• A recent report on the average age at first childbirth from the CDC’s National Center for Health Statistics showed that as of 2006, women in the US waited an average of 3.6 years longer to have their first baby, as compared to 1970.

• There is not enough discussion in our society about the effect of age on fertility.

• Women’s liberation is a good thing and women have made very significant advances over the past 40 years. Many women are pursuing advanced education and careers.

• However, there is a potential “disconnect” involved. Women are waiting longer to have children – but many are not educated about what that delay can do to their fertility.

These days, many couples try to have their first child when the woman is in her mid-to-late 30s. Some will get pregnant easily, and others end up needing fertility treatments. It is not uncommon for me to see a couple with the woman in her early or mid-40s who say that they had no idea that getting pregnant would be a problem. These are educated and intelligent people. Maybe they were not exposed to the right information about fertility and aging – or maybe they never paid attention to it.

• As the American Society for Reproductive Medicine has pointed out: “As women delay childbearing, there is now an unrealistic expectation that medical science can undo the effects of aging”.

• We try our to overcome the effects of age with advanced treatments such as in vitro fertilization. But IVF success rates decline significantly with advancing female age.

What causes fertility to drop with age?

• Success with fertility treatment using the woman’s own eggs is closely tied to her age.
• When using donor eggs, the recipient woman’s age is not important. It is then the egg donor’s age that matters.
• This tells us that the age of the egg is important and the age of the uterus is not.
• Because of declining egg quality, chances for successful pregnancy begin dropping in the early 30′s and usually drop faster in the mid-30′s (by about 36-37).
• For many women there is little or no fertility potential left by about age 40, and very few women over 43 are fertile.

Even with aggressive fertility treatment (such as IVF) success rates are very low by the mid-40′s. In 2006, the national average for live birth success rate in women over age 44 using their own eggs was less than 1% per attempt (CDC data). Miscarriage rates also increase significantly with advancing age.

Both the fertility decline and the increase in miscarriages are largely due to increased rates of chromosome abnormalities in eggs as women age. Research has shown that a structure called the meiotic spindle in the microscopic eggs in the ovaries becomes damaged with aging. The spindle is involved in organizing pairs of chromosomes for proper division into 2 sets during maturation of the egg. An abnormal spindle can cause disordered chromosome arrangements in the mature egg – and therefore in the embryo.

Can we test the quality or quantity of eggs in a woman?

Since we know that the issue causing fertility problems as women age is declining egg quality, it would help to have a test to check how good a woman’s eggs are. Unfortunately, there is not a good test for egg quality. A woman’s age is the best “test” for quality.

There are screening tests for “ovarian reserve”. However, these are tests of quantity rather than quality. Ovarian reserve tests include:

• Day 3 FSH and AMH levels – blood tests
• Ovarian antral follicle counts – determined by ultrasound.

Conclusions

• “Society” and the medical field should do a better job educating women about declining fertility with advancing age.

• If women are making a conscious choice to delay childbearing and understand the fertility implications – then at least they make a conscious choice.

• However, if they go to their doctor annually for a checkup – at some point (early to mid-30′s) there need to be discussions about declining fertility potential.

More information:

Age and Fertility

PGD – preimplantation genetic diagnosis (or PGS) – does it help to test the chromosomes of IVF embryos?

In Vitro Fertilization

Egg Donation

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

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• In June of 2008, Nadya Suleman was a single, unemployed mother of 6 children
• According to reports, she was receiving some “public assistance”
• All six of her children were reportedly conceived through in vitro fertilization
• All 6 kids were under 7 years old, including 2 year old twins

Then, she does IVF again

• In June of 2008, her IVF doctor transferred 6 frozen-thawed embryos to her uterus.
• Apparently, all six embryos survived – and 2 split into identical twins – so she ended up with eight fetuses growing in her uterus.
• Nadya declined having a fetal reduction procedure. Reduction can be done to selectively reduce the number of fetuses.
• The vast majority octuplet pregnancies would be expected to result in death of all fetuses after a severely premature birth.
• In her case the pregnancy progressed to viability. All 8 babies were born (prematurely) in January of 2009.
• This is apparently only the second living set of octuplets ever born in the United States.

Public debate rages

• Is she a fit mother?
• Should the fertility specialist have been willing to treat her at all?
• How many embryos should the doctor have transferred to her uterus?
• Should a physician that transfers that many embryos to a 33-year-old be sanctioned – or even lose his medical license?
• Why doesn’t the government pass laws to control fertility doctors?

Violation of guidelines of the American Society for Reproductive Medicine, ASRM

Her fertility physician has been identified as Dr. Michael Kamrava who practices in Beverly Hills California. The American Society for Reproductive Medicine is reportedly investigating Dr. Kamrava related to violating its guidelines on the maximum number of embryos to transfer. Although there are guidelines, there are not any laws in the US regulating the maximum number of embryos transferred.

The ASRM guidelines in place when Nadya Suleman had her IVF procedure said that the maximum number of embryos to be transferred to a woman under 35 years of age should be 1 or 2 depending on the specific medical issues. There was some wiggle room in the guidelines. Since they were frozen embryos, a max of 3 for transfer might also have been considered appropriate.

Comments from a fertility specialist

• Physicians, including fertility specialists cannot play god and judge who will be a “fit enough parent” to have fertility treatments.
• Patients undergoing fertility treatment desperately want children and can face huge financial burdens.

The costs of IVF treatment are substantial and although sometimes medical insurance in the US will cover fertility treatment and IVF, more often it does not. Therefore, patients often pressure fertility specialists to transfer more embryos with the hope that they will be more likely to be pregnant.

The ASRM guidelines on the maximum to transfer are appropriate. However, patients are sometimes unhappy about limitations on the number of embryos for transfer – particularly couples with financial difficulties due to IVF costs. For example, some couples will put a second mortgage on their house, max out credit cards, and borrow from parents.

As IVF success rates have increased over the years, the average number of embryos transferred to the uterus has declined. Some cases are now even having single embryo transfers (SET) by choice. This has become a more viable option with utilization of blastocyst embryo transfer which can result in better embryo quality and more control of multiple pregnancy risk.

However, although I have substantially increased the time spent discussing risks of multiple births (including twins), our rate of single embryo transfer is still low. Patients rarely accept single embryo transfer – even after hearing about increased risks with twins. Infertile couples fear failing to become pregnant at all more than they fear the risks to the babies from multiple pregnancies.

When will there be laws regulating the number of IVF embryos that can be transferred?

I think it unlikely that our government will pass laws regulating how many embryos can be transferred unless they also mandate insurance coverage for IVF treatments in order to relieve the financial burden for couples with fertility problems.

Conclusions

• The ASRM guidelines on the maximum number for transfer should be closely followed (whenever possible)
• In a case such as this, a maximum of 2 embryos should be transferred
• 6 embryos should never be transferred to a 33 year old woman – no matter what she says about accepting risks.

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

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The Society for Assisted Reproductive Technology (SART) released its version of the report on 2007 IVF cycles several months ago. However, clinics are not required by law to report to SART. They are required to report to the CDC. Therefore, the CDC report shows success rates for more clinics than the SART report does.

The CDC report covers data from 430 fertility clinics. Over 142,000 assisted reproductive technology (or IVF) cycles were done at these “reporting clinics”.

There were (as always) some fertility clinics that broke federal law and refused to report their data. These IVF clinics are referred to as “non-reporting clinics”. If fertility doctors will go so far as to break federal law to keep their IVF outcome statistics from the public – those “non-reporting clinics” most likely have very low success rates.

Before you choose a fertility clinic for IVF – check success rates.

Links to both the CDC and the SART IVF success rate reports

See our IVF success rates

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

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Learn about blastocyst transfer

Couples with infertility often need IVF to get pregnant.What should they know about IVF clinic success rates?

• An interesting and unusual aspect of IVF is that there is a definitive outcome for each procedure.
• When an IVF cycle is done there is a baby born from it – or there is not. Therefore, keeping track of (and comparing) IVF live birth success rates is very straightforward.
• Medical treatments in general rarely have such “black and white” outcomes.
• Another unique aspect of IVF is that (in the US) all IVF clinics are required by federal law to report their in vitro fertilization success rates annually to the government. The CDC, a US government agency produces a report called the “Assisted Reproductive Technology (ART) Report” detailing IVF success rates for all individual clinics.
• This report is commonly called the CDC IVF success rate report. It is released to the public on the web every year (usually in December or January).
• Another useful report, the SART report (Society for Assisted Reproductive Technology), is very similar to the CDC report – and it is released about a year earlier. However, clinics are not required by law to report to SART – so some clinics are not listed there.
• These 2 annual reports allow consumers to view and compare IVF success rates for reputable fertility clinics.

Common excuses used by fertility clinics with low success rates:

• “We take a lot of very difficult cases that clinics with high success rates turn away”
• “We take women with high FSH levels that will have low IVF success rates”
• “We have a high percentage of cases that have failed IVF multiple times”

What is wrong with these excuses?

• Few fertility clinics would turn away a significant number of couples because they are “difficult” cases with a low chance for success. Couples with fertility issues are savvy and would complain to their OB/GYN doctor, to their friends, etc.  The word would get out, and it would damage the clinic’s reputation.
• Also, most docs in this field believe in doing their best for every couple – regardless of their FSH level, etc. The goal is not to artificially “pump up” their own clinic’s success rates by excluding difficult cases.
• Patients that fail IVF and realize they have more significant fertility issues are the ones most likely to do internet research and compare IVF success rates.
• After failing IVF and then comparing success rates of numerous clinics, they are unlikely to choose a clinic with below average success rates for their next IVF cycle.
• The more IVF failures, the more motivation to seek a clinic with better success rates, even if it requires more travel.

Learn about what to do after failing an IVF cycle

Why do some IVF clinics have higher success rates?

• Why do some restaurants serve better food than others?
• Why are some models of cars more reliable than others?
• Because the work is done with precision and high quality control standards.  
• Expert and precise maintenance of quality control during the ovarian stimulation process, in the IVF laboratory, and during embryo transfer will maximize IVF success.
• We can’t do much (just good ovarian stimulation) to change the raw materials (eggs and sperm).
• However, we can work hard to expertly culture, select and transfer the best embryos.
• There are not any secrets involved in high quality IVF.
• It is not about patient selection.
• Some clinics work harder – and do better at getting it right.

How to improve success rates of IVF?

• Utilize the excellent resources on the CDC and SART websites.
  • Study in vitro fertilization success rates for fertility clinics in your area.
• You probably will have a better chance for success at a clinic with a high success rate.

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A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic.

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

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