Assisted Reproductive Technologies


IVF: The Next 30 Years

July 18, 2008Nature magazine's July issue has a special feature on the 30th anniversary of IVF. After discussing the legacy of IVF (subscrip. req'd), Nature asked a group of scientists what the next 30 years of IVF research will look like. Among the predictions:

  • Scientists will be able to create sperm and egg cells for anyone. Using sperm and egg cells derived from induced pluripotent stem cells, scientists will end infertility. Newborns and hundred-year-olds could become parents.
  • Embryo research will become a "fact of life": "They would become objects and would be used as objects...Maybe 20–30 years from now we'll read in newspapers that someone made 20,000 embryos and studied their development, and we'll decide it's OK."
  • IVF for less than $100: Cheap IVF will soon be made available in developing countries.
  • Healthy babies will be assured with the use of "genetic cassettes." Scientists will insert the cassettes into embryos to correct for diseases like Huntington's.
  • But people will still have sex: "IVF is expensive and uncomfortable. The old-fashioned way is cheaper and more fun and that won't change in 30 years."
  • Artificial wombs will change the abortion debate: "If an artificial womb were developed, the government could pass a law that requires people who have a termination of pregnancy to put the fetus into one of these wombs."
  • Alert the trial lawyers: There will be litigation over the health of IVF babies. "With the increasing availability of IVF, there will be more emphasis on safety. Not enough is known about the long-term health of the Louise Browns of this world — if there is a problem, it will be unexpected."

posted by Cheryl Miller | 10:20 am
File As: Bioethics and Medicine, Stem Cell Research, Assisted Reproductive Technologies, In Vitro Fertilization, Cloning, Third-Party Reproduction

Women Who Have Sold Their Eggs

July 18, 2008 • If you are in New York, you might want to stop by Lolita Bar next Tuesday, July 22nd. They'll be hosting a panel, "Women Who Have Sold Their Eggs," at 8 p.m. Panelists include graduate students Valerie Bronte and Diana Fleischman, Reason senior editor Kerry Howley, and "finance whiz" Marie Huber. The event is free. More details can be found at organizer Todd Seavey's website.

Can't make it to the Big Apple? Check out Kerry Howley's Reason article on selling your eggs.

posted by Cheryl Miller | 9:57 am
File As: Assisted Reproductive Technologies, Egg Donation, Third-Party Reproduction

Two Takes on Living With Infertility

July 9, 2008

Melissa at Stirrup Queens has two great posts up. The first is about Jenna Nadeau Currier's infertility memoir, The Empty Picture Frame. (Read more about Jenna in my article, "Blogging Infertility.") Here's Melissa discussing Jenna's idea of  parenthood as a "calling":

I felt strongly drawn to the idea of parenthood and I wanted to experience it very badly. I was willing to try multiple paths to get there. I made life choices/career choices based on the idea of motherhood and what type of mother I wanted to be. I'm lucky that this worked out for me because I made a lot of choices that I probably would have regretted since I gambled making them.

The second post is an interview with Kim Hahn, CEO of Conceive magazine:

Melissa: You are the founder and CEO of Conceive magazine. What gave you the idea to start the magazine?

Kim: While my husband and I were trying to start our family, I was frustrated by the lack of positive, consumer-friendly information about fertility. Specifically, I longed for a magazine as beautiful, upbeat, and informative as the many pregnancy and parenting magazines on the market. I saw a hole in the market for women trying to conceive. There are magazines for brides, pregnancy, and parenting, but there was a gap between the bridal and pregnancy magazines.
 

posted by Cheryl Miller | 9:46 am
File As: Assisted Reproductive Technologies, In Vitro Fertilization

ART in the News

Affordable IVF, Older Dads, and The World's Oldest Mother

July 9, 2008

posted by Cheryl Miller | 8:26 am
File As: Assisted Reproductive Technologies, In Vitro Fertilization, Surrogacy, Frozen Embryos, Older Mothers/Fathers, Third-Party Reproduction

Eugenics Watch: I, For One, Welcome Our New Genetic Overlords

July 7, 2008

What happens, if after pre-genetic screening, no unaffected embryos are found? Should they be transferred? And if so, who gets to decide?

That's the subject of a talk by Dr. Wybo Dondorp, a senior research fellow at the Department of Health, Ethics and Society at Maastricht University (The Netherlands), at the 24th annual meeting of the European Society of Human Reproduction and Embryology in Barcelona. If you read this Reuters article, you might think that the patients get to decide about the disposition of their affected embryos. You'd also be wrong.

According to Dr. Dondorp, decision-making about affected embryos must be "shared" between parents and doctor--except, that is, when the doctor disagrees with the parents. Then, the doctor gets to decide that it's not in the interest of the future child to be born:

"The present consensus is that where the classical indications for PGD are concerned, doctors should, as a general rule, not transfer affected embryos where no non-affected ones are available.

[...] The welfare of the child is closely connected to the classical indication for PGD: a serious disease caused by a single gene mutation for which there are no, or limited, treatments, and, in most cases, presenting early in life. An example is an embryo that is homozygous for cystic fibrosis, where the child will definitely have the disease. In such cases it is inconceivable that doctors would agree to transfer these embryos as it would be at odds with their professional responsibilities.

[...] It must be made clear that there may be, with conditions, room for shared decision-making about transferring affected embryos. But that does not amount to leaving it to the parents, as doctors cannot avoid their professional responsibility for the welfare of the future child."

Just to be clear, people with cystic fibrosis can live into "their 30s, 40s, and beyond." But no, their lives aren't worth living! For now, Dr. Dondorp hasn't yet ruled on the fates of people with genes for hereditary cancers or other chronic conditions. Those will be decided by a "case-sensitive evaluation of aspects relevant to the 'high risk of serious harm' criterion." Again, not by you, the potential parent!

So what if your doctor decides you shouldn't transfer your embryos? Dr. Dondorp has some helpful advice: 

In pre-test counselling it should be explained that if no non-affected embryos are available, the only options are trying a new cycle or being advised to reconsider one's reproductive plans such as refraining from reproduction, using donor eggs or sperm, or adoption.

But don't worry, the doctors won't immediately dismiss your views about the fate of your embryos. They'll pretend to listen first, and then do whatever they've already decided on. 

"Parental requests for transferring affected embryos should not be dismissed beforehand as a sign of irresponsible capriciousness. As the couple's primary wish may be for a child, they may reason that if a non-affected, healthy child is not what they can get, they will also be happy with, and good parents for, a child with a condition they at first intended to avoid. Respect for autonomy at least requires taking such requests seriously, even if, in view of all other considerations, doctors decide not agree to the requests."

posted by Cheryl Miller | 6:32 pm
File As: Assisted Reproductive Technologies, In Vitro Fertilization, Eugenics, Contemporary, Single Mothers by Choice

Two Studies About Donor-Conceived Offspring

July 7, 2008

Much ado about nothing? A study by scientists at Cambridge University found that children conceived by a surrogate mother or by donor conception are as "psychologically well" as their naturally-conceived counterparts. The children were only seven years old at the time so I'm skeptical as to how much this survey really tells us. What's more, most of them don't know they are donor-conceived:

In a press release, Casey added that she found a majority of parents of children born through assisted reproduction delayed telling the child about how he or she was conceived.

"At the time of the child's seventh birthday, only 39% of egg-donation parents, 29% of donor-insemination parents and 89% of surrogacy parents had told their children about the nature of their conception."

These figures contrast markedly with what the parents said they would do when they were questioned at the child's first birthday.

Another Cambridge study suggests that these seven-year-olds might not be so "psychologically well" in the future:

The children of sperm donors should be told of their origins as young as four, a new study suggests.

[...] 

Scientists at Cambridge University found that those who were told as adults were three times more likely to feel angry than children.

In total 38 per cent of adults characterised their feelings as anger, compared to 12 per cent of four to 11-year-olds.

Three times as many adults also said that when they found out they were shocked, compared to 27 per cent of children.

posted by Cheryl Miller | 5:05 pm
File As: Assisted Reproductive Technologies, Surrogacy, Egg Donation, Sperm Donation, Third-Party Reproduction

ART in the News

IVF is not so easy, fertility coaching, and more

July 2, 2008

posted by Cheryl Miller | 8:40 am
File As: Bioethics and Medicine, Stem Cell Research, Assisted Reproductive Technologies, In Vitro Fertilization, Embryo, Moral Status of the, Egg Donation

John D. Gordon, Internet Doctor

Part Two: On being a man in a woman’s world, when things go wrong, and more

July 1, 2008

100 Questions and Answers About Infertility

 John D. Gordon

Part Two of my interview with Dr. John D. Gordon. For Part One, click here.

When patients ask you for advice on the web, how do you typically respond?


JDG: If they don’t tell me how old they are, I ask how old they are. I’ll ask if there’s a sperm issue sometimes. Usually they lay out in their little shorthand exactly what they’ve been through. I’ll get these six-paragraph descriptions of everything they’re doing.

It’s hard. There’s this old joke: What’s the difference between God and a reproductive endocrinologist? The answer is: At least God knows he’s not a reproductive endocrinologist.

There is a feeling that there’s nothing you can’t accomplish with modern science, and there are certainly some physicians who play into that. That’s not always true. Sometimes things defy explanation; we don’t understand why things haven’t worked. The patient has been through an awful lot, spent $100,000, and has nothing to show.

At that point, it’s incumbent upon somebody to say, “This is about being a parent. Your goal is to become a parent. Obviously, your goal was to be genetically the parent, biologically the parent. But maybe that won’t happen. Therefore you might have to consider what does it mean to be biologically the parent, but genetically not the parent with donor egg or donor sperm? Or to be neither genetically nor biologically the parent and to pursue adoption? Or not to have a family and have a different life?”

Those are important things to present to couples. We’ve all seen patients who ended up broke, divorced, and unhappy at the end of this road. That’s not what we want to see. It’s a terrible outcome.

How did you choose fertility as your specialty?

JDG: My father and my brother are general surgeons, and general surgeons have a different view of the world. The old adage: “A chance to cut is a chance to cure.” Why would you want to be anything else except a surgeon?

I thought I wouldn’t go to medical school because I didn’t see myself as a surgeon. Then I came to the conclusion that I really like science and helping people so maybe medicine would be a good career.

I went to medical school, and thought maybe I’d be a pediatrician. I went on my first rotation and it was a disaster. I didn’t get along well with the residents, and I found it too traumatizing to deal with the sick children—it just broke my heart.

Then I did a rotation in Internal Medicine at the VA Hospital in Durham. That was really sad because all these guys were coming in with multiple medical problems and they’re constantly being admitted. They didn’t get better that quickly. It was depressing.

I went right from there to OB/GYN. I didn’t really know anything about women’s health, except that my father said the OB/GYN guys never slept because they were up all night delivering babies. I did the rotation; I loved it. There was medicine; there was surgery. The women were generally compliant patients. They listen to what the doctor has to say and don’t ignore medical advice--not like men. Men are terrible patients. And delivering babies is really exciting.

Then I did an elective in reproductive endocrinology. It was emotionally charged, but it was very goal-directed. You knew if you accomplished the goal or not, which I liked.

What’s it like being a man in a “women’s field”?


JDG: In the mid-Atlantic and the South, there are some women who prefer to have a male physician. Rarely do you find this in California. The default mode is “I want to go to a female physician because she understands me better.” I can’t argue with that: I can’t say what labor feels like; I can’t say what it’s like to have a bad period or an ovarian cyst.

At times, it would go in the other direction where male physicians were almost demonized: “Why are you in this profession? You shouldn’t be here.” There was a paucity of men in the program, and nationwide that’s continued where there are very few men going into obstetrics and gynecology.

You were immediately suspect. I remember one night being on obstetrics call at Kaiser. A woman was in labor, and I went in and introduced myself. She said, “I want a woman.” I told her, “It’s August. The only woman I have has been an intern for three weeks and she’s only done a handful of deliveries.” She said, “That’s who I want.” I’ve delivered like a thousand babies at this point. Fortunately, things went fine.

The good thing is in a subspecialty, you have patients who say, “I want the best doctor. I don’t care--male or female.” You’re somewhat protected in a subspecialty.

My wife had a female obstetrician for her first pregnancy and said she would never have one again. She felt all her symptoms were ignored or dismissed; she felt no one really was listening to her. It’s true a woman has experience of these things, but if a woman says, “This hurts,” I’m not going to say, “No, it doesn’t.” If she says “Every time you do a pap smear my cervix hurts,” I’m not going to say that’s impossible, because I don’t have a cervix. If you tell me it hurts, I’ll believe you.

What should patients look for in a physician?

JDG: There are a couple of things. The first thing is: What is the experience of the physician? Where did they train? Are they board-certified? What has been their reputation, and what are people’s experience with them and their practice?

The second thing is with IVF, it’s very important to have a good IVF lab. If you don’t have a good IVF lab, you could be the best, most caring physician in the universe and you’re not going to get people pregnant the way you should. That’s something the patients never see. They have to evaluate it based on statistics. The problem is there’s that old adage: There’s lies, there’s damned lies, and there’s statistics.

The problem with comparing practices based on statistics is that there’s a patient selection phenomenon going on as well. What I’ve always told patients is if you’re looking to compare two practices, look at their donor egg pregnancy rates because they should be a level playing field. Everyone has young donors, and everyone has older women who need donor eggs. Their donor egg pregnancy rates should be a yardstick by which you can compare practices--apples to apples and oranges to oranges.

posted by Cheryl Miller | 11:55 am
File As: Assisted Reproductive Technologies, In Vitro Fertilization, Conceptions Interviews

John D. Gordon, Internet Doctor

Part One: On blogging, dealing with problem patients, and more

July 1, 2008

100 Questions and Answers About Infertility

 John D. Gordon

Dr. John D. Gordon is a reproductive endocrinologist and co-director at Dominion Fertility and Endocrinology in Arlington, VA.  He’s practiced for over ten years, and trained at Stanford University and University of California, San Francisco.

Last year, he and his business partner, Dr. Michael DiMattina, published a guide for patients: 100 Questions & Answers About Infertility. To promote the book, Dr. Gordon launched a blog by the same name, and it’s still going strong after over 80 questions and answers. You can also find Dr. Gordon online at the International Council on Infertility Information Dissemination.

In his interview with Conceptions, we discuss how the Internet has changed his practice, how he handles problem patients, and what it’s like being a man in a woman’s field.

[Interview edited and condensed by Cheryl Miller. Part two to follow.]


How did you start blogging?

JDG: It was sort of a natural extension. For the last nine years, I’ve been answering questions on this other website called “INCIID” [pronounced "inside"]. They have different forums that are moderated by physicians. Basically, I post every day or two on questions that come up.

I served essentially as the Internet doctor for these couples. That has its own set of problems because you only get less than half the story usually. You get a modified version of what the patient understands their history to be so you have to be a little bit careful to avoid being dogmatic.

When my father-in-law was diagnosed with lung cancer several years ago, I went to a conference about lung cancer, and there was a book called 100 Questions & Answers About Lung Cancer. I thought it was a great book. I called up the publisher and said, “I see you have fifty titles but none of them are about infertility. Would you like us [he and Dr. DiMattina] to write a book about infertility?”

I thought, “Gee I’ve been answering questions several times a day for all these years.” So you start to see a pattern in the questions you get asked. Out of that grew the idea to have a blog to promote the book.

The other thing is I trained in California at Stanford and UCSF. It’s a different world out in California. Essentially, a male physician has to be twice as caring and communicative to get half the patients and respect of a female physician. My mode of practice has always been full disclosure, a lot of information to the patients, and getting them to be a partner in their healthcare decision-making. The blog is an extension of that.

How has the Internet changed your practice? Do patients seem more knowledgeable or maybe just think they’re more knowledgeable?

JDG: It’s a double-edged sword. I’ve never been threatened by patients asking questions. Patients have always come in--in the 12 years I’ve been in practice--with an article or two. The number of patients who do that has certainly increased with Internet.

The problem is that you do have self-proclaimed experts out there--usually other patients who have had their own experiences--and that can get patients completely turned around. Just this week, I had a patient who was almost having an anxiety attack because of some things she was told on the Internet by another patient. I told her, “You are an individual. You have a unique history to you. You can’t listen to what this other person is saying. We worked on a plan that takes in account your particular needs. Ignore her.”

The Internet also gives patients a bully pulpit. You do occasionally get a dissatisfied patient who can get out there and really throw rocks at you. But you can’t do anything about it. Because of doctor-patient confidentiality, you can’t say, “No, no, you got this backwards. Here’s why we told you that.” We can’t respond to it.

This happened just a couple of years ago. A patient on “INCIID” had posted a question saying, “My doctor wants to do a laparoscopy because he thinks my lining isn’t normal.” I thought, “That doesn’t make much sense. A laparoscopy isn’t going to see the lining because you’re on the outside of the uterus so you wouldn’t have any idea what was going on.” I replied to her, and then the phone rang. The receptionist said that a patient of Dr. DiMattina is on the line for you. I told her he would be back in a minute, and she said, “No, she wants to talk to you. She’s the one who has been posting questions to you.”

I pulled the chart and picked up the phone. I explained, “Your HSG test showed that your tubes are blocked. That’s why you need the laparoscopy.” She said, “Oh, yes, I remember. I don’t know why I got so confused.” So here’s a patient in our own practice who was told this is the procedure we’re doing and this is why we’re doing it, and then she gets completely turned around and relies on this disembodied Internet doctor for advice.

When people give advice without full information, you can really get into trouble. That’s why a lot of my posts end with, “Discuss this with your RE.” Patients are funny; they’ll put amazing stock in what this disembodied voice on the Internet has to say about their care when they’ve been under the care of a well-trained physician for years.

Do you think they’re “checking-up” on their doctors? Perhaps just looking for a second opinion?

JDG: There’s some of that. When people have bad outcomes, they’re trolling around looking for an explanation as to why things didn’t go well. We’ve all had patients like this. I usually say, “It’s obviously disappointing that things didn’t go well. Here are some thoughts I have as to how you should address this with the physician. Ask him about this.”

If their doctor stonewalls them and they want to have that discussion, maybe that’s not the right match. All physicians have different approaches. Some patients have left me because they don’t want to talk about [their treatment plans].

Do you read any infertility blogs?

JDG: On the patient side, I’ve read some of the infertility journey type of blogs. But I live it every day. I have enough of an emotional sine wave riding it with my own patients rather than signing on to someone else’s. It’s hard to read sometimes.

How do you decide what questions to post?

JDG:
Every post has been one question from the book. I’ve got a hundred questions--actually 99 since the last one is “Where can I go for more information?” I’ve worked my way up to 80 so I only have 19 left to do in the year or so I’ve been blogging. My goal was to work through every question in the book. I will keep blogging on subjects of a more temporal importance.

I wish I could blog more frequently. You’ve got a full patient load; it’s hard to carve out the time. I have a wife, four kids, and two dogs. The days are full.

[Click here for Part Two.]

posted by Cheryl Miller | 11:35 am
File As: Assisted Reproductive Technologies, In Vitro Fertilization, Conceptions Interviews

Two Bits of Good News

June 27, 2008

Here's a welcome development: India is working on legislation to address the recent boom in surrogate motherhood there:

Concerned with an increasing number of foreigners coming to India to rent a womb, the government is planning to come out with regulations to ensure legal and medical rights to surrogate mothers and children born to them.

"We have seen that couples fly to India, persuade a woman here to rent out her womb for money and then they happily take the child to their country. How do they get the child's passport?" an agitated Women and Child Development Minister Renuka Chowdhury told reporters here Wednesday.

...As of now, there is no law on surrogacy in India. There are certain guidelines issued by the Indian Council of Medical Research (ICMR) on surrogacy and Assisted Reproductive Technologies (ART), she said.

For experts, the major concern is the number of young girls opting for surrogacy, which is also affecting the Maternal Mortality Rate (MMR). Thus, issues like the minimum age limit and health conditions that need to be considered will come up for discussion. 

The most premature twins born in Britain just celebrated their first birthday:

Mikey and Gracie Swindell were born dead at 24 weeks.

Medics spent an hour battling to bring the twins — who each weighed 1 pound, 9 ounces — back to life.

[...] "We call them our little miracles," said Lisa Swindell, 28, of Chatham, Kent, who conceived the babies through in-vitro fertilization after she and her husband, Paul, tried to conceive naturally for five years.

posted by Cheryl Miller | 11:12 am
File As: Assisted Reproductive Technologies, In Vitro Fertilization, Surrogacy, Reproductive Law

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