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For many couples intent on starting a family, successful pregnancy can be an
elusive achievement. Although a good portion of these couples can benefit
from medical or surgical treatment from a general gynecologist, many of those
who cannot will seek guidance—and pin their hopes on—fertility specialists
and in vitro fertilization, or IVF.
Also known as assisted reproductive technology, IVF involves manipulating egg
and sperm to aid conception. The process, invented in the late 1970s, involves
extracting viable eggs from the woman, exposing them to sperm for fertilization,
and then implanting the embryos in the woman’s uterus. Sounds simple enough.
But that may be part of the problem, according to James Goldfarb, M.D.,
director of the Cleveland Clinic IVF program. Indeed, says Dr. Goldfarb, IVF is
not a simple infertility treatment (although, with the proliferation of
fertility centers and their aggressive marketing, some couples may be led to
believe that it is). For instance, the process described above—called a cycle—
lasts about a month, is costly and may or may not be covered by insurance.
Moreover, many couples must go through several cycles before achieving success.
Perhaps most important, IVF can take a significant toll on emotions, and, it is
not a risk free solution to infertility.
All of these issues, says Dr. Goldfarb, can be compounded by poor
communications with the fertility specialist. "Patients need to know what
they’re signing on for, and they need accurate information, beginning with the
first visit to the IVF physician," says Dr. Goldfarb, who has devoted his
career to understanding and improving IVF procedures and was responsible for the
first IVF birth in Ohio, which occurred in 1983.
Once used rarely, now used widely
According to the International Council on Infertility Information
Dissemination (INCIID), infertility is "the inability to conceive after a
year of unprotected intercourse in women under 35, or after six months in women
35 or over, or the inability to carry a pregnancy to term."
Although it was originally intended to treat infertility caused by damaged
fallopian tubes (the first success came in 1978), IVF is now used to treat
almost all causes of infertility when simpler treatments have not been
successful or are not an option. Recent statistics also show a marked increase
in the use of IVF, with 64,036 attempts occurring in 1996 and 107,587 occurring
in 2001.
The IVF process begins with a woman taking drugs that stimulate the ovaries
to produce multiple eggs. Progress is monitored by blood tests and ultrasound.
Once mature, the eggs are then surgically "harvested" from the ovaries
and placed, along with sperm donated from a male, into a special culture dish.
Fertilized eggs (embryos) are then removed from the dish and implanted in the
woman’s uterus. In essence, IVF takes the place of what usually happens in the
woman’s fallopian tubes during normal fertilization. The rest of the pregnancy
then proceeds the same way it would have had the pregnancy occurred naturally.
The major drawback of IVF is its expense, which costs approximately $10,000
per attempt, or cycle, and most insurance companies do not cover the procedure.
The women’s age is the most important factor affecting success. Other factors
include the skill and experience of the fertility specialists, says Dr.
Goldfarb. Getting good information about success rates can be tricky, says Nancy
P. Hemenway, executive director of INCIID, because no formal, standardized
mechanism for monitoring is in place to objectively track success rates.
"There’s really no reliable data on success rates," she says.
Couples are left to rely on the word of the fertility center they choose. Dr.
Goldfarb says success rates vary widely depending on the center offering the
treatment and a woman’s age. For instance, success rates range from more than
50% for women under age 35, to less than 5% for women over age 43.
The importance of asking questions
Couples entering an IVF program have to deal with a host of difficult
emotions, and poor communications with a doctor is likely to exacerbate them.
"Couples have to be confident that they’re being given all of the
information they need to make an informed decision, " says Dr. Goldfarb.
"If that bond of trust isn’t there, it makes an often difficult situation
worse."
At The Cleveland Clinic Fertility Center, says Dr. Goldfarb, doctors are
guides whose role is not to cajole patients down one path or another, but to
help them decide on the choice that works best for them.
Dr. Goldfarb’s main recommendation to couples seeking IVF guidance is to
ask as many questions as possible. "It’s important that couples fully
understand all of the options," he says. "If they’re unsure about
something a doctor says, they shouldn’t be afraid to ask more questions to
ensure they grasp the details."
Where to start
Armed with the basics from a fertility center—for example, an information
packet and Web site information, both of which the Cleveland Clinic IVF program
provide—couples should then meet with an IVF physician. At the Cleveland
Clinic, the initial IVF meeting usually lasts between 45 minutes to one hour,
but can go longer if necessary.
During the consultation, the physician should outline all of the options
available to the couple. Ideally, an IVF clinic should tailor each procedure to
the couple’s specific needs, says Dr. Goldfarb. The more involved the plan,
however, the higher the cost. "You want to choose a doctor who will find
the most cost-effective path toward pregnancy and who will tell you which
procedures are unlikely to improve the chances for success," says Dr.
Goldfarb.
As for insurance, most IVF programs have insurance specialists who can
examine a patient’s coverage and determine what it will cover; The Cleveland
Clinic’s program can even connect patients with financing organizations.
Count your eggs before…
Couples also need clear information about the number of embryos the IVF
specialists intend to implant. This is important because each embryo implanted
increases the chance of multiple pregnancies. And with the likelihood of
multiple births comes increased risk of complications for the woman and higher
costs overall for the couple. The number of embryos implanted will depend on the
woman’s age, reproductive history, and the number of embryos available for
transfer, among other factors, says Dr. Goldfarb.
To help determine which embryos are more likely than others to produce a
fetus, embryologists use a system to grade them. Grading is based on criteria
including the number of cells produced two and three days after fertilization
and the severity of fragmentation (as the embryonic cells divide, some may loose
tiny fragments of their structures). Only about 20% of embryos will receive
"perfect" grades. The Cleveland Clinic IVF program shares embryo
grades with couples shortly after embryologists post them, usually within 24
hours. Not all IVF programs have the same policy regarding release of such
information, so it’s important to ask about it, says Dr. Goldfarb.
"Knowing the right questions to ask can alleviate some of the anxiety
that accompanies such a complicated and emotionally taxing procedure," he
says. "It won’t guarantee success, but it might make it a little easier
for the patients to deal with."
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