EGG FREEZING 2.0; interpretation of emerging data can be confusing

Within days of writing about the modern benefits of egg freezing a new study was published in JAMA based upon old data. They looked at national data from 2013 and concluded that pregnancy rates from egg donors were lower if the eggs had been frozen than if they were fresh. That was probably true back then. But technology is advancing at an exponential rate. Reproductive medicine is arguably one of the most technology dependent fields of medicine. So applying 2013 results to current decision making is flawed from the very onset. Having said that, let’s consider what this publication may be able to teach us and how we should more accurately interpret it today.

This study looked at the 2013 Annual Report of the pregnancy rates from fertility centers in the USA which were collected by the Society for Assisted Reproductive Technology. The science and experience of most centers using this technology has advanced considerably since then.  In fact, it was in late 2013 that the Practice Committee for the American Society for Reproductive Medicine published the guidelines for oocyte cryopreservation.  In their review they pointed out the fact that much of the data that they analyzed was from Europe as few clinics in the USA had published their experience with egg freezing at that time. They also clarified how the difference in techniques used to freeze/thaw the eggs had progressed rapidly resulting in dramatic improvements in success rates. As a result, the removed the “experimental label” from the procedure because of these advances. However one of their most important ultimate conclusions was that “success rates may not be generalizable, and clinic-specific success rates should be used to counsel patients whenever possible.” Despite that clearly stated recommendation, this latest research paper lumped together all of the clinic data and created the latest public misinformation campaign.

Today, many more centers have experience in freezing/thawing eggs using the most modern technique of vitrification. As a result, more patients that need donor eggs are able to benefit from the lower cost and greater convenience of frozen eggs and still enjoy the very best in success rates. Better still, many egg banks offer special guarantees so that if a specific donor’s eggs do not perform well: they will have access to replacement eggs without additional cost. So the best message for patients in need of donor eggs today is to be a wise consumer. Patients should ask their clinical very candidly about their unique experience with frozen donor eggs. I think that they will find greater reassurance in today’s science than in yesterday’s news.

Boosting Pregnancy Rates for “poor responders” to IVF—new hope by applying existing technology

One of the greatest challenges in reproductive medicine is trying to figure out ways to improve pregnancy rates for women that produce a limited number of eggs. Other posts on this blog[u1]  address various steps to try to optimize/improve egg quality[u2] . But new data suggests that the use of intracytoplasmic sperm injection (ICSI) can improve embryo formation and more importantly increase a woman’s chance of becoming pregnant. Traditionally, ICSI has been used to overcome male factor infertility. Over the last several years, some centers have included it in all of their treatment cycles as a means of maximizing fertilization. Some experts criticized this practice since it was based upon a theory rather than clinical proof of an improved outcome. In fact, the American Society for Reproductive Medicine has a Patient Fact Sheet [u3] that describes the guidelines for the use of ICSI (last revised in 2008). Recently a large study attempted to settle this debate on whether or not ICSI should be used in women considered to be “poor responders” to fertility therapy.

One of the limitations of previous studies on “diminished ovarian reserve (DOR)” was the lack of an agreed upon definition of how to diagnose this condition. In 2011 an international meeting was held to form a consensus [u4] on the identification of “poor response to ovarian stimulation.” Their goal was to improve the design of future studies and provide practical guidelines as well as assist doctors in the diagnosis of this condition. To meet diagnostic criteria it was agreed that a woman must have at least two of the following:

  • 40+ years of age or any other risk factor for poor ovarian response
  • A previous cycle producing  3 (or fewer) eggs with a conventional protocol (excludes Mini IVF)
  • An abnormal ovarian reserve test (i.e., AMH [u5] below the age- related norms)

The recent study [u6] referred to in this blog post followed over 1000 IVF patients that had failed on a previous cycle and met the new criteria for “poor responders.” These patient/couples completed nearly 3000 total cycles of IVF with ICSI. They found that including ICSI—despite a normal sperm count—improved the ongoing pregnancy rate by 40%. Another noteworthy fact is that this study was performed in Israel where IVF is a fully covered health benefit for all citizens. This made it possible for patients to continue treatment without concern of cost thereby removing a “selection bias.” The potential benefit of ICSI—in the absence of a male factor—does make sense. Some studies show that women with DOR have a thicker coating on the egg making it more difficult for a healthy sperm to enter. Selecting a sperm for use in ICSI may also reduce the possibility of an abnormal sperm fertilizing an otherwise limited number of healthy eggs. Whatever the reason, most women with a poor response to fertilization are immediately directed to use donor eggs. However, this study found that ~35% of these “poor responders” achieved a successful pregnancy within 5 to 7 IVF attempts. The bottom line is that couples that would otherwise have been discouraged from completing a second attempt went on to have a baby at least 1/3 of the time.

So discuss with your doctor whether or not you may benefit from including ICSI in your next IVF cycle. In doing so, be careful to ask if there is an additional charge for this service. At CNY Fertility[r7]  Center, we are pleased to offer this augmented fertilization technique to all of our patients as part of the standard IVF cycle (included in the standard fee). Now we have more data supporting this recommendation.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.

IVF Success Rates Hit All Time High—but repetition is often the key ingredient to achieving pregnancy

The latest review of the pregnancy rate achieved through advanced reproductive techniques (ART) like in vitro fertilization (IVF) is the most encouraging ever. One press release read “Success of Fertility Treatment May Approach Natural Birth Rate.” Considering that many couples that need IVF have no other treatment options; this is an extremely encouraging revelation. Since the first successful IVF pregnancy was achieved in 1977 (resulting in the birth of Louise Brown in July 1978); it is estimated that 5 million babies have been born through this technology[r1] ! With the success rate and the need for treatment increasing, it is important that we consider what else we can do meet the needs of even more couples.

Here is what we now know. Even the most fertile couples have a natural fertility rate of about 20% for any given month. Their ultimate success is achieved through repetition; if not successful one month they can try next month, and the month after that until they are successful. Observation shows that they typically achieve a pregnancy rate of 65% within 6 months and 80% within a year. By contrast, couples that need fertility treatment have to pay for each cycle that they are attempting to conceive which often limits their effort to one or two attempts. New data shows that with persistence, infertile couples can achieve success rates that are as good or better than people that are considered fertile.

Specifically, the New England Journal of Medicine published data summarizing the results of nearly a quarter of a million women[r2]  treated at centers throughout the USA. This is the best estimate of the average success since it does not reflect a specific group of women or the experience of one specific IVF center. What they found was very hopeful. Nearly 60% of the women that were undergoing treatment had a baby (live birth). In fact, 30% of the women that underwent ART had a baby following their first IVF attempt! The majority of those not successful on their first attempt; did achieve a success rate as high as or higher than those of fertile patients the same age. In other words, IVF is able to overcome most obstacles to achieving a successful pregnancy except those related to age and its impact upon egg quality. Even though live birth rates were lower when older women used their own eggs; the same study found a cumulative live birth rate of 60-80% when women used an egg donor—regardless of the age of the woman carrying the pregnancy and delivering the baby.

Other studies released the same week [r3] demonstrated that women that were experiencing anxiety or depression before IVF did not have a lower chance for achieving a pregnancy. However, they did find that a failed IVF cycle can exacerbate these problems. This further emphasizes the need to focus on the success rates achieved with repeat IVF cycles. Currently there are about 1.5 million ART cycles being performed globally each year resulting in the birth of about 350,000 new babies. The key to focus on is that success rates are very high but it can take up to 6 IVF attempts for couples with more complicated problems to actually have a baby. Clearly the path to parenthood for couples that need ART is repetition. That is why it is so important to make treatment accessible. Personally, I am proud to work at a center that offers treatment at the most competitive prices [r4] in order to make IVF treatment accessible to all of those that need/want it.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.