Infertility affects approximately 1/8 reproductive age couples in the United States, however if they seek help, the chances of success has never been better. As couples enter into this world they are often faced with a daunting collection of procedures and terms that resemble alphabet soup. In this article we will explore the world of infertility and find out a little about what is new.
In Vitro Fertilization or IVF is often used when other infertility treatments fail and is one of the most common assisted reproductive technologies used today. Since the first “test tube baby” was born in 1978 over 3,000,000 babies have been born from IVF procedures worldwide. IVF may be used to overcome both male and female fertility issues. The procedure involves stimulating a woman’s ovulation to produce multiple oocytes or eggs. The oocytes are removed from the ovaries and placed in a dish in the laboratory where fertilization occurs. Three to six days later, the resulting embryo or embryos are transferred (ET) back into the uterus to establish a pregnancy. IVF was initially designed to bypass damaged tubes and is now used to treat unexplained infertility, endometriosis, abnormal sperm and poor ovarian function.
In the latest data reported by the Society for Assisted Reproductive Technology (SART), there were 61,000 babies conceived with the help of IVF in the U.S in 2012. Of the 3.9 million births in the U.S in 2012, about 1/100 were IVF babies. While the number of couples accessing IVF treatment has increased significantly, the number of multiple births has decreased. In 2003 a woman undergoing IVF had a 6% chance of conceiving triplets, the risk is now less than 1% and dropping. The rate of twins has decreased but still remains too high. One quarter of pregnancies in women who are under the age of 39 will have a pregnancy with twins. The overall chance for success for In Vitro procedures is about 1/3. For women less than 35 years of age pregnancy rates average 40-45%, but for women over 40 the chances of success are 10%.
Over the past 30 years techniques have been constantly changing to allow us to overcome many challenges in family building, improve pregnancy rates and reduce the risk of multiples. The number of embryos placed in the uterus is determined primarily by the woman’s age. The average number of embryos replaced has decreased from 3.5 in 2000 to 1.9 in the latest data, while pregnancy rates have increased and multiple rates have decreased. Single embryo transfer (SET) or the return of only one embryo to the uterus is now occurring in approximately 17% of all cycles. Excess embryos can be frozen to allow repeated attempts at pregnancy from single egg retrieval and to preserve fertility. While sperm has been frozen successfully for decades, advances have now occurred which allow oocyte or egg freezing. This process which was first reported in 1986 has had limited success until recent changes in techniques have resulted in more reliable oocyte survival and fertilization. There have now been over 1000 babies born worldwide, most in the past few years. Preliminary studies show that these babies do not appear to suffer a higher rate of genetic abnormalities or birth defects. Currently its use is limited by availability and cost. Outcomes are slightly less predictable than with fresh oocyte, the procedure is still evolving and long term larger studies are needed. It is hoped that oocyte freezing will soon become readily available and used with IVF for both fertility preservation and donor oocyte cycles.
In recent years, with the improvement of IVF techniques, the single most important factor in predicting the success of IVF-ET is the age of the female partner, not the fertility diagnosis. Oocytes from younger women possess greater fertility potential, and this potential is utilized in donor oocyte treatment. With this treatment, oocytes from another woman (the donor) are fertilized with her partner’s or a donor’s sperm and the resultant embryos are placed in the recipient’s (patient’s) uterus. The oocytes are stimulated and retrieved from the donor using routine IVF techniques. The oocytes may be donated by known or non-anonymous donation or by women recruited by a third party, anonymous donation. Anonymous oocyte donation usually occurs when a young, fertile woman donates all of her oocytes to a recipient during a particular cycle. This woman is not trying to achieve pregnancy and will therefore be reimbursed for her time and effort and the recipient is responsible for all of the treatment costs. Donor oocyte IVF is used for women who experience premature ovarian failure, genetic or age related oocyte defects. In cases where a young (less than 33 years old) donor is utilized, high success rates of 50-60% per cycle are expected.
Genetic testing can now be performed prior to implantation and now there are reports of the use of cytoplasm transfer to help overcome rare but deadly diseases of the mitochondrial. Couples who have a high risk of passing a genetic (hereditary) disorder to a child may consider pre-implantation genetic diagnosis (PGD). The procedure is done about 3-4 days after fertilization. Laboratory scientists remove a single cell from each embryo and screen the material for specific genetic disorders. According to the American Society for Reproductive Medicine, PGD can help chose embryos that do not carry the genetic trait, which decreases the chance of passing a disorder onto a child. New techniques in genetic screening now make it possible to screen all of the chromosomes of a single cell instead of looking for a specific gene abnormality. This technique is being applied more broadly to help choose normal embryos in cases with repeated IVF failure, advanced maternal age and recurrent pregnancy loss. At this point the technique is controversial as it has not been shown to significantly improve live birth rates when broadly applied and is not offered at all centers.
Overall IVF treatment has become more medically successful over the years and is gaining acceptance and broader application. It is still, however, cost-prohibitive for a lot of couples. Most assisted reproductive technologies are not covered by insurance and only 15 states have mandated coverage. The average cost for a single IVF treatment in the United States is over $12,000. Often, couples will need more than one treatment to conceive. Hopefully new advances will continue to make the treatment more affordable and insurance access will improve to include this very successful medical treatment.
Judith McBean, MD is board certified in Reproductive Endocrinology and Infertility. She practices at Brattleboro OB/GYN, a department of Brattleboro Memorial Hospital.