The Odds Have it…How to Evaluate your Infertility by the Numbers by John S. Rinehart, M.D., Ph.D., J.D.

Everyone is swamped with information overload today. The various forms of media provide an endless amount of data. But, does the information provided actually help or hinder attempts to achieve a pregnancy?

The answer will depend upon how a person views predicting the future. Oh, that again… just when you think you’ve got it figured out, someone changes the rules. Statistics actually provides a method of predicting the future. Not quite as snazzy as a crystal ball, but a lot more accurate. The ‘numbers’ can guide you to the best way to use all of this information that is at your fingertips and actually help yourself.
So how does statistics work? The most common misconception about statistics is that they will tell a person what will happen. Actually, they tell a person what might happen and how likely the event is to happen. Patients frequently ask whether a prediction/statistic applies to them. Yes it does, but that is not what a person wants to know. Most people want to know what will happen to them as an individual. Statistics speak to people as a whole, not the individual. If a physician tells a person that the chance of having an infection or a bleeding complication from an egg retrieval is about 3 in a 1000, that is reassuring…unless of course you are one of the three who had the complication.

Making smart choices in medicine rests upon the use of predictions. A prediction makes a statement, usually in the form of a percent or odds such as one in ten. Both types of predictions require two numbers; numerator and denominator. A percentage is nothing more than one number (numerator) divided by another number (denominator) expressed as a percentage. Unless you know both the numerator AND the denominator, a statistic is meaningless. Knowing the denominator frames your information into likelihood…or not. Think of it as the lottery. 1000’s of people have won a lottery…sounds like a good bet, no? Unless you realize that billions have played. It is the stories that are told, numerator only, that warp the statistics, and often the hopes and dreams of the people reading them. A seemingly great story of a pregnancy that was achieved against all odds seems like it could be YOUR story, until you put it into the context of the number of people who have attempted, and failed, to make it their story as well. Consequently, the horror story bandied around on any given day regarding risks from Infertility or any other procedure, may send its reader running…until/unless that number is put into context (by reporting the denominator as well) and the Unlikelihood of this occurring is realized. The point to remember is that rare events, whether good or bad, are actually predicted by statistics so rather than being wrong they are, in fact, correct.

Statistics allows a person to make a risk-benefit determination. What is my chance of being pregnant from the cycle of IVF versus what is the chance of significant harm from IVF? For example, there is actually a death rate for doing egg retrievals for IVF. It is quite low and perhaps incalculable but some estimates are 5/1,000,000. What most people don’t consider is that there is also a death rate from being pregnant. On any given year in the USA, the death rate varies around 16/100,000 live births. In 2008, the motor vehicle fatalities were 18/ 100,000 registered drivers. Interesting but let’s get back making a smart choice about getting pregnant!

So let’s say that you were just born and had never seen a coin nor bet on a coin toss. A somewhat nefarious fellow shows you only one side of a penny and all you see is Lincoln. He says he’ll flip the coin in the air and he bet’s you a buck that when it lands Lincoln won’t be on the coin. Again, you we just born so being somewhat gullible you think this is a good idea and you bet him the buck. He tosses it and “voila” it’s Lincoln- you win. Bolstered by your success, when he says he’ll make the same bet if you toss it again, you eagerly take the bet. But wait- what is this? A picture of some stupid memorial? Where did that come from? Now he wins and you learn an important principle. The coin has two faces and a smart choice would have been to have inspected the coin to begin with and determined what was on the other side. Furthermore, tossing the coin does not always guarantee that it will land on Lincoln. So what about a third toss? Should you take that bet? Here is where statistics can help you make a smart choice.

Anyone who understands a coin toss can understand the important points from using statistics to help make a decision. The problem with mass communication and overwhelming data is trying to determine the accuracy of a prediction. For example, suppose you are browsing the web and a 42 year old lady says she got pregnant on her fifth try at IVF. You are 42 and trying to decide if you should do IVF at all. The first problem with a personal story on the web is that it is impossible to tell if the story is accurate or even if it is true. Just because someone put it on the web does not make it factual. But let’s suppose the above is true. What is the chance of a 42 year old person getting pregnant and how fast should it happen? That information is available. A 42 year old just starting to try to get pregnant has less than a 50% chance of being successful. If the woman can get pregnant, it happens quickly, usually within the first 6 months of trying. The longer a woman tries to get pregnant and is unsuccessful, the less the chance that she can conceive.

So assume that you have been trying for six months and you are not pregnant. You consult an REI and that person suggests moving straight to IVF. Seems a bit aggressive on the first go? Now it’s time to figure out the odds of achieving a successful pregnancy on the first try for a 42 year old woman with a normal evaluation (semen analysis for partner OK, uterine cavity OK, ovarian reserve [hormone testing] OK). National data suggest that it would be somewhere around 10%. What would be the chance if you did nothing? That estimate is somewhere around 1-3%. Other choices like clomid or an Insemination protocol are probably not better than IVF and most likely somewhat less successful. With this information, our 42 year old opts for IVF…and doesn’t get pregnant. The story about the fifth time being the charm looms in her mind. Yet, doing a cycle of IVF was not as easy as she thought it was going to be, her response was not great and the quality of the two embryos that formed was only average. Oh, and she wants to be pregnant now. So what about a second cycle of IVF? The chance is still about 10%. Second cycle, not a great response and still no pregnancy. The thought of a third try is almost overwhelming. It is worth it? Use statistics!

What are the options? Do nothing, do another cycle of IVF, do a cycle of IVF using donor eggs or adopt. You already know that the chance of getting pregnant on your own is exceeding small- OK not zero- but really, are you feeling that lucky? Donor oocyte cycles are somewhat successful with a delivery rate around 50% for the first try. Adoption is an option but it is expensive and neither you nor your partner has any genetic input into the child, nor do you have the chance to carry the baby and deliver the child. On the other hand, when done properly adoption has a very good “success” rate. How about that third cycle of IVF? Estimates will vary but the literature that does exist suggests that after two tries for women between the ages of 41 and 43, the success for the third try at IVF is very low and perhaps not different from doing nothing. Knowing the statistics puts the options in perspective. It does not help make the decision because a lot of factors go into a decision about what form of treatment to use, but at least statistics allows a person to rank the options by the likelihood of success.

In the end, the best you can do is to gather reputable information, combine the outcomes, add the things that are important to you and go for it. The use of statistics can give you the best chance of getting what you want. All statistics comes down to the concept of the coin toss so don’t let the numbers scare you. Use statistics to achieve success.

Dr. Rinehart is a Founding Partner of Reproductive Medicine Institute (www.reproductivemedicineinstitute.com) with six board certified specialists in the field of reproductive endocrinology and immunology including the area of recurrent miscarriage, along with the treatment of endometriosis, in seven locations throughout Chicagoland. 

Why "Do" IVF? By Dr. Barry Jacobs

Why Do IVF?


Many patients I have seen who have failed to conceive using Clomid, and think IVF is the automatic next step. Not so. Clomid really is not associated with a good pregnancy rate. There are other protocols which do work better. Of course, for those who need it, IVF is one of them.

There are really 3 medical indications to do in vitro fertilization (IVF). One is for tubal damage. Tubal damage most commonly results from either previous infection or prior tubal ligation. Efforts at repairing the fallopian tubes usually results in may result in tubes that are open, but they are still damaged. If a fallopian tube is damaged, there is a significant risk that any pregnancy which may occur will be a tubal pregnancy. That is life threatening. Since IVF bypasses the tubes, there is no increased risk of tubal pregnancy.

A second reason to perform IVF is for severe male factor issues. If sperm are not formed properly, or they do not swim adequately, or if there are just too few of them, they need help to fertilize an egg. Once we have eggs in the embryo lab, we can literally inject sperm into eggs (ICSI). There is still no guarantee that fertilization will be achieved, but in the vast majority of the cases in which we perform ICSI, we are able to produce good embryos. Our pregnancy rates with ICSI are very nearly that of straight forward IVF.

Some newer technology now enables us to detect, in embryos, inherited diseases carried by one or both future parents. The first such inherited disease to be detected in embryos was cystic fibrosis. Today, there is an extremely long list of genetic diseases which can be diagnosed in embryos, and avoid having children stricken with those abnormalities. We have to remove one of the cells from a day 3, 6 to 8 cell embryo. Removing a single cell does not jeopardize the embryo, when the biopsy is performed by a skilled embryologist. There are now 2 different techniques to examine the DNA of the embryo and compare it to the DNA of the parents. The older technique is polymerase chain reaction (PCR). That is the same technology highlighted in some of the TV crime shows. The second technique is referred to as micro array analysis. Material from a single cell taken from an embryo is placed in a tiny well, in what amounts to a computer chip, and the chemistry of that cell can be analyzed. Once it is determined which embryos are identified which are not affected by the disease in question, normal embryos can be placed in the uterus of the intended mother.

Finally, there is a non-medical reason to consider IVF. Many patients do not have any insurance coverage to help pay the expenses of fertility treatment. At least in our practice, both the cost of 4 cycles of using FSH to stimulate ovaries and performing IUI and 1 IVF cycle are about the same. Also, the pregnancy rate for a single IVF cycle is about the same as for 4 IUI cycles. If we do not achieve a pregnancy with IUI, the next treatment protocol to try is IVF. A few of my patients have felt it more cost effective to skip efforts at IUI, and just do IVF. Although I do not encourage that practice, I find it difficult to argue with the logic. I those circumstances, I have acceded to their requests.

IVF is certainly a very useful tool to help a couple achieve a pregnancy. With improved technology and understanding of the physiology of embryos, our pregnancy rates have become extremely good, and I expect them to improve more. It is, however, important to keep things in perspective. IVF is just 1 more tool, and should not be the only tool.

Dr. Jacobs is a Reproductive Endocrinologist, practicing in Carrollton, Texas, a northern suburb of Dallas. He completed his residency training in obstetrics and gynecology at Baylor College of Medicine in Houston, and remained at that institution to become its first fellow once Baylor achieved accreditation for an advanced training program in Reproductive Endocrinology and Infertility. Dr. Jacobs has served on the faculty of several medical schools and was director of Reproductive Endocrinology at Texas Tech Health Science Center in Amarillo. Currently, in addition to his clinical activities caring for infertile patients and those with recurrent pregnancy loss, he is Chairman of the IVF committee at Baylor Medical Center in Carrollton.
Barry Jacobs, M.D., 4323 M. Josey Lane, Suite #201, Carrollton, TX 75010 www.texasfertility.comPhone: 972-394-9590 Fax: 972-394-9597

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IVF Virgins

I bet that title captured your attention! But we all have to start somewhere...whether it's for a surrogacy or dealing with an infertility issue where IVF (In Vitro Fertilization) may be the solution. First I need to clarify what I'm talking about. IVF is a process that includes many steps. A couple of the 'invasive' aspects are the egg retrieval and the embryo transfer. If you are a surrogate or using frozen embryos, you only have to deal with the embryo transfer part...lucky you! Not wanting to leave the men out, there is the semen collection HOWEVER that normally doesn't require a doctor's help. Or shots...or anesthesia...or bed rest...well...maybe....

So it's your first time going through an embryo transfer and you have read everything you can and hopefully talked with a few people who have actually gone through the process. I have had 3 embryo transfers. The first one 'failed' and numbers 2 and 3 both were doubly successful. I really believe the first one failed because I was a nervous wreck! The stress...no one to talk with and not a whole lot of information to be found on the Internet. (Remember this was 1998-1999) Plus the doctors were switched a few minutes before my first transfer. Not only was I nervous but I ended up with a doctor that I hadn't even met seeing me at my most vulnerable. ( not to mention my Intended Parents being in the room with me during my transfer! )

Let me give you the nickel tour of an embryo transfer...this information is found on www.InfertilityAnswers.net under Surrogacy.
Embryo transfers simply deliver the embryos into the uterus. There is no need for sedation or anesthesia. It may not feel any different from an annual Pap smear.


A speculum is placed into the vagina. The embryos (usually no more then 3) are placed in a catheter along with a small amount of fluid, and then the tiny plastic tube is introduced into the uterus through the cervix and the embryo(s) are transferred into the endometrial cavity.


After the procedure, the patient will need to rest in bed for one hour, with her head down slightly and feet up. After going home, she will need to rest in bed for the rest of the day. On the next day she can resume non-strenuous activity. Please note that each clinic has their own protocol and will advise the patient to follow their specified directions.

There you have it. Sounds simple enough...and it really is anti-climatic! Seriously. After the all the drama and build up to the embryo transfer, the actual procedure, which takes place at the clinic, is over in five minutes and you are on your way to the two week wait (more commonly seen as the 2ww) All the testing, ultra sounds, shots, pills and suppositories..all the poking and prodding and instructions to remember, the embryo transfer is by far the easiest thing to go through. It sure as heck easier then a pregnancy or labor or delivery! I think the actual 2ww is more of a psychological and emotional killer then anything else.

Being comfortable is KEY! Asking all the questions you have, no matter how insignificant they may seem, is so important. Having the people who support you the most with you is vital. Knowing what to expect is priceless! (Sorry to sound like a MasterCard commercial but it is true!)

Sharon
www.InfertilityAnswers.net

The attitude of entitlement or just poor judgement? 'Tuplet Mom and the IVF Fiasco

I was going to stay far away from commenting on the new Mom of octuplets (BTW that word isn't even on my spell check!) But I feel compelled to weigh in. Nadya Suleman is now the mom of 14. She could, just as easily, been the mom of 7 or 8 if those 6 embryos hadn't split and each and every one hadn't grown into an individual baby. And now they are born and every single person who hears this story is appalled. With the exception of Nadya Suleman. Although she couldn't take care of the first 6 children without the help of food stamps and disability checks (coming in for three of the previous children) and apparently student loans, yet she somehow found the money for the medications and the IVF procedures that have catapulted her into the media's front line with a bang. Eight little bangs I should say.

Ok....what would have happened if Nadya Suleman's IVF procedure had only produced twins or even triplets? I don't think it would have been a blip on the reproductive radar. Certainly not competing for air time along with the new stimulus package and massive fires in Australia! Would anyone really have cared about the fact that this new mom couldn't take care of what she already had? I doubt it. I bet her RE wished that she didn't even darken his door! Perhaps he didn't think all of the embryos had a prayer quality wise. Or Perhaps he wanted to boost his stats. I don't have enough information to judge. But now he and his practice is also under scrutiny as he should be.

I take you back to a post I did, in November I believe, when I returned from the ASRM conference in San Francisco. I was in line to register and was talking to one RE while another Dr, was listening in. I mentioned that I had been a surrogate mother twice and gave birth to two sets of twins. The Dr, who was listening asked how many embryos were transferred and I told him 3 each time. He was instantly disgusted and any Dr, who would transfer 3 embryos as a time! The older RE then asked how old I was for each transfer and I told him at the time of transfer 36 for the first set of twins and 40 for the second....well that did clear the air a bit because there ARE guide lines regarding how many embryos should be transferred depending on the age of the woman. Obviously these ASRM (American Society of Reproductive Medicine) guidelines were not followed in the case of Nadya Suleman.

And because of that fact, we (and I say WE as in the tax payers) have 8 preemies hanging out in CA while the world debates how the US reproductive industry could have allowed THIS to happen! Well folks, we have no regulation. We have guidelines, we have associations and reproductive societies but we don't have the type of regulation that other countries have. Nor do I think that would be the answer. EDSPA, the Egg Donation and Surrogacy Professional Association, is one place where self regulation is being discussed. I believe the ASRM is also a place that has its members practicing self regulation as well as other groups out there. BUT no one can control what one RE is doing. Or Surrogacy/Egg Donation agency or Embryo Donation agency for that matter.

There is a cry out there that says why didn't someone send Nadya Suleman to a psychiatrist. Its common that a surrogate or egg donor have a psychological evaluation but not Intended Parents who are infertile. It doesn't make much sense to have each and every IP who enters a facility with the notion of adding to their family through IVF to be psychologically evaluated (although a few visits with a mental health professional would be a good idea), it still would be prudent for the clinic staff to compile some back ground and use their common sense when choosing who to work with. And if they are unsure then maybe call in a psychologist for a 2nd opinion.

Back to my topic...sorry for the trip around the world....nothing can be done regarding Nadya Suleman. Her babies are here. But maybe we can all learn a lesson about "proceeding with caution" and, as professionals, knowing when to say NO.