The AFA Blog

Insurance coverage for young adult cancer patients to preserve fertility

by Corey Whelan

Around 1.5 million American men and women are diagnosied with cancer annually.  Ten percent of those are under the age of 45 and one percent will be younger than 20.  That translates into around 70,000 young adults, all under the age of 20 years old, who will have to grapple with this disease.  Statistics aside, if you or a loved one are diagnosed with cancer, life may never be the same.  Mind reeling, you may or may not think about options for parenthood later on.  Of course, many cancer treatments including surgery, chemotherapy and radiation may have the effect of rendering the person on the receiving end infertile.  Of course, survival is the number one goal but many cancer patients report that their ensuing infertility was just as devastating to them as their original diagnosis.

Fertility can often be preserved prior to cancer therapy beginning, for both men, women, boys and girls.  These options can be as simple as collecting and freezing sperm, or can become more complicated and expensive, including testicular needle aspiration for young boys or egg freezing for young women.

According to change.org, the vast majority of insurance comapnies and HMO's in the United States do not cover fertility preservation treatments such as those referenced above.

Currently, legislation addressing this issue is being decided upon in California.  Bill AB 428 is being sponsored by Assemblyman Anthony Portantino but your help is needed.  No matter where you live, your name on a petition requesting support of this bill will be meaningful and will not go unnoticed.  

Click here to read the petition letter and to sign it. Please.

For more information on fertility preservation and your options, click here

To watch a short video on fertility preservation, click here

Be the change.

Leading experts bring infertility prevention awareness to University of Colorado

DENVER, Feb. 21, 2011 /PRNewswire/ -- The American Fertility Association (The AFA), a national family-building non-profit organization, is heading to college campuses around the country to educate young men and women about infertility - a disease affecting one out of 6 couples in the U.S. The 2011 College Tour Series kicks off on March 4th at the University of Colorado in Boulder with a presentation entitled "Why Mother Nature Wants You To Get Laid Right Now". Students will learn about preventing infertility by avoiding certain environmental toxins, STI (Sexually Transmitted Infection) prevention, and about the realities of the biological clock. Brenda Strong, The AFA's national spokesperson, board member, and Desperate Housewives actress, will be on hand to talk about the benefits of yoga to help alleviate stress, which can affect fertility. She will also lead a yoga demonstration for the students. Though The AFA's goal is to prevent infertility whenever possible, sometimes infertility can't be avoided. Dr. Mark Bush, a reproductive endocrinologist with Conceptions Reproductive Associates in Denver, will speak at the event so students are aware of savvy treatment options.  Executive Director Ken Mosesian and Program Director Corey Whelan will discuss infertility prevention for men and women, environmental toxin avoidance, and STI (sexually transmitted infection) avoidance.

Later that night, The AFA will honor Dr. Mark Bush with the Joyce M. Vargyas, MD, Visionary Award at the Illuminations Denver cocktail party. Dr. Bush has extensive experience in all aspects of reproductive endocrinology, infertility, and assisted reproductive technologies. He has published numerous scientific and clinical papers in the field of women's health. Recently, Dr. Bush has taken a serious interest in elective single embryo transfer in order to avoid multiple births. The AFA strongly supports the use of single embryo transfer when possible for the safety of the patient and the child.

This year's Illuminations Denver will focus on The AFA's work, empowering young men and women to take control of their fertility. Illuminations Denver will be held at Palazzo Verdi at Fiddler's Green, and special guests will include Brenda Strong, Dr. Kevin Fitzgerald from Comedy Central and Animal Planet and pianist Joseph Eisele with the prestigious Young Musicians Foundation of Colorado. The event is designed to raise much-needed funds to support the educational outreach work of The American Fertility Association.

The media is welcome, and encouraged, to attend both events. The AFA would like to thank all of our sponsors who are helping to make both of these events a huge success, including our Platinum Event Sponsors, Ferring Pharmaceuticals and Conceptions Reproductive Associates, and our Gold Event Sponsor EMD Serono. Special thanks to Disney / ABC Television Group for their support as the Charter Sponsor of our 2011 College Tour. If you're interested in sponsoring Illuminations Denver or purchasing tickets, please contact Corey Whelan at 718-853-1411.

Press Contact: Merry Armentrout Director of Communications, The AFA 205-470-9406 [email protected]

The American Fertility Association, a 501(c)(3) national non-profit organization, is a resource for infertility prevention, reproductive health and family-building. AFA services and materials are provided free of charge and without reservation. These services include an extensive online library, resource directory, hosted message boards, daily fertility news and a toll-free support line. http://www.theafa.org or 888.917.3777

This press release was issued through eReleases(R). For more information, visit eReleases Press Release Distribution at http://www.ereleases.com.

SOURCE American Fertility Association

Read more: Preventing Infertility and the Future of Fertility Treatments - The Denver Post http://www.denverpost.com/coloradocorporatestatements/ci_17442679#ixzz1EdBw9Rec
Read The Denver Post's Terms of Use of its content: http://www.denverpost.com/termsofuse

Off Camera

  By Jamie Schenk DeWitt

 In today’s world of 24/7 media coverage, and people’s obsession with anyone famous, celebrities are using their influence to change the social and political landscape.  They have moved beyond their traditional movie screen roles to the world stage to express their views on poverty, social injustice and man's inhumanity to man.  I applaud these efforts and the change that has occurred because of their actions. 

One area where celebrities are not consistently honest is in the realm of infertility.  Before I went through infertility treatments, I never questioned the pregnancy of a celebrity in her late thirties or early forties.   There was always a wonderful picture of her pregnant belly and a warm fuzzy story in People Magazine announcing the birth of her baby or babies. Yet after having experienced IUI (Intrauterine insemination) and IVF (In vitro fertilization) I now have to wonder if that same starlet spent months staring at a negative sign on a pregnancy stick or had to hear a nurse repeatedly telling her that unfortunately she was not pregnant, but to try again.  

Don’t get me wrong.  I am not saying that every celebrity who gets pregnant has to announce whether or not she conceived naturally or through artificial insemination.  People are entitled to their privacy.  I only wish that women who were in the spotlight struggling with infertility issues would raise their voices and share their fertility journey to motherhood in order to educate other women about the realities of infertility. 

More and more young women are graduating from college and entering the work force focusing on their careers and personal lives.  They put off marriage and children waiting until their late thirties.  It is important that we arm them with the facts about their biological clocks, so they can make educated decisions about how to be in charge of their fertility. 

When I was thirty-five years old, I received a phone call from my OBGYN informing me that my FSH levels (follicle stimulating hormone) were extremely elevated for someone my age.  My OBGYN was basically telling me that I had “old eggs that were of poor quality.”  I feel that education and awareness can prevent other females from receiving this call.

There are some celebrities who are willing to use their status to educate people about infertility issues. I want to take this opportunity to thank them. Giuliana and Bill Rancic are two such people.  They have openly shared their infertility struggles with their TV audience on their reality series, Giuliana and Bill.   In addition, they have spoken about this issue on The View, in US Magazine and wrote about it in their new book, I Do, Now What?  After having spent a year trying to get pregnant naturally, Giuliana underwent fertility treatments.  She got pregnant via IVF but unfortunately, eight weeks later, she had a miscarriage.  Throughout the couple’s attempts to have a baby, they honestly shared their feelings about the experience, how it affected them and what they learned.  

In an exclusive interview with AOL Health Giuliana states, “It’s just that for some reason, through the years, infertility has been a very taboo subject. These women in Hollywood … I think they just like people thinking they’re perfect. They don’t want to admit they have flaws. They feel like it’s going to somehow hurt their careers. They don’t want to show that they need medical help; they keep it very hush-hush. I felt like I had been duped, in a way, by a lot of these women. I’ve been interviewing actresses for the last 10 years, so I would see them and I’d go, “They’re so fabulous. I want to live like that! I’m going to focus on my career, and then at 40, I’m going to have twins!” I would talk to these women and be like, “So, ‘blank actress,’ you’re 41, and you just had twins and that is so amazing.” And they would say, ‘Well, twins run in my family!’ I remember, someone told me that as you get older, your chances of twins are more likely. Well, now I know that’s because at 40, you’re doing IVF. So that’s why this is important to me. Regular women need to see women in the spotlight having problems.” 

Rancic continues, “My thing was, I knew nothing about any of this. I thought I was still so young. We did IUI and that didn’t work. We did more tests, and [the doctors] said, “You’re 35, and your eggs are old.” And I’m like, what? I was so shocked, and I said to myself, had I known it was going to be so hard to get pregnant maybe I would have frozen my eggs at like 30 or 28."

Thank you again Giuliana and Bill for openly sharing your experience and being pioneers willing to step out from behind the camera to honestly share your fertility journey to parenthood.

For a more detailed list of starlets and celebrity couples that have been openly discussing their struggles with infertility please check out: http://abcnews.go.com/Entertainment/slideshow/celebrity-infertility-battles-10542271

Photo: Celebrity Baby Scoop

Scientific Strides With Embryo Transfers

 

by Iris Waichler

I was fascinated by a recent article I read in Time Magazine.  It announced that researchers at Stanford University had discovered they could film embryos developing during the first 2-3 days after they were placed in a Petri dish.  Why is this so important?  Having this information helps embryologists identify “the best embryo to transfer to a woman’s womb.” 

            Ten years ago my husband and I sat in our R.E.’s office. It was our last IVF treatment.  We had decided to stop infertility treatment if this treatment failed.  I had spoken with professionals, people who had experienced infertility treatment, and read everything I could about IVF treatment to prepare for this final attempt. 

            The embryologist popped his head in the room and said, “We have 3 embryos. One of them looks great, one is marginal, and the other doesn’t look so good.” I will give you 5 minutes to decide how many to transfer” and he disappeared.   It was one of the most difficult moments in my years of infertility treatment.  What did it mean when an embryo is described as “marginal”? How could we make a life changing decision with so little information? How dare they put us in this position? I realized all my preparations would not help with this choice.  We decided to go with the amazing looking embryo and leave the others behind.  I was concerned if I became pregnant with one of the other 2 embryos there was a danger of having a child with developmental or medical problems.  Ours was a happy ending with the birth of my healthy daughter. We called her “amazing Grace.”

            The science of observing and understanding embryo development has evolved so people trying to build their families today will have more valuable information than we did when facing our transfer decision.   Researchers have learned what to observe to identify the most “viable embryos.”

 

            1. “The time it took to cleave from a single fertilized egg into two cells.

            2. The time between each of the next two cell-division cycles. (Faster is better)”

 

            Stanford experts say this information offers a “93%” accuracy rate determining which embryos would make it through the next couple of days.  This means transfers can be done as soon as 2 days after the embryo is fertilized.  The Stanford team believes this film technique will improve pregnancy success rates and also reduce the need for multiple transfers resulting in fewer multiple births. 

 Iris Waichler, MSW, LCSW, is a licensed clinical social worker who has counseled people experiencing infertility.  Ms. Waichler is the author of the award winning book “Riding the Infertility Roller Coaster: A Guide to Educate and Inspire”. She currently writes freelance infertility and health related articles.

 

 

Oocyte Cryopreservation: Is it Ready for Prime Time?

By John A. Schnorr, M.D.

There are two major innovations in the field of Reproductive Endocrinology which will revolutionize what we do and dramatically improve patient care.  The first is the ability to successfully cryopreserve eggs with a high pregnancy rate.  The second innovation would be the ability to mature immature eggs in test tubes so they can later be fertilized and transferred into a woman’s uterus with also a high pregnancy rate.  Fortunately, there have been some major breakthroughs in the first innovation which is oocyte cryopreservation. 

There are multiple advantages to oocyte cryopreservation.  One of the main advantages would be the ability to delay procreation which is especially applicable for patients with cancer who will undergo chemotherapy.  Additional advantages include cryopreservation of eggs rather than embryos for ethical or religious reasons, to delay procreation for social reasons and the ability to salvage IVF treatment cycles which have gone awry from inadequate sperm specimens to ovulation disorders. 

Embryo cryopreservation first became successful in the mid 80s and remains a mainstream technique in Reproductive Endocrinology care. There are, however, additional challenges that an egg poses rather than an embryo.  The challenges posed by eggs include increased water content, a mitotic spindle which is responsible for segregating chromosomes during the fertilization process, and the outer barrier to the egg, called the zona pellucida, which can harden with the freezing process.  Early on in egg freezing technologies, we essentially use those same technologies that are successful with embryos and found lower egg survival rates along with lower fertilization rates and ultimately lower pregnancy rates.  This technique is referred to as the “slow freeze” approach to oocyte cryopreservation.

The newer technique for oocyte cryopreservation is called vitrification and is a technique which requires the use of higher concentrations of cryoprotectant agents which first dehydrate an oocyte and then secondary agents are used which actually permeate the egg and stabilize the intracellular contents for the freezing process.  The egg is then quickly cryopreserved in a fraction of a second by literally plunging the dehydrated oocyte into liquid nitrogen.  This process of aggressive dehydration and cryoprotection with the permeating agents and rapid freezing helps to avoid ice crystal formation within the oocyte and appears to improve oocyte survival.  This technique is in stark contrast to what is considered the slow freezing approach in which cryopreservation of an egg could take over two hours of freezing.

Success rates with egg freezing are directly related to the quality of the egg at the time of cryopreservation.  There is absolutely no evidence that cryopreservation would ever improve egg quality but rather would have the potential to hurt egg quality.  Accordingly, most studies on egg cryopreservation use women less than 35 years of age in the study group, since age is a strong marker for egg quality.  Using slow freezing technologies over the last decade, studies show that approximately 50-75 cryopreserved eggs would be necessary to produce one pregnancy.  The newer vitrification technologies appear to show improved oocyte survival rates and pregnancy rates.  Over the last three years, success rates have improved with vitrification, such that it typically takes 20-25 eggs to achieve one pregnancy. 

If you are considering oocyte cryopreservation, it is important to work with a center that is established in the field of oocyte cryopreservation and most importantly is doing research under an investigational review board (IRB) approved protocol.  By all means, at this time, oocyte cryopreservation is a research-oriented procedure and is not ideal for everyone.  Over the next several years refinement of oocyte cryopreservation techniques will occur and it will become mainstream treatment and a big step forward in improving patient care!

John A. Schnorr, MD is the Division Director of Reproductive Endocrinology at the Medical University of South Carolina and the Medical Director of Southeastern Fertility Center in Mount Pleasant, South Carolina

 

Everything Fertility

by Merry Armentrout

I moved from Birmingham, AL to Boston when I was 22 years-old.  I immediately fell in love with the city.  There are so many differences between my Southern hometown and Beantown.  When I left Birmingham most of my friends were either planning a wedding or enjoying life as a newlywed.  I was doing neither, and was delighted to find the twenty somethings in Boston were relishing single life as well.  There's not that constant pressure to get married and start a family in a city such as Boston.  I noticed people my age were more concerned with finding a career, not pushing a baby carriage.  This isn't necessarily a good or bad thing, but when facing the inevitable truth of a woman's biological clock , well, I hate to sound cliche, but time is a ticking...

Many women don't realize they're fertility starts to decline at about 27, maybe, after months of trying to conceive you're getting nervous, or a gay couple might not know their options if they want to start a family, and a single woman could be curious about sperm donation...all of these scenarios are someone's reality in Boston.  Luckily The AFA, along with Fertility SOURCE Companies, are bringing the people of Beantown a free lesson in Infertility 101.

On September 14th, Dr. Merle Berger and Susan Pinnell, RN from Boston IVF and Susan Crockin, Esq. of Crockin Law and Policy Group, will be leading a casual discussion, over dinner, on everything fertility...from infertility prevention and reproductive health to egg donation and surrogacy.  The talk will take place at M.J. O'Connor's Irish Pub at Park Plaza in Boston, starting at 6:00pm.  The best part part- the event is free- including the dinner buffet.  The setting is casual and relaxed, so this is a great time to learn the facts, and find out solutions for your fertility needs.  Reservations are required, please contact Corey Whelan at [email protected] or 718-853-1411.

If you live in Boston, I hope you take advantage of this opportunity.  Whether you're curious about what steps you can take now to help preserve your fertility, finding a surrogate or want to learn about egg donation, this is a great setting to ask questions and get answers from experts in the field of infertility and third party reproduction law.

 

 

 

PCO and other Fertility Related Topics

by Fred Licciardi, M.D.

PCOS (Polycystic Ovaries) and Ovarian Drilling.

Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Androgens, by the way, are the hormones that get changed into estrogens, so androgens are absolutely necessary for normal repoduction, but in PCO the androgens are in excess. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because they do not always work, can cause scar tissue, and there are other alternatives.

There are other ways to stimulate ovulation, including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option.

Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling.

So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin.

What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.

Other PCO Topics

Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.

When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.

Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.

Egg quality clomid vs FSH? Probably similar.

Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.


Sperm Topics:

Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.

Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.

Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.

Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.

Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.

Miscarriage

What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.

Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.

Frozen Embryos

Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.

What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.

General Topics

Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.

Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.

Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.

What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.

How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.

Gleefully a Gleek

by Merry Armentrout

I’m a gleek.  If you don’t know what that means, you’ve never tuned into the TV show Glee. Every Tuesday night I wrestle the remote away from my husband, and plant myself in front of the tube to watch an hour of high school kids singing and dancing through the halls of McKinley High. The show revolves around a motley collection of high school students who endure the ridicule of being in the glee club for their love of music.  The choir is aptly named “New Directions”, and the club desperately wants to earn respect from their classmates, and more importantly to the group of social outcasts, popularity.  New Directions covers songs from past eras, such as Journey’s Faithfully, to the hits of today, most recently an entire episode dedicated to Lady GaGa. In my opinion, the singing is awesome, but my husband rants and raves about the group butchering all of the greatest hits.  When he does this, I simply tune him out, and turn the TV up.  He isn’t a gleek, but I am, and every week viewers are coming over to my side.  This makes me happy not because I’m right, and my husband is dead wrong, but because as the show gains popularity, so do the story lines on the show dealing with family building.

When I first watched the show, I was so enthralled with the singing I overlooked the plotlines which coincidentally coincide with The American Fertility Association's four goals: Infertility Prevention, Reproductive Health, Adoption and LGBT (lesbian, gay, bisexual, transgender) family building.  

New Directions is led by Spanish teacher Will Schuester, or as the kids call him, “Mr. Shu”.  Mr. Shu not only has the challenge of leading New Directions to victories at competitions, but is dealing with a divorce after learning his wife, Terri, faked a pregnancy to save their marriage. Using such a dramatic measure as wearing a prosthetic bump for 9 months is not something you hear about often, unfortunately, infertility is…one in every 10 couples in the U.S. are infertile.  This statistic translates to 6 million people having trouble conceiving a child. Reproductive specialists define infertility as the inability to get pregnant after 12 months of unprotected sex.  Most reproductive endocrinologist would recommend seeing a specialist if you’re over 34 and haven’t conceived after 6 months.  If you’re interested in finding a reproductive endocrinologist, please look through The AFA's Physican's Networkto find an infertility center near you.

The star of New Directions is Rachael Berry.  Rachael lives with her two dads who had their daughter through egg donation and surrogacy.  Recently, Rachael found her birth mother who told her she accepted money in exchange for not contacting Rachael until she was 18. The two realize their reunion isn’t what they imagined, and decide, for the time being, a relationship would be too complicated. They say farewell through Lady GaGa’s popular song, Poker Face.  With the help of technology, such as egg and sperm donation, and a growing network of surrogate agencies, same sex couples and single patientshave the ability to be parents.  The AFA supports all people in their family building journey, and provide information on LGBT Family Buildingand third party reproduction.

Lastly, high school wouldn’t be complete without a teen pregnancy. Head cheerleader and ironically, President of the Celibacy Club, Quinn Fabray, finds herself in a pickle when she gets pregnant not by her long-time boyfriend, Finn Hudson, but bad boy, Mohawk- sporting Puck.  She decides to give the baby up for adoption.  Many couples begin their family building journey with hopes of conceiving a baby, but after failed infertility treatments, look in a “New Direction”- adoption.  Adoptions by lesbians and gay men are becoming increasingly popular; unfortunately, there are still legal and social discriminations. Adoption is a wonderful option and opportunity for many hopeful parents and The AFA is happy to provide resources on the adoption processand helpful agencies.

I’m a gleek for so many reasons. I love the songs, the characters and am thrilled the show is highlighting family building options.  This demonstrates infertility is no longer a taboo topic, but an accepted reality many people will face.  Times are changing, and it’s exciting to see these issues woven into the plotline of a primetime TV show.  Even if you have to fight over the remote, tune into the Glee finale next Tuesday night, and come join the winning team. My husband will eventually learn that I’m always right…

Some Complications of IVF and Egg Freezing

by Fred Licciardi, M.D.

This blog is a segue into egg freezing. I realize that for most of the infertility community, egg freezing is not applicable, but I do get many questions about it. Plus, I suspect that many of you are the family fertility experts or the neighborhood fertility pros, unfortunately your struggles have made you experts, and you too may face questions about the topic. Some of this also applies to regular IVF, so it’s worth a read through.

I am writing today because a good understanding of IVF and egg freezing requires you to know the fine print. It’s not that the fine print is bad news; it’s just part of the full disclosure. This installment will deal with drug and procedure complications of IVF, which also applies to egg freezing. More specific egg freezing blogs will follow.

From a patients perspective, 95% of egg freezing is just like any other IVF cycle, which is summarized as follows. A woman takes 1-2 hormonal injections per day for about 2-3 weeks (depending on the protocol), and during that time she needs office monitoring, about every other day, where blood tests and ultrasounds are performed. We use the information from the monitoring to adjust the drug dose if necessary and to tell us when the right time is to remove the eggs. Once the time is right, a retrieval is performed. This is a procedure done usually in the office, but some programs have it done in their hospitals. It’s done under intravenous sedation, which means the woman is totally asleep, feels and remembers nothing, but is not intubated and breaths on her own. Using the ultrasound for guidance, a needle is passed through the vagina, into the ovaries and into one follicle at a time. A suction machine pulls the fluid from the follicle into a test tube, and in the fluid is one cell that’s the egg. Usually eggs are retrieved from follicles on both ovaries.

The test tube gets handed to the embryologist in the adjacent lab, who finds the egg in the fluid and then does the rest.

The retrieval procedure takes about 20 minutes, and when done you wake up right away. You are watched in the recovery room for one hour, and off you go home. The next day you would get a phone call to confirm the number of eggs that were retrieved and the number of eggs that were frozen (yes, in many cases there is a difference).

Sounds pretty simple? For most women but not all, it actually is relatively easy, but it requires time and of course money (we’ll get to that).

There are potential complications with any IVF or Egg freeze IVF cycle, but they are rare.

One is ovarian hyperstimulation. This is where the ovaries are very sensitive to the medications and become too large. Normally, the unstimulated ovaries are about the size of walnuts, and the medications may make them the size of lemons. This can be a good thing because if you are going through the trouble of the procedure, you would like to get as many eggs as you can, but within reason. Problems occur when the ovaries become too large, whereby they may leak fluid, and this fluid can spread to the abdomen and lungs and result in hospitalization. Very sick women may develop problems with their liver and kidneys and be at a high risks for blood clotting in their legs, lungs and other places.

What is happening is that as the fluid goes to places it’s not usually found, it leaves the circulatory system, making the blood thicker than usual. So there is too much fluid in the abdomen, but not enough in the bloodstream. The treatment keys are properly managing the fluid imbalances. If there is extra fluid in the abdomen or lungs, drainage is usually appropriate. If the blood becomes too dry, we need to add a little fluid there.

I realize this sounds hideous, but in fact severe ovarian hyperstimulation is very very rare in IVF and even rarer in women who freeze their eggs. Early pregnancy makes hyperstimulation worse, and since no immediate pregnancy will become of egg freezing, the odds of hyperstimulation become remote. I’m not saying it can’t happen, and mild and moderate forms of hyperstimulation are more common, but severe forms would be exceedingly rare. Plus a good infertility clinic should be able to treat this complication safely.

Still with me? What about the retrieval?

Well there’s the anesthesia. In my 20 years of being involved with 15,000 plus cycles, I have never seen a complication related to the anesthesia. Next topic.

What else? Well, we do push a needle into the abdomen, so there is a potential for bleeding and infection. The odds of needing a transfusion are less than 1 per thousand. The odds of getting a significant pelvic infection requiring hospitalization and IV antibiotics are similarly low. Women with a history of pelvic infection should receive prophylactic antibiotics at the retrieval to reduce their risk, because women with a past infection are more likely to get a second.

And then there’s torsion. The ovaries are inside your pelvis hanging by their blood vessels, not too different from the way testicle hangings on the outside. As the drugs increase the size of your ovaries, they get heavier and may make them more prone to spinning around, twisting the vessels and choking off the blood supply. You would know this is happening because it causes severe pain and nausea. Torsion can happen before the retrieval or after. It can even happen 1-2 months into the pregnancy (the ovaries of pregnant women may remain large for a couple of months after the drugs are stopped. This is because the hCG from the pregnancy stimulates the ovaries to retain their cysts to make more progesterone until the placenta takes over).

Of course for egg freezing, there is not an increased risk of torsion during a pregnancy because the pregnany will get started with the ovaries normal sized. Ovary-enlarging fertiltiy drugs are not used for the thaw cycle.

Torsion is a rare event, occurring in less than 1 in 1000 cases. The ovary can be untwisted via an emergency laparoscopy. If it is untreated, the ovary can die from lack of circulation. However, we have not had this happen to anyone. The key is to call your doctor if you have pain. Losing an ovary does happen with torsion, but the usual scenario here is pain in a woman who is not undergoing fertility treatment, but develops any type of ovarian cyst that enlarges the ovary. Typically, she has pain for a while and is told to wait and see, and then she finally is told to go to the busy emergency room where she is given pain medications. Then many more hours go by waiting for the GYN consult, and by the time they get her to the operating room it’s too late. In the infertility world, your first phone call sets off the alarms and you are evaluated and treated in plenty of time.

And then there is the potential for the ectopic pregnancy.

So that’s the yucky drugs and needles part.

Next time we talk about the pitfalls of egg freezing will try to answer the question, “Will egg freezing help me?”

Donor DNA & The Future Of Third Party Assisted Reproduction

by Sioux Oliva, Ph.D.

 DNA testing is changing the way we understand family on our planet—including in the world of assisted reproduction. DNA tests are now routinely done for maternal, paternal and geographic origins, inheritable disease markers (carrier status test), genetic risks (disease risk test), and to learn in advance what medications are best for you (drug response test). More DNA data is being shared on the Internet and companies offering these services are growing exponentially: we have reached the tipping point. It is now easy for donor children to get on the Internet and look for DNA matches. Donor children did not sign any anonymity agreements with anyone and are free to look for and contact a donor if so inclined. This presents a new opportunity for AFA members to discuss how the end of donor anonymity can shift the current playing field from secrecy and shame to one of openness and new understanding.

 One way or the other many donors will be “outed” as DNA testing continues past the tipping point. What can we do to ensure the greatest good for these created families? The first would be to bring this discussion out into the open so parents: 1) can deal with why they feel the need to be secretive; and 2) can make a plan to be honest with their children about their biological origins. In a few years the cost of DNA testing will be low enough that it will become part of any medical history. Donor children will easily be able to discover that their genealogy is different from the parents who raised them. This brings us to the two sides of this issue regarding donor DNA: the hard science and the social science aspects for donor families. The hard science: with DNA testing becoming commonplace, donors will not remain anonymous forever. A donor child can go online now and look for half siblings by placing their DNA markers on any number of websites to search for their relatives and this trend will only continue to grow.

The other issue is the social science aspect where we to help families build an honest family history for their child that accurately represents their biological and social background. This story is essential for both parents and children. Studies and experience have demonstrated that donor children feel anger, betrayal, and distrust towards their parents when they find out as young adults that their parents were not honest with them about their biological origins.

 A friend who recently became pregnant with her first child at 42 using an egg and sperm donor decided to keep it a secret from her child, family and friends. The only reason I knew of her situation is because I had experience in assisted reproduction and she came to me for guidance. We met and talked about her experience with her doctor and therapist. Her doctor never mentioned how DNA testing could bring her secret out into the open, nor did her therapist mention that children do feel betrayed and angry at not being told the truth about their biology. This lack of vital information from professionals is a disservice to her and her family. We need to guide our clients to the best possible scenario. Ignoring the fact that donor anonymity will be history well before her child is 18, and how betrayed her child will feel if this is kept from her/him is not in anyone’s best interest.

 Not every child will want to find their donor, or will find the donor they seek, nor will all donors be discovered through searching. However the need for donor children to discover their biological origins will not cease. Our acceptance of these facts: 1) donor children will seek to find out their biology; 2) that donors will not be able to remain anonymous as the tide continues to shift; puts the responsibility on us to move the parents out of their shame and into embracing and sharing the fact that science made it possible for them to have the children they love so much. We can act to create an easy transition for them now instead of setting them up for a future with difficult truths emerging.

Sioux Oliva earned her Ph.D. in History from the University of Southern California. She is an historian in private practice doing family and estate history and history project management through her company, Legacy History. Sioux clients’ include Mrs. Robert F. Kennedy, the estate of Marilyn Monroe, Sally Quinn and Ben Bradlee, The Getty, The City of Los Angeles, and The Autry Museum of the American West. In 2005-2006, she worked for Growing Generations, which gave her experience in the world of assisted reproduction. DNA testing is part of her family history presentations and part of her proposals for clients due to the additional genealogical and historical information it provides.