IVF limits for older women could lead to the mother of all battles

Dr. Rakoff — Fri, 11 Nov 2011 05:00:13 +0000

Susan Tollefsen, with her ex-partner Nick and daughter Freya Lucia. Picture: Daily Mail Source: the Daily Telegraph

JUST because you can have children doesn't mean you should have them.

A British woman has shocked many by admitting she should not have had a baby at 57.

The retired teacher fell pregnant using IVF, becoming Britain’s oldest first-time mother. her daughter, Freya, was conceived using sperm from her partner, Nick – who was 11 years younger – and a donor egg. Do you agree? Blog with Susie all day at the Big O

The woman, Susan Tollefsen, is now separated from Nick, and believes there should be an age limit of 50 for IVF treatment for women, she told the UK Daily Mail this week.

As she admitted, she realises now that her time is running out, and she wishes she was younger so she could watch her daughter grow up, get married and have children of her own.

It’s an astonishing admission from someone who fought so hard to become a later-life mother, and who has been a pin-up girl for the birth-at-any-age movement. Just a year ago she was saying she was "full of life and healthy at 60" and wanted another child.

But 18 months on, she now admits that she may be too old to be a first-time mum.

It’s a message that many could do well to listen to. Just because technology enables us to become mothers at 57, it doesn’t mean it’s a good idea.

As a mother of three, I am not about to deny anyone else the right to have a child of their own. but there is a limit.

And I think Tollefsen is probably right: 50 is about the oldest you’d want to be. Do the maths. You’ll be 60 when they turn 10, 71 at their 21st, and dropping off the perch by the time they have kids of their own.

And the older you get, the more health risks both mothers and babies face.

Of course, it’s always worth noting that no one jumps up and down when men have children in their 60s and 70s, even though elderly sperm brings problems of its own.

The issue is that the reproductive technology available to us today enables us to have children for many more years than many people in society think is actually appropriate.

In most cases it’s a good thing, but some people, like Tollefsen, take advantage and just go too far.

Having children is not a right that should be granted to just anyone, regardless of their circumstances.

However, it’s important to note that most women who give birth later in life do not do so out of choice.

Yes, there are some women who leave their childbearing to their 40s, choosing to spend their 20s and 30s partying and getting promoted at work. Let’s face it, this is what a lot of men do without anyone passing judgment.

But, as research released this week shows, most women who are childless are simply waiting until they have met Mr right, or until they have enough money, or can buy a house of their own.

A study, published in the Journal of Population Health, found just 20 out of 569 women – 3.5 per cent – aged 30 to 34 are childless by choice.

This is precisely why I am sympathetic to the plight of older mothers. many of my friends who gave birth for the first time in their 40s did so after spending a decade on IVF programs, or after waiting for years to meet the right man.

Most would have loved to be a younger mother, but it just wasn’t to be.

In any case, even with the vast improvements we have in assisted reproduction, there are still relatively few women giving birth over 44.

Figures released this week from the Australian Institute of Health and Welfare shows that only one woman in 100 over the age of 44 using assisted reproduction delivers a live baby. this is despite the fact that one in four women using IVF or other fertility technology is aged 40 or over. Let’s keep things in overall perspective, though.

The average age of Australian mothers is 30.7, and Australian fathers 33.1, according to the Australian Bureau of Statistics. And both figures are relatively static.

So there’s no need to merge the childcare centres and old folks’ homes just yet.

Could IVF Study Mean End of Multiples?

Dr. Rakoff — Wed, 09 Nov 2011 05:00:13 +0000

The end of an era is upon is, ladies. no more Octo-mom, no more Kate plus 8, and no more risky pregnancies for a huge number of IVF pregnancies. at least if other fertility clinics follow the lead at the University of Iowa where a study found that today women under the age of 38 have just as good of a chance of getting pregnant using one embryo in the transfer as multiple embryos.

Unless you’re one of those people who dream about having twins, triplets, or even more, this is fantastic news. after all, women carrying multiples are at an increased risk for diabetes, having premature babies, or babies born with cerebral palsy. Cutting down these risks for women who are already under bodily stress is an admirable goal. so let’s hope fertility clinics embrace this idea, and we can all stop looking at moms of twins and wondering what the story is. you know, if you do that sort of thing.

It wouldn’t be completely unreasonable, since while IVF only accounts for 1 percent of the births in America, it accounts for 17 percent of the multiple births. so when you’re seeing more twins at your pre-school, you would be excused for assuming some of them were the result of IVF. I’m usually wondering how much sleep parents of multiples are getting, but that’s just me.

I happen to know a large number of moms who came by their twin babies naturally. or rather, it was in the family. “Naturally” is a loaded term these days, isn’t it? It seems those twin genes are hardcore, or at least they have been in my experience. so while we will still see twins, and even the occasional triplet, the days of mega multiples should end.

Of course that’s assuming fertility clinic physicians act ethically. and we know not all of them do that when given the opportunity to super-size a lady’s womb. But now, at least, we’ll know which doctors are the quacks and which ones have mom’s and baby’s best interests at heart.

Do you think this policy should be used at every clinic?

Image via Dan Bock/Flickr

Bourn Hall eyes first Dubai IVF clinic in Q1 2012

Dr. Rakoff — Fri, 28 Oct 2011 04:00:15 +0000

World renowned Bourn Hall Clinic will open its first in vitro fertilisation (IVF) centre in the Middle East and North Africa region in early 2012.

The IVF pioneer said in a statement that its expansion into the region would see a facility open in Dubai’s Sheikh Hamdan Centre, Jumeirah.

The 22,000 sq ft Bourn Hall Clinic is set to welcome the first patients in early 2012 and has the capacity to treat about 50 couples per day, at various stages of their treatment, it added.

The Dubai facility will feature a state of the art laboratory complex, the first of its kind in the GCC, where couples can view lab procedures taking place through a specially integrated viewing area.

It will also include operating theatres, inpatient and outpatient rooms.

Bourn Hall Clinic is synonymous with IVF on a global scale and pioneered most of the standard treatment protocol procedures adopted worldwide.

Over 11,000 babies have been born following treatment from the UK centre alone.

Known as the father of IVF, Professor Robert Edwards co-founded the world’s original IVF clinic at Bourn Hall Cambridge in 1980 after pioneering the first birth of a child conceived using IVF in 1978.

Karen Mohring, general manager, Bourn Hall Clinic Dubai, said: “We have designed the Dubai facility to be a world leader in terms of the environment in which eggs, sperm and embryos are nurtured.

“We will offer a comprehensive range of advanced infertility treatments which are fully Shariah compliant and our plan is to help 2,000 couples per year to achieve parenthood.”

At capacity, Bourn Hall Clinic plans to have seven embryologists, six consultants and 14 nurses specialising in IVF treatment.

Government and private hospitals in the Gulf are expected to open more IVF centres this year, to cope with soaring demand for the treatment among infertile couples, experts said in September.

Healthcare operators and government agencies are thought to be expanding their existing offerings or opening new centres, to deal with increasing infertility rates in the region, healthcare analysts said.

“The Middle East is host to a booming and high-tech Assisted Reproductive Technique (ART) industry,” said Sandeep Sinha, the deputy director of healthcare for the Middle East at consultancy Frost and Sullivan.

“Governments of Middle Eastern countries are opening up IVF facilities in their existing set up hospitals and few are coming up with collaboration with private facilities.”

Clinics expected to open this year include a new IVF centre at Tawam Hospital in Al Ain, which has already assisted in the births of 1,000 babies since 1990, and Lifeline Hospital Group’s new Burjeel Hospital in Dubai, set to offer pre-implantation genetic diagnosis.

NEWS: ESHRE Defines Poor Response to Ovarian Stimulation

Dr. Rakoff — Fri, 23 Sep 2011 04:00:13 +0000

The lack of clear consensus on the definition of poor ovarian response (POR) in ART has made it difficult to compare results of various studies conducted to improve ovarian response; in turn hindering the identification of poor responders and selection of an optimal ovarian stimulation strategy. In a first realistic endeavor, the European Society of Human Reproduction and Embryology (ESHRE) working group proposed a standardized, simple, and reproducible definition for POR. The ESHRE consensus is published in the recent issue of the journal, Human Reproduction.

On behalf of the ESHRE working group, Anna Pia Ferraretti from the S.I.S.me.R Reproductive Medicine Unit, Bologna, Italy, and coworkers, arrived at a consensus on the definition of POR, and recommend that at least two of the following must be met to consider patients as poor responders:• Advanced maternal age or presence of other risk factors of POR• History of POR• Abnormal ovarian reserve test (ORT)

Apart from the above three criteria, the ESHRE group suggested the following:• Patients can be considered as poor responders following two POR episodes after maximal stimulation, if advanced maternal age or abnormal ORT is not a factor.• Although one stimulated cycle is necessary for diagnosing POR, patients with advanced age or abnormal ORT may be categorized as poor responders, as both the factors suggest the possibility of decreased ovarian reserve, and therefore serve as markers of stimulation cycle outcomes. Such patients should be classified as ‘expected poor responders’.

The Group indicated that such a comprehensive criteria will help researchers select a homogenized population for future studies, and lower bias due to spurious POR definitions; thus facilitating the comparison of results for obtaining accurate conclusions.

Several studies have attempted to arrive at an objective definition of POR. In one such study, Kailasam et al (Human Reproduction, 2004) proposed the inclusion of the degree of ovarian stimulation in the definition of POR during IVF cycles in women 3,000 IU FSH cumulative dose to obtain sufficient follicles. Cancellation at ≥300 IU FSH/day is linked to a substantially worse prognosis and was also considered as a criterion to define POR. The scientists indicated that their findings may help in the development of a standardized definition for poor response.

With the absence of uniform criteria for defining POR, the recent consensus could assist both clinicians and researchers improve ovarian response and treatment outcomes, as well as develop and evaluate protocols for its prevention and management.

1. Ferraretti AP, La Marca a, Fauser BC, et al; ESHRE working group on Poor Ovarian Response Definition. ESHRE consensus on the definition of ’poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum Reprod. 2011 Jul;26(7):1616-1624.

2. Kailasam C, Keay SD, Wilson P, Ford WC, Jenkins JM. Defining poor ovarian response during IVF cycles, in women aged Hum Reprod. 2004 Jul;19(7):1544-7.

How much do fertility clinics charge for the first and subsequent attempts of IVF in Brisbane?

Dr. Rakoff — Tue, 30 Aug 2011 04:00:13 +0000

I believe the costs differ for each case, but i'm just interested in an approximate fee. I don't have private health insurance and am well aware IVF may be means tested. Please state the name of the clinic/s.

im afraid youll have to call the centres.

$10,000 K+ for each cycle in USA

How much do fertility clinics charge for the first and subsequent attempts of IVF in Brisbane?

IVF Tutorials – IVF – Embryo Development

Dr. Rakoff — Wed, 04 May 2011 04:00:07 +0000

Oocyte (Egg) stages

Germinal Vesicle (Immature)

The germinal vesicle, indicated by the arrow, shows this egg to be in prophase I of the first meiotic division.

(Please note that eggs and embryos are usually surrounded by a layer of corona cells, these look like a halo around the egg when spread out. the cumulus cells spread out even further and generally have the appearance of a fluffy cloud. the cumulus can often be seen without a microscope. the egg together with these cells is sometimes called the oocyte-cumulus-corona cell complex. in many of the pictures below the cumulus and coronal cells have been removed leaving the bare egg/embryo. the cumulus and coronal cells are either removed prior to ICSI so maturity can be assessed and so a good seal can be achieved between the egg and the ICSI holding pipette. the enzyme used to remove the cumulus and coronal cells is Hyaluronidase. in the case of conventional insemination – sperm added to the media and allowed to penetrate the egg naturally – the cumulus and coronal cells are digested by the sperm and the remaining cells are removed when checking for fertilisation)

Metaphase 1 (Immature)

The germinal vesicle is no longer visable and a polar body has not yet been extruded.

Metaphase 2 (Mature)

In these pictures we can clearly see a polar body as indicated by the arrow. the polar body is a sign that the egg has reached metaphase 2 in it’s development, and that the egg is mature and ready to fertilise with either conventional insemination techniques (adding sperm to the media surrounding the egg) or ICSI (injecting a sperm directly into the center of the egg).

Embryo Stages

2PN Stage (Normal Fertilization – day 1 after insemination)

Below we can see a normally fertilised egg. the arrow indicates the two circles (pronuclei) containing small dots (nucleoli). One of the pronuclei contains genetic information from the egg the other from the sperm. It is thought that polarity of the pronuclei and even distribution of the nucleoli between the two pronuclei indicates the potential quality of the developing embryo. the pronuclei are usually checked between 16-18 hours after the sperm is added to the egg.

The 2PN will eventually disappear with the union of two gametes this is known as Syngamy. the zygote is now on it’s way to become an embryo.

Day 2 after insemination (2 – 4 Cell Embryo)

24 hours after the 2PN were seen the embryo has already started to divide.Blastomeres often divide evenly,although asynchonously, so it is not uncommon for embryos to have an odd number of cells and uneven blastomeres. we can also see various indicators of poorer quality in the embryo such as fragments or multinucliation of blastomeres.

Day 3 after insemination (8 Cell Embryo)

Approximately 72 hours after the eggs were first inseminated they will usually have reached around the 8 cell stage. in the IVF program it is common to transfer the best of the embryos from a treatment cycle back to the uterus at this stage. if the patient will be having preimplantation diagnosis to test the genetic makeup of the embryo, the biopsy (removing a cell from the embryo to test) will usually be performed on this day.

Day 4 after insemination (Morula)

The embryo continues to divide, and there is increased cellular adhesion until the distiction between the blastomeres becomes difficult to see. the embryo at this stage is called a Morula.

Day 5 after insemination (Blastocyst)

The morula will continue to develop and start to cavitate. the embryo begins to turn into a hollow ball of cells known as a blastocyst. the blastocyst consists of two main parts an area denser with cells called the inner cell mass (ICM) which will eventually form the fetus, and the trophectoderm which will go on to be the placenta. the picture shows two blastocysts, the one on the left is an expanded blastocyst, the one on the right has expanded and is hatching from the shell (zona pellucida) and is getting ready to implant.

IVF Tutorials – IVF – Embryo Development

Dr. Jeff Rakoff, Formerly, Director Fertility Center of Scripps Clinic

Dr. Rakoff — Wed, 16 Mar 2011 22:23:12 +0000

IVF, Infertility, Dr. Jeff Rakoff, Formally Director Fertility Center of Scripps Clinic

Anxiety, depression may not hinder IVF success

Dr. Rakoff — Sat, 12 Mar 2011 05:00:10 +0000

NEW YORK (Reuters Health) – Among women undergoing fertility treatment, symptoms of anxiety and depression do not seem to reduce their chances of becoming pregnant, a new study suggests.

The findings, say researchers, should offer women some reassurance that such psychological symptoms do not have a strong effect on in vitro fertilization (IVF) success.

The multicenter study enrolled 783 Dutch women having their first fertility treatment. the women were asked to complete a questionnaire to assess anxiety and depression symptoms when they were put on the waiting list, 1 or 2 months before the procedure, and 1 day before the treatment.

A total of 421 women had complete information available for analysis. Overall, anxiety and depression symptoms were unrelated to the odds of becoming pregnant. These signs of psychological distress were also unrelated to the cancellation rates.

The findings do not minimize the importance of psychological well-being in women having IVF, the researchers report in the journal Human Reproduction. Studies show that many women suffer anxiety and depression after a failed IVF attempt, and research is still needed to see how to best identify and treat these women.

What’s more, "stress" should be considered a "wide concept," and this study did not look at all the forms stress can take — or the possible impact on IVF success, explained lead researcher Dr. Bea Lintsen of Radboud University Nijmegen Medical Center in the Netherlands.

Still, Lintsen told Reuters Health, "the message can be reassuring.

The chance of pregnancy seems not be influenced by anxiety or depression."

Some past studies have linked psychological distress to a lower likelihood of IVF success, while others have found no such connection. this study, according to the researchers, appears to be the largest one to date to look at this relationship.

They point out, however, that further large studies are needed to "reveal more information about the interrelationship between emotions and fertility."

For now, Lintsen said, it’s possible that counseling women that there is a low likelihood that depression or anxiety symptoms will harm their IVF success may actually improve their mental health.

SOURCE: Human Reproduction, January 29, 2009.

Anxiety, depression may not hinder IVF success

First IVF Babies Born Using New Chromosome Counting Technique

Dr. Rakoff — Fri, 25 Feb 2011 05:00:08 +0000

ScienceDaily (Feb. 7, 2011) — The first babies have now been born in the UK using a new technique pioneered at Oxford University to select the best embryos for IVF. The advance could bring hope to many British couples struggling to have a child and going through many cycles of IVF treatment.

George and Helen Ashton from Gloucestershire are thought to be the first couple to have babies in the UK after using a technique called microarray CGH with IVF embryos five days after fertilisation.

The technique allows the embryos to be checked for the right number of chromosomes before implantation in an IVF treatment, lessening the chance of miscarriage or Down’s syndrome.

The Ashtons had twins last November following treatment at the Oxford Fertility Unit, an independent IVF clinic which maintains strong research partnerships with the University. The boys, Alex and Louis, are now 11 weeks old.

The strategy of applying microarray CGH, or comparative genomic hybridisation, to five-day-old embryos, or ‘blastocysts’, was developed by Dr Dagan Wells and Dr Elpida Fragouli at the University of Oxford, with funding from the Oxford Biomedical Research Centre and in collaboration with partners in the health services and industry.

‘If a sperm and egg come together and produce an embryo with the wrong number of chromosomes, the embryo will usually fail to establish a pregnancy or miscarry,’ explains Dr Dagan Wells of the Nuffield Department of Obstetrics and Gynaecology.

As with routine IVF treatment, several eggs are produced and fertilised. Five days later at the blastocyst stage, a small number of cells are removed from the growing embryo and microarray CGH is used to check for any significant abnormalities present in the chromosomes. in effect it scans the DNA packed up in the cells’ chromosomes for any clear problems. Results are available 24 hours later.

Based on this information, it is possible to make sure that only embryos with the correct number of chromosomes are transferred in IVF, improving pregnancy rates as a result.

The Ashtons had first tried IVF in 2004 and had had five unsuccessful IVF cycles. they were told that it was probably down to bad luck and poor embryo selection, so the couple went to the Oxford Fertility Unit and had their embryos tested using microarray CGH.

"We were of the opinion that this was going to be our last go,’ Mr Ashton said. ‘Array CGH has been a godsend to us — but the big issue is that not many people know about it."

There have been other couples who have given birth to babies after receiving this treatment in Oxford, and a couple from Lancashire had a baby shortly after Christmas after opting for a closely related technique at a Manchester clinic.

Tim Child, director of the Oxford Fertility Unit and a senior fellow at the Nuffield Department of Obstetrics and Gynaecology at Oxford University, said: "We are proud that Oxford Fertility Unit was the first clinic in the UK to use blastocyst chromosome screening successfully. We have a number of couples who have already given birth to babies using this method and we look forward to helping many more."

An ongoing study by Dr Wells and colleagues, part of which was published in the journal Fertility and Sterility last year, has revealed that pregnancy rates after chromosome testing were increased by more than 50% in a group of 200 American patients undergoing IVF treatment. Other studies by the Oxford University group have shown microarray CGH has an accuracy of greater than 95% for detecting abnormal embryos.

Dr Wells says: "for IVF treatment there are two problems. Firstly, many of the embryos produced in a typical IVF cycle have the wrong number of chromosomes or significant chunks of DNA missing or duplicated. secondly, the usual assessments done in an IVF clinic, which involve looking at embryos under the microscope to see how they are growing, cannot distinguish embryos with lethal chromosome problems from those that are healthy.

"The method we have developed allows us to identify which embryos have the correct number of chromosomes. These embryos should have the best chance of producing a baby and the lowest chances of miscarrying or having Down’s syndrome."

Dr Wells does caution that a randomised clinical trial is necessary to be able to say exactly how much benefit microarray CGH provides in reducing the risk of miscarriage and Down syndrome and in improving IVF success rates, and further clinical studies are needed to reveal which patients will benefit the most. there is evidence, however, that couples who have experienced several miscarriages may benefit from this type of testing.

The technique is available now — a company Reprogenetics now provides the test to multiple IVF clinics in the UK — but adds an extra £2,000 on top of the cost of an IVF cycle. The hope is that new innovations being developed at the University of Oxford will lower prices further in the near future.

"in the long run, this could actually save the NHS money," says Dr Wells, "as well as reduce the emotional and physical stresses suffered by couples who often have to undergo multiple cycles of IVF treatment in order to have a child."

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The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by University of Oxford.

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First IVF Babies Born Using New Chromosome Counting Technique

How many ivf cycles did you have to have success?

Dr. Rakoff — Sat, 19 Feb 2011 05:00:13 +0000

I am 37 and think that my cycle of ivf has been unsuccessful. I had bleeding on sunday and monday. the embroyo transfer was on November 30. I have one frozen embroyo left. I am just curious on other womans experiences.

Sorry to hear that it was unsuccessful for you this time.

Try to keep positive and also try to relax once you've had the next transfer. sometimes giving yourself a break for a month or two can help. You're 37 so you still have time on your side and if it doesnt work then you can always do another complete cycle.

We did two IVF cycles. the first one resulted in a chemical pregnancy and the second cycle (in November) was successful! I'll be 6 weeks on Wednesday so I'm really, really hoping this one sticks. We didn't have any frozen embryos left after either cycles. I have to say, I didn't think this cycle was successful and figured I would "just know" if I was pregnant. well, I was wrong! keep your chin up and stay positive! I know, easier said than done. I really hope this works for you… IVF is such an emotional rollercoaster.

I was 34 and my husband was 36 – our diagnosis was unexplained infertility. After 4 cycles of Clomid, 3 with Clomid, IUI and HCG trigger shot, 3 IUI cycles with injectibles that all ended in failure . . . we moved onto IVF and were blessed on our first cycle. Our twins will be 16 months old the day after Christmas.

Good luck and loads of baby dust to you!

My wife was 40 and I was 41. Other than minor cysts (that were removed), most of the issues were on my side (low sperm count and no motility). We opted for ICSI IVF.

We were lucky enough to get five embryos with three with real potential. We succeeded on the first try.

My wife had minimal issues with fertility, and, at 40, amazed the doctors with the number of good eggs she produced. the health of her reproductive system may have helped with the success.

Best of luck and keep positive.

I have gone through 2 rounds of ivf. the first failed, the second took. neither cycle left us with any frozen. I was 28 and my husband was 35 and our problem is my husbands' sperm count. We transferred 3 great quality embryos each time, but the second time we did assisted hatching and ended up with twin boys.
Just remember to try to stay positive because I really think that helps. I hope you're wrong about your transfer but if not, keep trying. one day it will be your turn! Good luck!

I have been trying to concieve for 3.5 years . We have been doing IVF for 2 years -2 natural clomid, I IUI, 5 stimulated cycles, 5 fresh embryo transfers and 2 frozen and no success yet!! I am now 38.

Just have to keep going ! I believe it will happen one day .Good luck x

My first IVF took had a baby boy, He was born to early. He lived for four days. nothing to do with Ivf. I am in my second cycle of ivf. I had bleeding the first time. It's called implation bleeding. You have to keep on trying.

How many ivf cycles did you have to have success?