The following article is an excerpt from the new book A Baby at Last!, written by Zev Rosenwaks, MD, Director and Physician-in-Chief of the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at the Weill Cornell Medical Center, Marc Goldstein, MD, Director of the Center for Male Reproductive Medicine and Microsurgery and Surgeon-in-Chief of Male Reproductive Medicine and Surgery at Weill Cornell Medical Center, and health and medical writer Mark L. Fuerst.
When to Do In Vitro Fertilization
Almost a quarter of a million babies are born each year through assisted reproductive technology (ART) procedures, and nearly 4 million babies have been born worldwide using a remarkable technique that combines sperm and eggs outside the body, known as in vitro fertilization (IVF). This ART procedure retrieves multiple eggs, mixes them with sperm in the laboratory, and the embryos that grow in a special culture media are then implanted into the uterus.
More than 115,000 IVF treatment cycles are performed in the United States each year, and this figure continues to grow at a steady pace. An IVF cycle costs between $10,000 and $15,000 and, on average, a woman requires more than one cycle to achieve a pregnancy. For each cycle, a woman undergoes hormone injections to stimulate her ovaries, the eggs are fertilized outside the body, and the resulting embryos are then transferred back into the uterus with the hope that an implantation will occur several days later.
About half of all women under age 35, 40% of all women who are 35 and 36, and one third of women who are 37 through 40 will have a baby after a single IVF transfer at Weill Cornell.
Candidates for IVF
Couples who require IVF treatment fall into many categories. No matter what the cause for their infertility, if conventional treatment has not resulted in a pregnancy, they become candidates for IVF.
Candidates for IVF include couples with tubal factor infertility; couples where the male partner has severely compromised semen parameters (decreased sperm density, motility and/or morphology); when the man has no sperm in the ejaculate, due to either an obstruction or poor or no sperm production; women of advanced maternal age and diminished ovarian reserve; women with untreatable endometriosis; couples with unexplained infertility or antisperm antibodies; and even couples who carry genetic abnormalities and do not want to pass this on to their children.
IVF was originally devised to bypass the need for a healthy fallopian tube, where the sperm and egg normally meet for fertilization. Currently, when a woman has obstructed tubes or scaring around her fallopian tubes, her options are surgery or IVF. If a woman is older than 35 or if she has had unsuccessful tubal surgery, Dr. Rosenwaks generally recommends IVF as the best treatment. However, a sterilization reversal using microsurgery to reconnect the fallopian tubes may be the best choice for a woman under age 35 who has had a sterilization procedure, who has a normal ovarian reserve, wishes to have more than one child, and has an adequate amount of tube left to repair. For all other women with tubal infertility, IVF may be a better option because it doesn’t require general anesthesia or major surgery.
The severity of a man’s infertility dictates the best treatment. If he has at least 5 million active sperm, Dr. Rosenwaks generally recommends intrauterine insemination (IUI) either in a natural cycle or with ovarian stimulation (superovulation) of his female partner. If the couple doesn’t achieve a pregnancy with IUI or the man has less than 500,000 active sperm, then Dr. Rosenwaks recommends IVF with intracytoplasmic sperm injection (ICSI).
As noted above, a woman’s age, as well as her ovarian reserve, which reflects the biologic age of her ovaries, is critical to determining her fertility potential. To get a sense of a woman’s ovarian reserve, Dr. Rosenwaks measures her blood levels of follicle-stimulating hormone (FSH), estradiol, and anti-mullerian hormone (AMH) levels on day 3 of her cycle. A high FSH level indicates a woman has a diminishing ovarian reserve and suggests she may need more aggressive treatment. AMH levels can be used to confirm the diagnosis; low levels denote poor ovarian reserve. A clomiphene challenge test can help confirm a diminished ovarian reserve. No test result should absolutely eliminate or preclude treatment. Dr. Rosenwaks encourages women of any age with diminishing ovarian reserve as well as women age 36 and older to have an IVF procedure sooner rather than later.
When endometriosis does not respond to medical or surgical treatments or a woman is age 35 or older, then IVF should be the couple’s treatment of choice.
Couples with unexplained infertility who do not get pregnant during several cycles of superovulation plus IUI are often quite successful with an IVF procedure. The IVF procedure allows Dr. Rosenwaks to evaluate sperm and egg interaction directly and also to evaluate the quality of the embryos. In fact, couples with unexplained infertility have higher pregnancy rates with IVF than couples in which the woman has a tubal problem.
Antisperm antibodies can be managed with IUI, IVF, or ICSI. IUI plus superovulation is the least expensive option but does not work as well as IVF or ICSI. IUI may be successful when levels of antisperm antibodies are low. Dr. Rosenwaks recommends IVF when the woman has antisperm antibodies in her blood or her cervix or when a man has more than 50% of his sperm bound with antibodies. Couples with antisperm antibodies who undergo IVF have the same success rate as those without antibodies. ICSI is the most expensive of these procedures, but it has the highest success rate because the direct injection of sperm into the egg completely bypasses any antibody problems either in the female or male.
Fertility specialists now have the ability to examine embryos in the laboratory before they are implanted. This has expanded the uses of IVF technology to help avoid the transmission of some genetic disorders. Preimplantation genetic diagnosis (PGD) can identify chromosomal abnormalities related to a woman’s advancing age from a single cell removed from a three-day-old embryo, as well as detect specific genetic defects such as cystic fibrosis and sickle cell anemia.
Technological advances such as these, along with ever-improving IVF techniques, make it possible for more women than ever before to have babies at last.