Category Archives: What’s New

What’s New at Florida Institute for Reproductive Medicine or F.I.R.M., the leading IVF clinic with 7 FL and GA locations and operations based in Jacksonville, FL, includes our IVF clinics in Jacksonville, Tallahassee, Daytona Beach, FL, Brunswick, Thomasville, and Valdosta, GA 

Egg Freezing

The ability to freeze a human egg offers at least two important options for women: fertility preservation for women faced with potentially sterilizing therapies and individuals postponing childbearing, as well as couples requiring in vitro fertilization (IVF) who are ethically opposed to freezing (pre)embryos.  Being able to freeze eggs also allows for the establishment of egg banks, greatly improving the efficiency and lowering costs for donor egg IVF.

We have been able to freeze (pre)embryos since the early 80’s, a technique that is routinely performed in most reproductive medicine programs.  Freezing an unfertilized egg is much more difficult because of the large size and water content, i.e. as the egg cools ice crystals develop which can damage the working components known as organelles.  When a (pre)embryo is frozen, the essential task of these organelles has already been performed.

The first pregnancy from a frozen egg was achieved by Dr. Chen in 1986.  Following this pregnancy there were no other pregnancies until the early 90’s.  With the abolishment of (pre)embryo freezing by the Italian government there was a resurgence in egg freezing technology.  Dr. Borini and others refined the protocols for egg freezing, and with the advent of intracytoplasmic sperm injection (ICSI), whereby a single sperm could be injected into an egg the efficiency of egg freezing increased.  Dr. Dunsong Yang, the head of embryology at the Florida Institute for Reproductive Medicine, was one of the early pioneers in refining the egg freezing protocol, greatly improving its efficiency.

The Florida Institute for Reproductive Medicine has one of the largest experiences with egg freezing in the nation with over 63 babies born, including the first baby born in the world to a cancer patient who froze her eggs prior to chemotherapy.  Currently we are seeing pregnancy efficiencies of approximately 10 eggs equating with an ongoing pregnancy for egg donors 35 years or less and approximately 14 mature eggs for those 36-38 years of age.  In general, we do not freeze eggs beyond 38 because of the high percentage of abnormal eggs.  Our work on egg freezing has been chronicled in People, Self, Pink, Conceive, and Woman magazines as well as on CBS, NBC, BBC News, and the Today Show.

To date, in the world there are approximately 3,000 babies born from frozen eggs.  Health data on these infants continues to be very reassuring.  Until, however, high numbers of these children have reached adulthood and reproduced, the absolute safety of this technology cannot be asserted.  For that reason egg cryopreservation is still recommended to be done under an IRB (institutional review board) approved protocol.  At the Florida Institute for Reproductive Medicine we keep yearly surveys of our cryo egg births through annual questionnaires to parents and pediatricians.  Costs for egg freezing at the Florida Institute for Reproductive Medicine mimic those of an IVF cycle, i.e. approximately $10,500.

We will store eggs at no charge for a period of five years, after that time there is an annual storage fee of $400.  For our cancer patients seeking fertility preservation, we have been able to get medicines donated by the Ferring drug company, saving patients approximately $3500.  The longest an individual has stored eggs to date and had a successful pregnancy is 6 ½ years.  We do not believe there likely is a shelf life to frozen eggs.

Post Tubal Ligation Tubal Reanastomosis Versus In Vitro Fertilization

Approximately 10% of women who undergo tubal ligation subsequently wish to have another child – the most common reason being a new male partner who has never fathered children.  Tubal ligation involves the interruption of the tube, typically in the mid portion or rarely resection of the distal end of the tube.  All tubal ligation patients have the option of in vitro fertilization (IVF), assuming they have good ovarian reserve, i.e. a reasonable number of good quality eggs left in their ovaries.  Ovarian reserve can be checked by a variety of means, the most accurate being an ultrasound count of follicles in the ovary along with a blood test known as antimullerian hormone level.

To be a candidate for tubal reconstructive surgery it must be ascertained that the patient has sufficient healthy remaining tube and that the distal working end of the tube has not been removed or damaged.  If a tubal ligation has been performed using cautery often extensive tube damage has occurred.  These individuals in general are not good candidates for surgery.  Prior to considering tubal surgery a semen analysis to rule out a severe male factor should be performed.  If a severe male factor is found, IVF using intracytoplasmic sperm injection (ICSI) is likely to be the best option.

If the female partner is older than 35, despite good ovarian reserve she is likely to have an increased proportion of poor quality eggs, often resulting in a significant delay to conception.  For the older patient IVF is likely to be the preferable option.  If ovarian reserve is poor, donor egg in vitro fertilization is the most realistic option.  If the female partner is 35 years or less with good ovarian reserve pregnancy rates of approximately 70% can be expected with surgery, comparable to cumulative pregnancy rates with IVF.

At the Florida Institute for Reproductive Medicine tubal reanastomosis is being performed on an outpatient basis with the use of the da Vinci robot allowing individuals to return to work typically within one to three days.  Surgery is associated with a significant increase in the risk of an ectopic pregnancy, i.e. a pregnancy getting “stuck” in the tube.  This condition can be serious requiring emergent surgery.  If a couple decides they only want a single pregnancy the issue of future contraception must be addressed.   At the Florida Institute for Reproductive Medicine, using the robotic laparoscopic approach we are able to offer this surgery at a cost of $6,750 (cost for an average IVF cycle is $11,000).  The primary disadvantage of IVF is a high multiple pregnancy rate.  For individuals less than 38 years of age multiple pregnancy rates range from 20-40%, 98% of these being twins.  While the great majority of twins do very well there is an increased risk of morbidity and mortality.  Almost all multiple pregnancies are delivered by cesarean section.  The issue of a multiple pregnancy can be avoided by electing to transfer a single embryo.  For couples who are ethically opposed to IVF because of the issue of freezing (pre)embryos, this can be avoided through egg freezing.  Because of the disadvantages associated with surgery approximately 9 out of 10 couples at our center are electing IVF as opposed to surgery.  With the advent of the low cost outpatient robotic approach, we believe this ratio will decrease.

An Explanation of IVF Success Rates

Following passage of the Wyden bill in 1991, fertility programs in the United States were required to report their in vitro fertilization (IVF) pregnancy data to the Centers for Disease Control (CDC). This bill was intended to give the consumer a means of evaluating a particular IVF program. While the majority of programs in this country do report some do not. The penalty for not reporting is minimal – these programs are simply listed by the CDC as non-reporting. Reporting programs are subject to unannounced audits by qualified embryologists to verify data. At the Florida Institute for Reproductive Medicine over the last 21 years, we have been audited on two occasions and have passed both. A program not reporting their data to the CDC can report whatever data they wish, knowing they are not going to be audited. For that reason, it is wise to avoid any non-reporting program. To check and see if a program is a reporting program, check the website www.cdc.gov/art/art2010 (/art2009, /art2008, etc). I would suggest checking for at least the last three to four years as some clinics may report their data only when it is favorable.

When evaluating IVF success rates, it is important to look at live pregnancies from both fresh and frozen cycles. Some programs may report clinical or chemical pregnancy rates, approximately 5-20% of these pregnancies will end in miscarriage. Probably the biggest difference in cumulative pregnancy rates between programs is the difference with cryopreserved embryos. At the Florida Institute for Reproductive Medicine our fresh and frozen embryos have consistently been in the top ten percentile of programs nationwide. When evaluating pregnancy rates, it is also very important to look at the average number of embryos transferred. Many programs reporting very high pregnancy rates are achieving these results by transferring inappropriately high numbers of embryos. This practice inevitably results in a high percentage of multiple pregnancies. Multiple pregnancies are associated with increased morbidity and mortality to both fetuses and mother. At the Florida Institute for Reproductive Medicine for most individuals 38 years or less we are transferring two day 5/6 blastocyst embryos. For individuals less than 35 who are in a very good prognostic category we frequently will transfer a single blastocyst. For women older than 38 we may transfer up to three day 5/6 blastocyst embryos.

IVF Value

Costs in the U.S. for in vitro fertilization typically range from $10,000 to $18,000 inclusive of medications.  Added potential costs include intracytoplasmic sperm injection (severe male factor) $500 – $2000, assisted hatching (patients 38 years and older) $500 – $2000, as well as costs associated with cryopreservation of embryos $500 – $2000.  Costs for subsequent thawing and transferring of cryopreserved embryos typically range between $1000 and $3000.  Costs most often are not covered by insurance.  At the Florida Institute for Reproductive Medicine, our costs have always fallen around the lower end of these ranges.  We always strive to provide IVF at the lowest cost possible, making this therapy available to the greatest number of patients.

Infertility patients faced with in vitro fertilization are primarily interested in their chances of taking home a baby from all their IVF embryos.  Given the very real concern over multiple pregnancies, i.e. potential significant morbidity and mortality, along with the cost and social difficulties associated with a multiple pregnancy, limiting the number of embryos transferred is appropriate.  At the Florida Institute for Reproductive Medicine the majority of our patients are transferred no more than two embryos.   Additional embryos are cryopreserved.  This brings up the issue of pregnancy rates associated with fresh as well as cryopreserved embryos.  IVF programs practicing in the United States are required by law to report their pregnancy data to the CDC each year (http://www.cdc.gov/art/ARTReports.htm).  One of the greatest differences in IVF programs is their cryo embryo pregnancy rates.  Many programs have very poor results with cryopreserved embryos.  For younger patients, less than 35 years of age, who likely will have embryos to cryopreserve, this represents a big disadvantage.  Generally, fresh pregnancy rates will be somewhat higher in any program due to selection bias, i.e. when embryos are created, typically the embryologist will select the best looking embryos to transfer fresh, cryopreserving the remaining embryos.  At the Florida Institute for Reproductive Medicine our fresh and frozen pregnancy rates have been among the highest in the country.  Therefore, when trying to determine the value that a particular IVF program offers, it is important not only to take into consideration the cost, but also the pregnancy rates obtained from both fresh and frozen embryos.

A further consideration is the total number of embryos obtained.  This number will vary depending on the patient’s age/ovarian reserve as well as the stimulation protocol, retrieval, and laboratory efficiency.  At the Florida Institute for Reproductive Medicine, given the new and aggressive stimulation protocols used, the majority of our patients less than 35 years of age have embryos for at least one cryo IVF transfer, many have embryos available for a second cryo transfer.  Therefore, total reproductive potential is the sum of the fresh transfer plus all cryo IVF transfers.  Looking at the total reproductive potential in the context of IVF costs, we believe that the Florida Institute for Reproductive Medicine offers one of the greatest IVF values in the country.

Why Can’t I Have Another Baby?

Almost half of infertility occurs following an initial pregnancy that may have occurred soon after discontinuing contraception.  This problem, known as secondary infertility, is often overlooked or downplayed by physicians who see these patients as being fertile and are then reluctant to evaluate or treat.  Maternal age and the duration of secondary infertility are critical issues.

We know that women are born with a certain number of eggs – they never make any more eggs the rest of their life.  The number and quality of eggs declines as a function time, resulting in a significant decrease in pregnancy rates after age 35, and a drastic decrease after 38.  Infertility is defined as a lack of conception after one year of unprotected intercourse.  For individuals 35 years or older, most reproductive medicine specialists recommend initiation of a work-up after four to six months of trying.  Ultimately, again, remaining egg number and quality are the critical issues.

Evaluation for secondary infertility should be identical to that of primary infertility targeting those issues that are most suspect.  Almost 40% of all infertility is male related.  Even if a male has fathered a child, semen parameters can change drastically due to a variety of health changes including medical problems, surgeries, traumas, or infections.  A semen analysis will evaluate a male’s current fertility status.  If there has been a change in male partners, particularly if the new partner has not fathered children, certainly male factor may be the issue.  Almost 50% of infertility is female related, primarily ovulatory or anatomic problems.  While a female may have a history of regular ovulatory cycles prior to, her ovulatory pattern can change drastically following a pregnancy, especially if there has been a significant weight gain.  If prior pregnancy was delivered by cesarean section, adhesion scar formation certainly can occur and be associated with significant tube compromise.  Loss of weight will often bring about a return of regular ovulatory cycles.

If there has been a long time between the first pregnancy and initiation of a second pregnancy, certainly the issue of egg quality may be the problem, especially if mom is now over age 35.  Strategies to try and improve fertility due to an egg quality issue include superovulation (getting the patient to release multiple eggs) or in vitro fertilization (transferring more than one embryo back to the uterus).  If the initial pregnancy was delivered by cesarean section and especially if there was a history of infection, adhesions may be causing a tubal factor.  If there was retained placenta following delivery, uterine scarring can occur – hysteroscopy (outpatient surgery – scope is used to look into the uterine cavity) should be considered.  With a significant time delay before initiating a second pregnancy, conditions like endometriosis, the growth of endometrial tissue outside the uterine cavity, i.e. in the pelvis, may cause significant anatomic distortion.  Likewise, fibroid tumors that may have been small and clinically insignificant prior to pregnancy may now be large and compromising fallopian tubes or the uterine cavity.

In conclusion, secondary infertility is a very common problem.  Delaying evaluation and treatment is often associated with severely diminished chances for pregnancy.  Secondary infertility should be approached in an aggressive, targeted manner especially in the context of advanced maternal age.

Meet the Experts: A Family Building Expo

Saturday, November 19, 2011 8am – 11am, St. Luke’s Hospital Auditorium. Presented by Resolve, the National Infertility Association. Are you one of the 1 in 8 couples of childbearing age in the U.S. diagnosed with infertility? Are you interested in learning more about your family building options? This EXPO is for you. Door prizes include a free IVF cycle and other professional services. Cost: $10 per person / $15 per couple in advance or $15 per person / $20 per couple at the door. Register in advance at www.resolve.org/Jacksonvilleexpo.

Fertility Treatment and Ovarian Tumor Risk

Recent headlines have reported that IVF treatment is linked to ovarian tumors based on a recently published study. The findings are not different than was was reported over 10 years ago, and media coverage often misleads the public into making assumptions that may not be true. Many studies in the past have reported positive or no linkages with fertility treatment and ovarian stimulation and future risk of ovarian tumors. This study from the Netherlands was retrospective in nature, meaning that they started with women who had tumors, then looked to see what type of treatments they had. This type of study can possibly find causal linkages between a treatment and an outcome, but are in no way definitive as there are many biases that are introduced. You can breathe a sigh of relief that the study did find no link between IVF and ovarian cancer in a follow up of 15 years time. The only relationship was with possible “borderline” tumors, often called “low malignant potential” tumors. These are not invasive cancer and are not considered pre-cancer tumors, though they can grow like a tumor over time. The prognosis with this tumor is usually very good and tremendously different than with invasive ovarian cancer. Below is a blog from the American Fertility Association that helps to clarify a lot of this information.


Tumors of low malignant potential

Posted by Corey Whelan on Oct 27, 2011 with 1 Comments

http://www.theafa.org/blog/tumors-of-low-malignant-potential/

A new study out of the Netherlands and published in Human Reproduction is making the news today. It is entitled “Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort”. Reuters picked it up as “Fertility treatment raises tumor risk in study”.

It is of course understandable that The AFA’s phones have been ringing off the hook. Women are alarmed by this report. Briefly, I wanted to share a few facts about the study and urge you to please relax while you read this.

This long term study compared women who had done in vitro fertilization (IVF) with two other groups of women; 1)the general population, and 2)sub fertile women who had not done IVF. The researchers reported an increased risk level for the IVF group of developing borderline ovarian tumors. The research also showed that the overall incidence of invasive ovarian cancer was not significantly elevated, but increased with longer follow up.

The important thing to note here is that borderline ovarian tumors are actually cysts of low malignant potential. I am not minimizing the value of this study However, the term as is being reported in Reuters and picked up by media outlets, that women are twice as likely to develop ovarian cancer after IVF, is misleading. Patient’s individual risk of getting ovarian cancer if they do IVF is not 50% higher than it would be were they not undergoing treatment. The increased risk of acquiring invasive ovarian cancer for this group is around 1.76% greater after 15 years. If you however, put together the statistics for borderline ovarian tumors along with the statistics for ovarian malignancies, the rate goes up to 4.23%. That being said, we don’t want women to wind up in either group if they can help it.

I reached out to Dan Potter, M.D. to get his opinion on the study. His comments, verbatim, were:

“This is no different than the study that was published here in the U.S. about 10 years ago. The lead author is an epidemiologist. Oftimes in studies such as this, the researcher starts with the conclusion they wish to arrive at and then they work backward to prove it. I’m not saying that’s what happened here, but these are the most problematic issues that I see in this study.

  1. They linked all of the ‘malignancies’ in the registry to patients in the two study groups (IVF and non-IVF) regardless of whether they returned the surveys or not. This creates a falsely high incidence. They compared them to ‘general population rates’ who basically have the equivalent of a survey return rate of 100%. See how they appeared to start at the conclusion and work backwards?
  2. Borderline tumors, also known as tumors of ‘low malignant potential’ or LMP are not malignancies. There is no such thing as ‘invasive cancer’ and ‘non-invasive cancer’. Cancer is invasive. Borderline tumors are not cancer and while not benign have low malignant potential. The 5 year survival rate of borderline serous tumors (the most common type) is ….…100%.
  3. They seem to speak of ‘invasive cancer’ and consider the borderline tumors ‘non-invasive’ cancer. The definition of malignancy is invasion so this simply does not make sense from a medical perspective.
  4. Their control group is women diagnosed with infertility that did not do IVF. They did not stratify these patients as to whether they became pregnant or whether they were on the birth control pill, both known protective factors. In fact, there is not control for whether the patient even had a hysterectomy or oophorectomy for endometriosis. It is hard to get ovarian cancer when you do not have ovaries. Prior use of fertility drugs in the controls may have led to pregnancy so that they did not pursue IVF. Pregnancy, BCPs, oophorectomy are all protective.
  5. There were 19,146 patients in the IVF group and 28 ‘invasive cancers’. Using their methodology they would have expected 21. Both of these number are very high compared to what we would expect in the US (about 10x higher). Not sure why they diagnose it more frequently there.”

So, to sum it up. You should absolutely discuss this study with your physician and weigh your own personal risk, based on medical and family history and genetic background. And, if you want to talk about it, please feel free to call.

Comments:
Great news about fertility treatment from the Netherlands!
The study, a large cohort of Dutch women with infertility, showed that
the incidence of invasive ovarian cancer was NOT increased in either IVF
treated women or Non-IVF subfertile women followed for up to 15 years
after treatment.

The study of 19,146 women who underwent IVF and 6,006 women treated with
lesser forms of fertility therapy over a period of 13 years, found 28
and 9 women respectively developed invasive ovarian cancer, (37 cases /
25,152 women) a rate that was the same as the general population in the
Netherlands.

9 of the 28 cases of invasive ovarian cancer found in IVF treated women
occurred beyond the initial 15 year observation period when the authors
would have expected to find approximately 3. No medical information
about other exposures that these women may have had during those
intervening years was accessible.

Borderline ovarian tumors, a non-lethal ovarian growth that may never
become cancer but may require surgery, were seen more frequently in
women who underwent IVF compared to Non-IVF subfertile women.

There are many risk factors for ovarian cancer and non-lethal borderline
ovarian tumors independent of treatment including infertility itself,
use of exogenous hormones; lifestyle factors; and family history of
cancer. The current study obtained this critical information by
questionnaire.

A limitation of the study is that while 71% of the subjects who
underwent IVF returned the 23 page questionnaire, less than half (48%)
of those who received lesser treatment responded.

Factors known to decrease the incidence of invasive ovarian cancer
including pregnancy and the use of oral contraceptives, now commonly
used in conjunction with IVF treatment, were not independently assessed.

Alan Penzias, MD

How to Evaluate an IVF Program with 5 Important Questions

Five of the Most Important Questions to Ask

1)  Ask to see the program’s official CDC pregnancy statistics.

The Wyden Bill requires that all IVF programs report their results to the CDC yearly.  While this is a law, it is not enforced by any significant penalty.  Treatment centers that do not report their data know they cannot be audited.  These clinics may be reporting erroneous data.  They may be transferring excessive numbers of embryos to achieve pregnancy.  Transferring excessive numbers of embryos leads to high rates of multiples, resulting in potentially serious morbidity and mortality to the babies and Mom.  Often programs have good fresh IVF transfer rates, but poor results with cryopreserved embryos.  Pregnancies from cryopreserved embryos can add a tremendous amount to a couple’s cumulative chance of having a baby.  Again, ask to see official CDC take home cryo IVF pregnancy rates.

2)  Ask if the clinic has regular office hours on Saturdays and Sundays.

Infertility is time specific.  If the clinic is not operating seven days a week, care, i.e. inseminations, IVF retrievals and transfers are often being compromised.

3)  Ask if the embryology lab is headed up by an embryologist certified as a highly complex lab director (HCLD).

This certification is given to embryologists who have obtained an advanced degree of training and equipment knowledge and have passed a rigorous certification exam.  Ask if the center has a secured facility for storage of your cryopreserved sperm, eggs, or embryos.  Ask how often liquid nitrogen tanks are filled and checked.  There should be documentation of these checks.  Ask if the program has a back up alarm system.

4)  Ask about cost for IVF.

Typically IVF costs range anywhere from $10,000 to $18,000 inclusive of medications.  Ask if there are additional charges for intracytoplasmic sperm injection (ICSI), typical cost $500 to $1000.  For assisted hatching, typically $500 to $1500, and whether cryopreservation, typically $500 to $1500, is included in the cost estimate.  Costs to do a subsequent cryo IVF transfer cycle range from $1000 to $3000.

5)  Ask if the physicians at the clinic are board certified or board eligible in Reproductive Endocrinology/Infertility.

Reproductive Endocrinology/Infertility subspecialists are OB/GYNs who have gone on to do two or three more years of subspecialty training in Reproductive Medicine.  To maintain board certification subspecialists must continue to keep up with important medical advances and take a re-certification exam yearly.

Answers to these five questions will go a long way in directing you to one of the better IVF programs in your area.  Do your homework – chances are your referring physician has no knowledge of these five issues.

Biological Clock

A female has the maximum number of eggs she will ever have as a fetus in utero at 20 weeks gestation, approximately 20 million.  During the last 20 weeks of in utero development, over 90% of the eggs will be lost, forming scars in the ovary.  At the time of birth, there are about a million eggs.  At puberty, when the brain-ovarian axis matures and ovulation begins, a few hundred thousand eggs remain.  The process of egg loss is known as atresia, and will continue until the last egg is released – menopause.

Each month when the menstrual cycle begins, a number of eggs start to develop – this group of eggs can vary in size from one to as many as thirty or forty eggs, depending on the number of eggs an individual is born with and her age.  With each reproductive cycle the entire group of eggs starts to develop; one egg out of this group develops to maturity and is released, i.e. ovulates, but the entire cohort of eggs is lost.  On rare occasions, more than one egg may ovulate, bringing about the opportunity for a multiple pregnancy.  This process of egg loss continues until menopause.  Typically, five to six years before menopause, cycles will become increasingly irregular as the quality of eggs that are released are often poor and may not produce enough estrogen to trigger ovulation.

Some individuals are born with much lower numbers of eggs.  These individuals are at risk for premature menopause – sometimes this occurs as early as the teenage years.  It is unknown why some women are born with fewer eggs, but likely is a function of genetics, i.e. menopause is often closely timed to maternal menopause.  The time of menopause can be influenced by a number of environmental factors, including surgeries, radiation, chemotherapy and smoking.  Starting your period early does not accelerate menopause.  Likewise, being on birth control pills, which prevents ovulation, does not delay menopause.  Again, there is a programmed loss of eggs each month.

Am I at risk for premature menopause?

It is important to identify those individuals that may be at risk for early menopause, not only for fertility concerns, but also for potential hormone replacement needs.  There are three primary means to guesstimate ovarian, i.e. egg, reserve:

Age

Age can be looked at as a rather crude guesstimate of remaining ovarian reserve, as some individuals are born with much greater numbers of eggs than others.  Certainly it is true that on average a 20-year-old is going to have far greater ovarian reserve than a 30-year-old, who would be expected to have far greater ovarian reserve than a 40-year-old.

Again, because of differences in the number of eggs someone is born with and potentially harmful environmental factors, there can be considerable variability in ovarian reserve at any age.  More accurate assessments of ovarian reserve include:

Hormonal Tests

Day 3 FSH/estradiol levels

Inhibin levels

Clomiphene citrate challenge tests

Antimullerian hormone

Ultrasound Assessment of Ovary

Counting the  number of egg/follicle units in the ovary, “antral follicle count” early in the cycle, typically days 2-4.

Combining different ovarian reserve tests is likely to give a more accurate assessment of ovarian reserve. Ovarian reserve can decrease abruptly in some individuals, likely representing an accelerated period of atresia, much like what happens in the second half of intrauterine development.  This is relatively common and can be seen in patients whose mother had an early menopause or who have been exposed to chemotherapeutic drugs, radiation, or destructive ovarian surgeries.  For others there are no obvious causes.  If an individual is at increased risk for accelerated egg loss, it is important to do regular ovarian reserve testing, especially if future fertility is a concern.

Fertility Preservation Options

Oocyte Cryopreservation

Oocyte cryopreservation is a relatively new, exciting technology for those individuals who do not have a male partner or who are uncertain as to whether they will stay with their current partner.  Worldwide, there are approximately 1500 babies born from frozen eggs.  Because of the limited number of babies born and relatively short follow up on these children, this technology should still be considered research and therefore should be carried out under an IRB (Institutional Review Board) protocol.  The institutional review board serves to review results from oocyte cryopreservation both in terms of efficacy and safety.  There are many programs throughout the country advertising egg freezing.  Many of these programs have had little or no success.  It is, therefore, important to ask some key questions when trying to identify a competent institution.  Namely, the number of babies that have been born from that particular embryology lab, not an affiliated lab or program.  Ask the number of eggs that were frozen to achieve these pregnancies, thereby getting an idea of efficacy.  The number of eggs available to an individual less than age 35 years of age or younger, on average, will vary typically between 8 and 16 each month.  For those individuals 36 and above, the cohort size is likely to be reduced, averaging between 5 and 12.  Ovarian reserve testing, again, will give a better estimate of individual egg number.  Depending on the efficiency of the program and an individual’s ovarian reserve, more than one stimulation cycle may be necessary to have a realistic chance for pregnancy.  Programs involved with oocyte cryopreservation should maintain a registry as to any birth defects or any development problems.

Florida Institute for Reproductive Medicine has been involved with oocyte cryopreservation since 1998.  To date, we have had 63 babies born from frozen eggs.  On average, we have required ten mature eggs to produce a healthy ongoing pregnancy in mothers 35 years or less.  For individuals 36-38, we are requiring on average fourteen mature eggs.  We do not offer oocyte cryopreservation for individuals over the age of 38, as the great majority of these individuals will have low ovarian reserve and a very high percentage of poor quality eggs, i.e. they are unlikely to benefit from cryopreservation.

Pre-embryo or embryo fertility preservation

This is an appropriate option for those individuals who are in a stable relationship.  In general, if there is any concern about potentially discarding an embryo, the option of cryopreserving pre-embryos should be considered.  Freezing a pre-embryo is, in essence, freezing male and female nuclear material that are close to each other but have not combined to form an individual.  Pre-embryo and embryo cryopreservation have been available since the mid-1980’s.  There have been hundreds of thousands of babies born from both pre-embryos and embryos.  There is a large body of reassuring health data, on babies born from (pre)embryos.  Fertility rates with (pre)embryos vary tremendously depending on the reproductive medicine program.  Each advanced reproductive medicine program in the United States is required by law to report their data to the CDC; therefore, before considering an individual program, check with the CDC registry (www.cdc.gov/ART/ART2011) on the program’s cryo IVF data.

Costs for oocyte cryopreservation as well as (pre)embryo cryopreservation should mimic those of a typical IVF cycle; the steps are basically the same.  Ongoing storage costs will typically vary from $100 – $400 per year.

Endometriosis Awareness Video

In connection with Endometriosis Awareness Week (7-13 March), the World Endometriosis Society (WES) launched a video to help women across the globe recognise symptoms of this painful and debilitating disease before their long-term health and quality of life are affected.

Endometriosis from Endometriosis.org on Vimeo.

One in 10 women of reproductive age worldwide are thought to have endometriosis, which is characterised by chronic pain: menstrual, pelvic, mid-cycle, during sex, during urination or bowel movements.
Significant effects

Lone Hummelshoj, secretary general of WES and well-known international campaigner for women with endometriosis, said:

    “We have created this video to help educate women about what is normal, and what isn’t when it comes to pain and help them to recognise the symptoms of endometriosis in order to seek treatment early, before their long-term health is affected.

Endometriosis indiscriminately affects women during the prime years of their lives. The pain associated with endometriosis significantly affects these women’s ability to finish an education, build a career, maintain a relationship, have a sex life and, for many, compromises their fertility.

Unfortunately, we still see that when a woman seeks professional help, low awareness and a long, unclear referral process means she will typically wait years for a diagnosis and proper treatment. This has to change. Endometriosis is not a life-style disease – there is no prevention, but it can be treated.”

Don’t take no for an answer

Diana Wallis MEP, Vice President of the European Parliament, is a sufferer herself and campaigns for increased awareness of endometriosis. Before her diagnosis, Diana struggled against the dismissive attitude towards her symptoms:

    “Over a period of 10 years, I was told ‘you’re working too hard as a professional woman –take it easy.’”

As a newly-wed Diana underwent a full hysterectomy, an operation that could have been avoided with earlier diagnosis and treatment of her endometriosis. She now calls for all young women who recognise symptoms described in the video to take action:

    “Don’t be like me. Don’t take no for an answer. If you feel something is wrong, you could have endometriosis. There are things that can be done to help you. Go and get advice, but also make others aware, because I don’t want you to end up like me”, said Wallis.

What is normal?

The video explains the prevalence, symptoms and treatments of the disease. WES President and Professor of Gynaecology at Maastricht University, Hans Evers, said:

    “It’s difficult to say what is normal and what is not normal, but as a general rule women know what is too much pain. There is a difference between menstrual discomfort, and pain that prevents you from going about your daily life.”

Professor Evers appealed directly to young women, and asks them:

“Endometriosis is a serious, chronic disease that requires treatment. I would like to invite women to take the initiative and see their doctor to have endometriosis diagnosed.”

friends of F.I.R.M.

Hi Dr. Winslow, We just wanted to write and let you know that we are settling in nicely out here in California. Charlie is wasting no time making a name for himself out here. He met the President of the United States the other day, and was on every news station and newspaper in town. […]

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