRM guidelines and opens the clinic up to criticism and scrutiny. The doctor here was a ‘co-dependant enabler’ of our tragically narcissistic lead player. A simple 2-letter word, ‘NO’ would have prevented this.

Our clinic cut-off used to be 55. I personally have helped a 54 year-old conceive. We now adhere to ASRM guidelines precisely because of what we are seeing happen here.

Maria lied to her doctor about her age. The doctor is on record as saying that she falsified records from Spain. He went on to say that he should not be in the business of checking passports. Passports are not as easy to fake and frankly he SHOULD have asked to see it. She was a beautiful woman and did look younger than her real age. But 50 something is still iffy and it should be clinic policy to verify by best possible means a patient’s true age where the reality will make a difference in management. A reproductive tourist like Maria would have had her passport handy. A minimally curious doctor should also have wondered why a Spaniard would need to travel to Los Angeles when Europe’s busiest egg donor program is in Valencia, Spain!

Society as a whole is to blame for this too. Our belief that we are entitled to anything we can conjure and the unquenchable thirst we have for sensational stories create the tableau on which such a picture is painted.

Let me be clear that I do think age limits are sexist, but I also believe that the power of true feminism is not in mimicking male patterns of behavior but in giving women the power to choose wisely for themselves. Maria and her doctor chose unwisely.

Oh Bitch Please!

Categories
Donor Egg • Egg Donation • Family Building • Fertility • Infertility • IVF

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Child-Free Living on Father’s Day

June 22, 2009 - Monday
Posted by admin

About 10 years ago, I received a call from my dad just before Father’s Day. My mom had recently died from her second bout with cancer, and my dad and I had become extremely close as a result. After the usual check-in conversation (how are you feeling, how are the dogs, etc…) he asked if my partner and I had thought about having children, and if so, when he might look forward to that blessed event.

I was caught a little off guard, and all I could say was “why?”

My coming out about a decade earlier was not initially well-received. For my mom, who told me she had known since I was a teenager, it removed any plausible denial that she had left, and solidified in my mind that mothers are truly psychic. For my dad, it was an event of seismic proportion, but not for the reasons that you might imagine. I was a baseball fan (go Giants then, go Diamondbacks now) and a private pilot - two activities that he in no way associated with being gay. “But you like sports!” was a phrase I got used to hearing over and over again as he sought to come to terms with my announcement.

Though everything smoothed out very quickly thanks to our nieces and nephews immediately accepting us, we had never broached the topic of having children with our parents. Not that we hadn’t thought about it. In fact, we had been giving it serious consideration for about six months when my dad popped the question. And that’s really the point of my writing today. Because everyone that I know who considered having children, the decision was not a casual one. As a gay couple, we considered adoption. There are many worthy organizations out there, the Dave Thomas Foundation for Adoption being one of the best. What about surrogacy? Growing Generations which was one of the pioneers of surrogacy for the gay community, offered another option.

In looking back, our wrestling with the question was about us getting to the place where we recognized that child-free living was an equal option to having a child, so the decision could be made from that perspective. There were many considerations that went into our process, many of them purely emotional and all of them highly personal. My partner was - and still is - a second grade teacher. He has a brilliant way of interacting with children that most parents only aspire to and genuinely loves being with kids and teaching them. For my part, every time I held one of our friends’ babies, something inside me felt great. I kind of melted into the little one in my arms. We thought about how happy it would make my dad and my partner’s parents to have another grandchild. We looked at the practical side as well, knowing the costs involved, both financial and emotional. We looked at the rewards of guiding someone from infancy to adulthood and to deep satisfaction that we imagined in seeing our child live out his or her full potential. Perhaps most importantly, we asked ourselves what was as the heart of the matter, and the answer was creating family.

Ultimately, we opted for child-free living. And we realized that we had constructed a family around us that fulfilled our needs and that allowed us to contribute to others. A family that included our parents, our sisters and brothers, our nieces and nephews, our godchildren, our friends’ children, our friends at church, and yes - even our dog. Because for us family is that most special group of people that we choose to surround ourselves with, and that may or may not be related to us through birth. It is the group that we want to accompany us on our journey on earth. It was not an easy decision, but for us, it was the right one, and ten years later, it still feels right. 

I’m going to give my dad a call in a few minutes to wish him a Happy Father’s Day, and to thank him for the answer to my oh-so-simple question 10 years ago when I asked him “why” he wondered if we were going to become parents. “Because,” he replied, “I think you and Bob would make great dads.”

Happy Father’s Day, dad. I love you.

Ken Mosesian
Executive Director

Categories
Adoption • Donor Egg • Egg Donation • Family Building • Surrogacy • Third Party Reproduction

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Facing Change

March 16, 2009 - Monday
Posted by Ken

Last year I wrote an article addressing how issues surrounding the topic of infertility would only become more intense in the coming year. What I didn’t realize is the degree to which the infertility conversation would enter mainstream media, and how quickly.

Thus far in 2009, the topic of infertility is everywhere. Whether it’s the mother of eight babies in California or a 60 (plus) year-old woman becoming pregnant through in-vitro fertilization (IVF), infertility has become part of most people’s daily listening and reading, if not daily conversation.

As I write this in mid-March, I’m wondering what’s going to happen this week when the Georgia State Senate considers a “personhood” bill, which defines life at the moment of conception and ascribes all human rights to the embryo from that point forward. The bill would make anyone who damages or destroys an embryo criminally liable, subject to both fines and imprisonment. It would further forbid any disposition of unused embryos except the option to donate them to another couple, (and they do mean married, heterosexual couples).  The option to freeze embryos for use at a later date, donate them to scientific research, or dispose of them would be illegal if this bill becomes law.

There are several other bills floating around state legislatures right now. Many are designed to dictate to physicians and patients having difficulty conceiving how many embryos they can create, how many they may transfer, and what the disposition of any unused embryos must be.

New questions are being raised about the use of sperm taken posthumously from a male for the purpose of continuing a family line or ensuring inheritance. Who has the final say in these matters?

Egg freezing is emerging as the most asked about fertility topic of the year. Women and men want to know if eggs can be frozen for use at a later date, similar to what is currently being practiced with unused embryos. If so, what’s the success rate? Is this something we should be encouraging? Are there risks? What are they?

Egg freezing, taking sperm from dead men, legislators dictating what physicians and patients can and can’t do, and the very real possibility of microscopic tissue being called a “child” are just some of the issues The American Fertility Association (The AFA) is helping consumers sort through as they begin or find themselves in the midst of their family building journeys.

7.3 million American women experience difficulty conceiving or bringing a pregnancy to term. Fertility challenges among men may be just as high, as male factor infertility is the sole or contributing cause in about 40% of infertile couples.  We are, indeed, faced with a significant challenge.

In addition to providing education and support for those facing fertility challenges, this year, The AFA began an infertility prevention program in which we take education to young women at places they already frequent – like nail salons and health clubs.

Why? There are types of infertility that can be prevented. Avoiding environmental toxins, taking into account the biological clock (fertility begins to decline at age 27 for women and 35 for men) and preventing STD’s are all things that can keep options open for individuals and couples if and when they decide to have children. As everyone knows, prevention, when possible, is the best cure.

Our mission is simple: prevent infertility whenever possible and support people in building families of choice. To learn more, visit us at http://www.theafa.org.

The American Fertility Association, a 501 (c) (3) national non-profit organization is a lifetime resource for infertility prevention, reproductive health and family building. AFA services and materials are provided free of charge to consumers and available to everyone without reservation. These services include an extensive online library, monthly online chats, telephone and in-person coaching, a resource directory, hosted message boards, daily fertility news and a toll-free support line.
http://www.theafa.org or 888.917.3777.

Ken Mosesian
Executive Director

Categories
Donor Egg • Donor Sperm • Egg Donation • Egg Freezing • Embryo Donation • Family Building • Fertility • Fertility Preservation • Frozen Embryos • Frozen Sperm • Infertility • IVF • Reproductive Freedom • Sexual Health • Sperm Donation • Third Party Reproduction

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Super Tuesday - Are You Voting For Your Family?

February 4, 2008 - Monday
Posted by Stuart

Today, when voters from 24 states go to the polls to select the candidates who will represent the major parties in the next election, I’m thinking about how direct our democracy is. I’m thinking about how I voted by absentee ballot for the people who represent my family’s best interests. Not just the family I have at this moment, but the one I’ll have in three weeks when my son is due to be delivered, and the one I reserve the right to have in the future.

As one-half of a gay couple with our first child ready to be born through the amazing assistance of an egg donor and surrogate, I’m keenly aware of the huge strides we’ve made in legalizing many types of family formation. At the same time, I’m acutely conscious of how all that progress could be taken away with the stroke of a pen or the judgment of a court.

That’s why I know deep in my bones that my vote makes a difference. Yours does too.

I suppose it all came home last week I was at lunch with a friend who told me she was voting for one of the candidates who I think is probably the worst on many of the issues that the AFA stands for. I was a little upset at my friend, the mother of two children via surrogacy, for not factoring in reproductive and family building rights into her candidate selection criteria.

Now while I’m gay, and she’s straight, I realized then and there, this isn’t about the politics of sexual orientation. This is about the threats to the basic human right to have family. This is about the threat to assisted reproductive medicine that could wipe out our choice to freeze embryos and to dispose of unused ones according to our individual moral codes. This is about fending off constant challenges to selective reduction, egg donation, genetic diagnosis, surrogacy and gamete donation. And we’ve got to be alert and educated because sometimes the assaults are obvious and sometimes, as in the Colorado push to confer the legal rights of personhood on a fertilized egg, stealthy. We take many of these rights for granted but each of these has come under attack in the last few years.

When I read the papers, listen carefully to the platforms of various candidates, I do know we’ve got to be grounded enough to vote for those who will stand up for the essential right to create family in the ways that are suitable to us. Not according to the ideological dictates of a given administration. But according to our individual hearts.

Knowing just how fragile our family buiding rights are, I believe that this next election is crucial. The results will have a profound impact on our future and that of succeeding generations. I’m voting with all of that in mind. All I can say is I hope you will too.

Stuart Miller
Co-Chair
American Fertility Association

Categories
Adoption • Egg Donation • Family Building • Surrogacy

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