ART 101

Assisted Reproductive Technology (ART) has gotten a bad rap from idiots like Octomom and her doctor, who I hope had his license revoked. Having eight babies puts nine lives at risk. What kind of a mother willfully does this? What kind of physician agrees to participate?

All things ART-related fascinate me, so here’s some good stuff.

The American Society for Reproductive Medicine (ASRM) claims that:

• 1/3 of infertility cases are attributed to male factors
• 1/3 are attributed to female factors
• 1/3 are a combination of male/female factors, with about 20% of this population attributed to "unexplained" factors
  

IVF Optional Features
The treatment of male-factor infertility can be treated with ICSI, where a single sperm is injected directly into an egg. The sperm can even be extracted by testicular tissue removal in a process called Testicular Sperm Extraction (TESE). ICSI with TESE is an alternative to vasectomy reversal, as well as sperm donation in the case of heterosexual couples. Patients should plan on spending an extra $2-5K for one or both of these IVF services.

Pre-implantation genetic testing (PGS/PGD) is an option that will cost you about $3-4K extra. Two physicians I’ve consulted with disagree on this issue. One is a big advocate, the other claims only a small percentage of abnormal embryos will implant anyway, so the body usually takes care of this on its own. Only 9 chromosomes out of 23 can be analyzed. A false-positive or false-negative occurs in about 10% of embryos. There's also a low risk of accidental embryo damage.

The Moral Police?
Physicians have been criticized for discriminating against single women, unmarried couples, and lesbian couples by refusing to treat them. This may not be the result of a physician’s personal beliefs; it could represent the religious/moral views of the affiliated hospital. In order to bypass any hospital obstacle, a physician would need to set up an independent practice like this one did.

Decisions, Decisions
ART can bring up some dilemmas few people think about (and why would you?). Most of them won’t apply to us, but they’re still interesting to ponder:

If you freeze your leftover embryos and decide you don’t want another pregnancy, what would you do with them?

1. Destroy them?
2. Donate them for research?
3. Adopt them out?

If you put your embryos up for adoption: Would it be a closed or open adoption?

If you’re on the receiving end of embryo adoption: How much genetic/background information would you want from the donors of the embryo?

Questions like these are why lawyers and embryo adoption agencies get involved.

Donor Eggs
Consider the use of donor eggs. Some conservative physicians won’t perform IVF on women with poor quality eggs. But the only true assessment of egg quality requires removing them from the body in the context of IVF. Blood tests and ultrasounds provide some information; however, major life decisions – having a child that is genetically related to you – are sometimes made based on these tests. Would you use donor eggs to increase your chance of pregnancy? As a woman, are you okay with carrying and having a child that is not genetically related to you? If so, when would you tell your child that he/she was conceived with donor eggs? Similar questions arise when donor sperm is used.

And Finally, the Multiples Issue
The ASRM provides guidelines on the appropriate number of embryos to be transferred. This is a decision that should be agreed upon by the physician and patient(s). The option of selective reduction should be discussed before a decision is made on the number of embryos transferred.

Blastocyst culture and transfer is a good way to prevent multiples. Blastocysts are embryos that are approximately 5 days old. The advantage is one of selection; fewer embryos (generally only two) are transferred, reducing the risk of multiple gestation. Blastocyst culture provides the embryologist with more information from which to choose the embryo(s) that are most likely to implant and become a baby. However, the ideal candidates are patients under 35 with a low FSH and large number of good quality embryos, or women using donor eggs.