Improvements in IVF Success and Reducing Your Risk of Conceiving Multiples

February 27, 2007 - Tuesday
12:58 PM to (EST)
Guest Speakers: Robert Stillman, MD
Shady Grove Reproductive Center

Categories
IUI • IVF • PCOS • Pregnancy

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Corey_Whelan	Hi everyone and welcome to tonight's AFA online educational session. I am Corey Whelan, your chat moderator. Tonight we are very lucky to have Robert Stillman, MD, of Shady Grove Fertility. Dr. Stillman is here to answer all of your questions on Improvements in IVF Success and Reducing the Risks of Multiple Pregnancy. We are very lucky to have him here; he is a renowned leader in the field. Personally, as a mom of twins who started out as higher order multiples, this subject is very personal for me and I want you all to get the best information available. So I am so glad that Dr. Stillman is here with us.
Corey_Whelan	I see that Dr. Stillman has already logged on and we have a few early birds, so welcome to all of you! I invite you all to type in your questions and please have patience; Dr. Stillman will do his best to answer them in the order that they were written in.
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dr_stillman	I'm happy to join you all and answer questions as best I can. Hopefully you will excuse my typing!!!
sage2	Dr. Stillman, what percentage of blasts split into identical twins? I have heard .1% and also 5%.
dr_stillman	our experience which is the largest in the country (3000=) transfers 50% of which are blastocysts has 1.6% monozygotic/identical twins
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dr_stillman	that should have been typed "3000+ Embryo transfers in 2006
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dr_stillman	identical twins are of course a result of the splitting as opposed to non-identical twinning which is the result -in IVF - of transferring more than one embryo
Corey_Whelan	Hi, welcome to everyone who is starting to log on! We have just started chatting with Dr. Stillman
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Corey_Whelan	I invite all of you to ask your questions - we all learn that way.
sage2	Thank you. I am currently in the middle of a cycle, my embroyos are at day 4 today. At day 3 they were all great quality. I am afraid to have twins, and so plan to replace only one blast tomorrow. Assuming good quality blasts, what is my chance of pregnancy with one blast vs. my chance with two? Ditto on chance of twins with 1 v. 2.
dr_stillman	I'll give you one minute more to start asking questions and then I'm going to start typing on my own!!!
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Corey_Whelan	Good luck, Sage.
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Corey_Whelan	And welcome, Jill and Joy
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Jill_986	Thank you
Patie	How many embryos do you recommend to transfer for IVF?
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Corey_Whelan	And all of you too!
Corey_Whelan	Patie, please let Dr. Stillman answer Sage's question and he will get to you as well
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dr_stillman	Sage2 - the pregnancy rate with blastocysts is higher than day 3 -so having embryos strong enough to go to blast is great -and transferring one to avoid twins is a great idea. Your program should give you statistics. At Shady grove our eSET (elective single embryo transfer ) pregnancy rate for blast is 68% i none cycle versus 66% for TWO blasts and the twin rate wth 2 is 52%!!!
faith0505	Hello All, What new improvement in the IVF successes have hapen within the last two years?
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sage2	Thank you! Encouraging statistics, I think we are making the right choice.
Tracy_Kaylie	so dr., you have a higher pregnancy rate for one blast vs two?
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Patie	what is a blast?
dr_stillman	the numbe rof embryos for transfer at IVF depends very much on age of the female, the prior cycle history if any and how the embryos look - especially blasts. There are newer recommendations form SART including transferring a single embryo in the best prognostic group of patients. you can find the table and recommendations in my article coming out TOMORROW!! the Feb 28 article in JAMA as well as on the SART website. The JAMA article isa ll about reducing embryos to reduvce complications of multiple pregnancy
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dr_stillman	improvements mainly are in the laboratory culture to blatocyst -or at least improvements in blast culture. more groups shoud culture to blast to get the best rates -it isn't eadsy and many gave up becasue they weren't do well - but they should just do better, not quit!!
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moondreams	Hi Dr. Stillman, I have 4 great quality 5 day frozen blasts left from an ED cycle. I had a 9 week miscarriage with 2 fresh and a chemical pregancy with 2 frozen. I am going for another FET and wondered if you recommend putting in 2 or 4. After this, I will close the chapter and move on.
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dr_stillman	our pregnancy rate in patients putting back one embryo using there own eggs is actually higher than putting back two!! counter - intuituve, but the difference is small and we jsut call it the same - but the eSET IS NOT lower and the twin rate is 1.6% versus >50) - and one transferred leave one extra for freezingg for anothe rtrey or another baby from the same egg retrieval/stimulation etc
Tracy_Kaylie	Is there an age over which you'd still recommend transferring 2 or more, regardless of risk of twins?
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dr_stillman	I recommend putting back 2 for the FET -why rsik triplets or 4 when there s no advantage to more once they are frozen. yes, it is anopther transfer, but you don't want a complicated pregnancy after all that hard work
moharden	What is the average egg retreival for woman in their 30s?
dr_stillman	our primary recommendation for eSET is 37 or less with blasts - and ALL donor egg recipients (sincve the donors are <34). SART -and we -= transfer more as age increases sinc ethe odds of any one impalanting -or more -decreases so ''hedging the bet' becomes apporpriate - but it can be avoided in younger patients. The SART recommendations are age and blastocyst specific as to the number recomended for transfer
Jill_986	Dr. Stillman, I am currently in my 2nd IUI, but in looking to the future, am researching the IVF option. I am 29y.o. just diagnosed w/PCOS. The costs of IVF in the states is so high, I was wondering if you knew anything about IVF procedures done overseas, specifically in Thailand? We'll be there this sumnmer, and we are exploring the option of doing IVF there.
dr_stillman	our average for all women at Shady grove is 14 eggs. early 30's it is higher -18. later thirties 14, older women fewer
Corey_Whelan	Jill, we have a chat next week specific to pcos, please be there. There is a lot you can do in the us without resorting to going to Thailand.
dr_stillman	do not know anyhting about THailand success rates. South Africa also advertises alot and is less expensive and their rates are not bad
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moondreams	that's what i was leaning towards. thanks for confirming.
moharden	Sorry if this is a repeat question...I joined a little late, but my husband and I will be starting our first round of IVF. I'm 30 years old and want to know how many embryos we should implant? 1 or 2? What are the chances of getting pregnant with IVF only implanting one embryo?
dr_stillman	travel costs are high so that may offset some gains - plus hotel etc
dr_stillman	if one good quality blastocyst at 30 in her first IVF cycle we would very much urge only one for transfer. If dfay 3 embryo we might go with 2
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dr_stillman	the success with the one blast at your age would be 68% ongoing pregnancy rate per transfer
Jill_986	does dx of PCOS effect those rates?
desperatehw	I'm 24, healthy, diagnosis of severe male factor infertility. ICSI is our only option. Could I be forced to put back only 1, considering my age?
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amccloskey	My husband and I have done 3 rounds of IUI with clomid. We are now starting FSH injections with IUI. I am almost 36. What are my chances of multiples?
dr_stillman	PCOS patients usually have more eggs, although with very high number of eggs the embryo quality sometimes can be effected - but lots of eggs at young age - especially if well stimulated regimen - metformin, low dose stim,ulation etc our numbers are still 68% - and avoiding highe rseverity of OHSS that occurs in twins compared to singleton is a good reason to go with one in PCOS patients who are more prone to OHDS
dr_stillman	that should be OHSS!!
Corey_Whelan	ovarian hyperstimulation syndrome, y'all
Jill_986	it's interesting you say that, b/c my friend just had her first IVF transfer, and it resulted in SEVERE OHSS
Corey_Whelan	I think desperate hw is next
Jill_986	sorry
dr_stillman	our data with several thousand IUI cycles broken down by age would put you at a 20% pregnancy rate per IUI cycle with a 35% chance of multiples - most of those twins -but not all. Today we had JUST this situation -not kidding TODAY -36 3rd FSH IUI cycle -triplets but one was in the tubea and needed surgery this afternon and tiwns in the utersu
Patie	Please discuss the benefits of blasts vs. embryo transfer. This is a new concept that has not been discussed with us by our doctor. My ED is 24 and I am 46 - my transfer is scheduled 2 days after retrieval. We have to decide how many embryos to transfer which will be this weekend - please advise
dr_stillman	no one should FORCE you to put back any number of embryos. they are YOURS and the decision should be yours. It's incumbent on your doctors to advise you -and we'd RECOMMEND / URGE you to put back one at your ange and diagnosiss with a good blastocyst - but NEVER demand it
Corey_Whelan	hang in there, Patie. Give Dr. S a few secs..
dr_stillman	lots of groups do not do blastocyst culture - many have tried and stopped. as I said it isn't easy - time , efort, expertise etc - but the effort is worth it - as randomized studies between blastocyst and day 3 'cleavage stage ' embryos testifies -andis recognized in the recommmendations of SART - and summarized by my JAMA article tomorrow - that blast is better for those who have embryos that reach that stage -and a 24 y/o donor is someone sho should easily do so
moharden	For a 30 year old female, if they retrieve 18 eggs, what is the rate for successful embryos/blasts, to either cryopreserve or transfer?
dr_stillman	culturing 5 or 6 days compared to 3 allows the lab to separate out the better /stronger embryo and select those much better than can e done day 3 - and allows fewer to be put back. we do not add 'a special sauce' betw/ day 3 and 5 - just allow the embryos to sort themselves out -the stronger wil lgrow and others will not -as long as the lab hasd a treack record of not being the rate limiting factor limiting growth potential of the embryos
jgwiggs	okay i must be a little out of the circle, what exactly is the blast? i've done iui.
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dr_stillman	30 y/o 18 eggs 80% of our transfers would be blastocyst and of those 68% would be pregnant with one transferred. Day 3 transfer of two -we rearely do one since we don;t kow which one to pick as weasily -would be 50% with 40% of those twins
AmandaUNCC	Hi Dr. S. I am 28 and had 43 eggs retrieved almost 2 months ago.. Out of 10 fertilized, 2 were frozen on day 5 and the transfer should be near the end of the March. I am going to get two back. with my stage 3 endo, I'm worried that I do not have the "glue" factor that I need for these babies to stick.. I am I just paranoid? and yes, I had sever OHSS after 43 eggs
dr_stillman	blasticyst is the stage of an embryo when it implants - it is a embryo with 100+ cells (can't count them all) with a fluid filled cavity and an 'inner cell mass' that becomes the embryo and the outer cells which become the membraanes and placneta, ALL embryos that impplant - youo, me, everyone everyon implants only as blastocysts
dr_stillman	43 eggs. wowo, no wonder you had OHSS. and good they didn't do a frsh transfer. puttin back 2 thawed embryos would be my recomendatioon -esp sinc ethe risk of OHSS is not present in the frozen transfer cycle
moharden	What do you mean by "putting back"?
dr_stillman	my typing is really terrible - especially trying to type quickly/ sorry
AmandaUNCC	Thanks for confirming my thoughts. Thanks for your advice
dr_stillman	embryo transfer (sorry)
dr_stillman	you are welcome
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jgwiggs	okay,so for a 42 yr old thats been trying for 23 yrs. technically 2 with fertility phys. what is the best bet for a positive result? husband has low sperm count.had 1 failed iui
dr_stillman	age and history would allow transferring many embryos -3,4,5 with very low risk of mulitples -almst no risk of triplets. the older patient with your history is the exception to the rule of put fewer bacvk to be safer
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jgwiggs	thank you
dr_stillman
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dr_stillman	28 people and no questions!! ?
AmandaUNCC	I just wish someone could tell me if I am going to have twins!!!
amccloskey	What are the effects of FHS injections?
titapedro	what are the chances of getting pregnant with first ivf?
dr_stillman	you won't have twins if you put back one!!
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fritzrose	Is there an increase risk of birth defects with ivf? ie. autism, etc...
titapedro	is there an increase of defects with ICSI?
dr_stillman	FSH injections stimulate the ovaries so the effects are related to increased estrogen, increased stim to the ovaries and the risk of multiple pregnancy. The latter is the most significant long term effect!. the injections themselves are certainly abother but new pen devices and really smlall needles minimize pain and difficulty
Patie	Are there many risks with twin pregnancy - esp for a petite woman?
Joy	What, if any, chance is there of having multiples if only one embryo or blast is transfered back to the uterus ("putting back in")?
Wendy	Would you recommend, then, "older" patients choosing an Egg Donor, try and find a "younger donor"- higher egg retrievals?
moharden	With male factor infertility (count of 13, motility of 15%) What would be the likelyhood of successful IUI with a 30 year old with PCOS. Or is IVF the only viable option?
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dr_stillman	fortunately most twins do okay, but lots more hypertension, pre=eclampsia, premature delivery infant complications and -I'm sorry to say -death are jsut some of the risks of twins - not as severe as these complications as with triplets - but much more than singleton -we have some of this also on our website www.shadygrovefertility.com and in the JAM article I've talked about
dr_stillman	multiple occur between 1-2% of the time with transferring one vack.
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desperatehw	female age 24, male 26 with only 1 million sperm, is it critical for us to do ART as soon as possible? How long can we wait without decreasing odds of success? What are the odds of success for healthy 24 year old?
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dr_stillman	the use of an egg donr of someone 'just 10 year younger - 32 instead of 42 - increases the prgnancy rate from 5-10% with many embryos transferred to 68% in one cycle with one embryo transferred.
christalp	i am a 30 year old with PCOS. I have been on metformin and clomid and have done 2 IUI without success. What are the chances that IVF would work for me
Corey_Whelan	chris, I mentioned this before but just in case....please join us next week for a chat devoted to pco.
christalp	thanks
dr_stillman	ART will be all that is likely to be succesful wih very severe oligospermia -belwo 5million - very very low otherwise, but your age allows some time - although for little gain - for a few more years before ratyes decline - our 68% with one embryo - including very severe male factor -still is seen into the 30"s
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dr_stillman	also oyu may want more than one child and later transfer of cryo'd embryos or needing a new fresh second or third cycle for a second or third child makes starting earleir better
desperatehw	thanks, we're just not able to financially right now
Corey_Whelan	desperate, you should log onto Shady Grove's website to learn about their shared risk program if money is an issue.
arwamsted	what are the chances of multiples when doing shots & IUI vs IVF (like how do they compare)?
desperatehw	thanks
AmandaUNCC	You will never think you have enough money, unfortunately
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desperatehw	no we actually would be denied the loan, and couldn't afford the payments
moharden	I think my question was missed : ] ::smile
Patie	i advise desperatehw to buy an ovulation monitor before persuing assisted fertility
desperatehw	can'-t with only 1 million total sperm
dr_stillman	many centers - likemShady Grove have many finacial plans -shared risk 100% refund if you don't have a baby, or studies with medications that cover much of the cycle or becoming a 'split egg donor' where anonymously you give 1/2 the eggs retrieved to a couple neding an egg donor and they pay for almost all of your IVF cycle and medicaitons - and oyu keep the other 1/2 of the eggs - win - win. And at your age it would be unlikely you would have any decrease in pregnancy rates from using half the ggs. it's an option
dr_stillman	sure you can? why not??
desperatehw	I just meant I wouldn't benefit from an ovulation monitor, given my husbands condition
dr_stillman	with 1 million sperm you need to do ICSI -one sperm for one egg - so you only need 10, or 20 or 25 or whatever number of eggs you have - 1 million is MORE than enough.
Kris_S	Hello Doctor, I am a 42 yr old , with poor lining issues I have a total of 2 of my own embryoes and 4 frozen DE. I was wondering how many of the DE should we transfer?
moharden	Dr Stillman, is IUI an option with combined issues of male factor infertility (13 million ct, 15% motile) and PCOS variant in a 30 yr female?
dr_stillman	I was referring to success with ICSI and helping to have it paid for by split egg donation, soorry if I missed the question/discussion about the monitor
Corey_Whelan	folks, we're at just about the five minute mark, so please type in your last questions.
desperatehw	thanks, I've been looking into shared egg donation, it seems like a good option for me
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dr_stillman	13 million 15% motiltiy IUI success is, unfortunately very low. I wish it were higher. the 'total number of motile sperm' used for insemination in an IUI after the 'washing' would be so low as to make coneption unlikely- completely reversed with IVF ICSI - even with one embryo transferred
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moharden	thank you, that's what we thought. You have been very helpful. Good luck everyone.
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dr_stillman	our teminology is 'split' and I remember since it involes the Patient "P" donating haf her eggs rather than anon-paitent donor sharing her eggs among two or threew omen -we're doing lots of that at much lower donor egg costs and optins, but your would be 'split' at least in our Shady Grove terminology
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dr_stillman	saMMY CAN'T MAKE UP HER MIND
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AmandaUNCC	where is shady grove?
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dr_stillman	Rockville maryland is our main office. we have 8 offices in and around washington and one in Baltimore
arwamsted	what are the chances of multiples when doing shots & IUI vs IVF (like how do they compare)?
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dr_stillman	more prengnacies with IVF, but you can control the multiples by controling how many embryos to put in. IUI is much lower success but if successful, 3 or 4 or 5 follicles canlead to twins or triplets or....like our patient I talked about earleir from today with 4 follicles and now triplets including one in the tube and 2 in the uterus.
Kris_S	My partner will be carrying my own bio-embryos (2), and I will be carrying the DE, however I have poor lining issues and I am 42 is 2 DE enough or should we transfer all 4? My donor was 25.
Corey_Whelan	no more questions, please. Dr. Stillman, I want to thank you SO MUCH for your time tonight
Patie	Thanks Dr. Stillman !
arwamsted	thank you!
Corey_Whelan	You gave us all amazing information and I know that I learned a lot! And thanks to all of you too for being here
AmandaUNCC	thank you and best wishes to all
dr_stillman	you arer all welcome. BEST OF LUCK TO YOU ALL
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Corey_Whelan	And I want to wish ALL of you SO MUCH LUCK on your journey
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Corey_Whelan	our time together, is officially at an end. Goodnight
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RF15015	I was on the phone with a potential surrogate. I missed the whole discussion. Can I get the transcript?
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RF15015	Does anyone know the answer to that question?
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desperatehw	the transcript will be available
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desperatehw	at least all the previous ones are
desperatehw	I was just reading them
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Improvements in IVF Success and Reducing Your Risk of Conceiving Multiples

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