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The American Fertility Association Blog

Infertility: where religion and science meet

August 3, 2009 - Monday
Posted by Ken

In a recent article titled Reconciling Religion and Infertility, the author thoughtfully outlines the beliefs and teachings of Judaism, Islam, and Christianity and how those beliefs affect each tradition’s teachings about infertility treatment. The article was written from the perspective of helping the 10 percent of the 10 million people worldwide that will be diagnosed with cancer this year and who may require fertility treatment. The term “oncofertility” has been coined for the field that assists patients in looking at fertility preservation options.

From my perspective, there are three key points raised in the article. First, those diagnosed with cancer have not been routinely offered fertility preservation options. Second, there is a real desire for dialogue with religious leaders on this issue, so that health care teams can better deal with people of faith who are faced with cancer and who desire to preserve their fertility. And third, that there are great variations between and within faith traditions on how to approach this issue, and those approaches may change or be nuanced over time as our understanding of technology continues to advance.

But the broader issue that the article points to is the importance of those undergoing or contemplating treatment to have a conversation about it. Have the conversation with your religious leaders. Have it with trusted family and friends. Share what you are going through so that assisted reproductive technology becomes human for others. Finally, share what you are going through so that the conversation becomes normalized in the population at large.

We often talk about the gains The AFA has made in terms of web traffic and media coverage. It’s not because I want The AFA or any member of the staff or board to have attention drawn to them. It’s because I want the conversation about this issue to become part of the mainstream so that the fear and shame, which still surrounds it, can be diminished.

So join the conversation. Health care professionals, patients, those faced with cancer, patient advocates, religious leaders, children born as a result of IVF – everyone’s voices are needed – and so are everyone’s ears; because talking is only half of it.

Ken Mosesian

 

Categories
Cancer & Fertility • Fertility • Fertility Preservation • Infertility • IVF • Reproductive Technologies

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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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Justice Sotomayor – How Will Her Confirmation Affect Those Suffering from Infertility?

July 22, 2009 - Wednesday
Posted by Lisa

By:  Theresa Erickson, Esq.

While watching the confirmation hearings last week (yes, I am one of those dorky lawyers), I was listening for any cues regarding how she may address a case that involved fertility treatments, fertility coverage, pregnancy discrimination (including pre-pregnancy for IVF treatments) and, of course, a woman’s right to chose, including the right to privacy involving medical treatments.  Now, mind you, I understand regulation may be needed in some areas of this industry, but I also do not want to see the government restricting our ability to create a family, regardless of marital status, age, or sexual orientation.  Again, these are issues that must be determined between a physician and their patient when he or she is accessing the health risks for the woman carrying the children, as well as any harm that may come to the future children in terms of prenatal health. 

I did discover, despite her attempts otherwise, that she appeared to hold a liberal point of view in many ways, which despite my own leanings, is important when it comes to autonomy for those patients and those involved in this industry.  However, regardless of her political stance, what is important is that she applies the law neutrally with a perspective of her life experience.  I know that many do not agree with that statement, but we all must agree that it is not humanly possible to take one’s own life experiences out of the picture when making decisions.  What we do want is for judges to use that experience, while simultaneously utilizing an objective vision when making decisions that will affect us all, as well as future generations.

Of course, much of what we do and what our clients/patients deal with is family law.  Judge Sotomayor has little experience in that area due to her previous posts as a federal judge, as most Supreme Court judges.  Even the Supreme Court itself has little experience in that area.  The most notable family law case is the case of Troxel v. Granville in which the Supreme Court did strike down a trial court judge’s decision to allow grandparent visitation involving a completely fit mother.  They were concerned that the judge had used his personal experience in making the decision since he stated he truly enjoyed his time with his grandparents as a child.  But, as I stated above, personal experiences do shape our lives and how we shape our decisions; however, in this case, the Court did not state that the judge did anything wrong in doing so, it was merely that it was a case with a backdrop of a fit mother.  Different set of facts could have created a different ruling. 

Now, with that in mind, Justice Sotomayor is a woman – she has no children, and she has been battling diabetes since the age of 8.  Does that make her more sympathetic to our plight or not?  I am not certain, as we do not know why she does not have children or if it was a path she chose.  But, we do know that she knows what it is like to battle a disease that controls your life, which should be good for those of us in the community. 

Remarkably, after reviewing her previous decisions, I was unable to locate much information on how she would rule if any such case comes before her.  In fact, she has not dealt with stem cell research regulation of Assisted Reproductive Technologies, healthcare choices, or on-point abortion cases; however, there are a few notable cases that she has dealt with as a judge:

1.  Saks v. Franklin Covey Co (316 F.3d 337 (2d Cir. 2003)) – This is a bioethical issues case in which she joined a Second Circuit opinion rejecting a claim that exclusion from coverage of surgical impregnation procedures, including in vitro fertilization, violated Title VII and the “Pregnancy Discrimination” Act.  Note that this does not assume that she is against IVF, only that she did not judge that that particular case was within the parameters of the Pregnancy Discrimination Act, which is her duty as a judge – to interpret law, not make laws.  For changes like this to be made, we need to address our Congress to have them amend these laws as they currently stand. 

      2.  Center for Reproductive Law and Policy v. Bush (304 F.3d 183 (2d Cir. 2002)) – Judge Sotomayor found that a “reproductive rights” group had standing to challenge the Mexico City Policy.  She concluded that the group had “competitive advocate standing,” on the grounds that the government’s allocation of a benefit “creates an unequal playing field” for organizations advocating their views in the public arena.  She agreed that the government had a rational basis for favoring “the anti-abortion position over the pro-choice position” with public funds.  Again, as the above case, since this case is not on point, we truly do not know how she would rule regarding the right to life, the right to abortion, status of embryos, etc.

Ultimately, based on her performance at the hearings and her record, and despite a few bumps in the road involving the case of the firefighters, it does appear that she will be confirmed prior to the start of the next Supreme Court session.  And, of course, I am truly excited, as a woman, as a lawyer, and as a member of the US Supreme Court Bar, that there is another woman on the bench.  Call me sexist, call me whatever you want, but we need diversity on the bench so that those who have never “walked in our shoes” can see the perspective, albeit objectively, when our cases come before them. 

 

 

Categories
Fertility • Infertility • IVF • Pregnancy • Reproductive Freedom

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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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Stories of Persistence

July 15, 2009 - Wednesday
Posted by admin

By:  Dr. Fred Licciardi



Dr. Fred Licciardi of NYU Fertility Center in NYC was one of the first voices in reproductive endocrinology to blog.  Being ahead of the curve has always characterized Dr. Licciardi for us here at The AFA, where we are some of his biggest fans.  We wished to share his compassion, insight and wisdom with all of you.  Please welcome Dr. Licciardi as the newest voice on our growing blogger team.  We will be syndicating Dr. Licciardi’s blog, as well as resurrecting many of his past posts, for you to read and learn from.

Thanks,

The AFA Staff



Reprinted from:  Wednesday, November 26, 2008


Anything we need or want, we hope for.

As stories from the internet have shown, some women with low chances can become pregnant.

Here are a few of my own. And these are only a few out of many others, these just came to mind.

Ms. A was 38 when we met. Her FSH was 22. She was “dismissed” from another program. 2 years earlier she delivered, but this was after trying for 18 months. The sperm motility was a little low, but the sample was close enough to normal, ICSI was not needed.

She first tried a day 2 start, her FSH was 13,4, and was cancelled and converted to IUI because there were only 3 follicles. The plan: keep trying. Her second cycle never got off the ground because of a day 2 FSH of 17.7.

Her FSH was 11.9 on her 3rd attempt and she went on to make 4 eggs, 4 fertilized . On day 3 one looked good, the other fair. This ended in an early biochemical loss.
Her next cycle we changed up the protocol a bit. She had 4 eggs, and 2 embryos transferred, both looked good. This worked, and she just delivered.
So here we have a woman who most doctors would tell there is no chance, but she persisted.

Ms. B was 35 when we met. Her FSH was 14. Her resting follicle count was less than 5. She started a cycle with an FSH of 12, got 6 eggs, poor fert and a cancelled transfer for arrested embryo growth.

Her second cycle was cancelled for no response (not one follicle).

She got pregnant on her own. This theme is an internet favorite. Buy the way, she did not use DHEA.

Mrs C. was 36 and suffered from severe edometriosis. She did 2 IVF cycles before we met.

She did 3 more retrievals with me, always making a good egg number and having good embryo quality. She travelled long distance to get to NYU. On her 3rd cycle (5th total) she became pregnant.

The next one goes under the dumb doctor category (that would be me). Mrs D, a 38 year old from overseas, e-mailed me and told me about her FSH of 25. Realizing she was from far away, I tried to save her some travel time and money and told her IVF was out, but donor egg was in. The couple came to see me, heard the donor egg schpeal and as I finished the husband looked up and said that his wife was going to be day 2 in a few days, could they try IVF while they were still in the States? Without boring him with the low odds speech, I just said, “sure why not.”

Sure enough the FSH was 12, she made 9 eggs and delivered twins. I think they are happy with me, but I am sure they have their reservations.

How can we put these all together?

1) They about women under 40. I don’t mean to exclude the 40 and over crowd from the hope discussion, as there are plenty similar stories about women in their 40’s, but the facts support that it’s easier to beat the odds when you are younger.
2) FSH may not be as important as we once thought. Again, a bad FSH is better under 40. Every so often there is a paper or abstract reminding us that pregnancy rates shoot down with increasing age and FSH levels. Which leads us to the next point:
3) Some infertile women can at times become pregnant on their own. We do use this fact when recommending that some women cancel their cycle or give up on IVF. We say yes you can get pregnant with IVF, but your odds are low, about the same as getting pregnant on your own. Of course this is much more difficult concept to accept when there is a severe male factor.

So for Mrs. A, C, and D, their persistence is what lead to their success. They did not accept the advice of a doctor; they did what they felt they needed to do. Of course we have to keep in mind that it is also true that there are women who try and try unsuccessfully.

Sometimes the fertility establishment is criticized for giving a bit too much hope, while profiting nicely from tons of women who are needlessly spending tons of dough. And sometimes we are criticized for not giving an infertile woman the chance she deserves.

But it will always be true that for most women with low odds, there is a small chance, and sometimes their only chance, using IVF. So it all goes back to getting to the right clinic and getting informed about your odds. After that it’s between you and your doctor, sometimes with a little tug of war.

Dr. Licciardi

Categories
Donor Egg • Endometriosis • Fertility • FSH • ICSI • Infertility • IVF

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