Options Besides Donor Egg IVF

I made it back to DC from Boston, thanks for asking. However, the journey was not easy. I boarded my AirTran flight at 6:15pm and at 6:35 pm the pilot announced that the plane was grounded for mechanical problems. Not to worry, advised the gate agent....another plane would arrive and take us to Boston at 8:30pm. Having heard this story one time too many, I hopped on the internet (than you Verizon for my wireless modem) and saw that there was a JetBlue flight to Dulles leaving at 7:50PM. My wife and I discussed the options and decided that I would stick with AirTran....big mistake.

At 7:30 pm the gate agent announced that the plan that was supposed to take us to Dulles was grounded in Newport News and we would now hopefully depart around Midnight! I grabbed my laptop and ran for the JetBlue desk. They confirmed that there was a seat on the plane but that the plan was boarding as we spoke. The nice lady called the gate and they agreed to hold the plane while I ran through security. Mercifully, there was no line at the security checkpoint and I made it on board with 1 minute to spare. By 9:45pm I was home in Maryland! When I called AirTran they informed me that I was on board the earlier flight and could not figure out how I was calling them from the DC area! Still had to get my car at BWI, but no plan is perfect!

Sometimes the road to our destinations takes us places that we didn't anticipate or desire. Life is a journey that is filled with twists and turns. In many of our patients that path leads towards family building options that they had never really considered.

Clearly, most patients are not thrilled when their RE announces that the only option remaining is donor egg IVF or adoption. Such a recommendation represents the end of a dream for those patients who wished to be the genetic parents of a child. The good news is that clearly donor egg IVF is very successful for many patients. However, not all patients are willing to consider egg donation. PB was one such patient and her story is rather revealing.

PB had successfully conceived with IVF back in 2005 and delivered her daughter without complication. When she returned to her clinic in 2007 she anticipated a good chance of success as she was < 40 years old and had an IVF baby already. However, after 2 FET cycles failed she attempted another stimulated IVF. Unfortunately, her FSH was 20 and her stimulation was poor and the cycle failed. She was told that although she was 38 years old that donor egg IVF was her only option. A friend told her about Natural Cycle IVF and she came to see me to discuss her options.

Meanwhile, our enthusiasm for Natural Cycle IVF remained very high and we made the decision in December 2008 to consider offering this option to older patients and/or those with a history of poor response to IVF stimulation meds. PB enthusiastically chose this option and underwent Natural Cycle IVF. She conceived on the 2nd attempt and is now >23 weeks pregnant. Needless to say, we were all thrilled for her and for the chance to offer another option to those patients who are not ready to pursue donor egg IVF.

We call this our IVF Hope Program to distinguish it from our standard Natural Cycle IVF Program (as we anticipate that the chance of success will be much lower in these patients who are looking to pursue a non-egg donor option). Interestingly, the use of Natural Cycle IVF in poor prognosis patients was the subject of a recent paper in Fertility and Sterility (see below). In this report, an Italian IVF clinic performed Natural Cycle IVF on those women who had failed to respond to fertility shots in THEIR OWN CLINIC! So clearly this was by any definition a group of low responder patients. Amazingly, their Natural Cycle IVF delivery rate was very good (all things considered) even in the older patients! At the Journal Club, Dr. DiMattina was placed in the position of defending Natural Cycle IVF while many of the other REs in attendance ridiculed the paper...even going so far as to physically rip the article into tiny shreds! Unfortunately, I was in Atlanta trying to convince my son to attend Georgia Tech and could not assist DrD in his defense of Natural Cycle IVF.

I think that patients should be allowed to make choices about their fertility treatment. Natural Cycle IVF is simply another choice. It does not work as well as stimulated IVF in good prognosis patients. It may be equally effective compared with stimulated IVF in poor responders...and may be the only ART option open to such patients who have failed to respond to stimulation previously. For those patients open to donor egg, donor embryo or adoption the role of Natural Cycle IVF is less clear as all those options work better so I would encourage patients to build their family through those means. However, some patients are not comfortable with Donor Egg/Embryo or adoption so for these patients a program such as the Hope IVF Program allows them to pursue another path.

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Wanted: Egg Donor

So here I am sitting in Logan International Airport trying to kill some time before heading back to DC and hoping that I don’t catch Swine Flu. I was in Boston all day to attend a special ceremony honoring my father, Dr. Edward Gordon, who just retired from active clinical practice at the age of 86 and ending 60 years of continual practice as a general surgeon. All three of his sons were in attendance as he received several commendations for his contributions to medicine. Following these presentations, Dr. Pauline Chen gave a very emotional presentation including a reading from her NYTimes best-selling book Final Exam. I asked her for some hints as to how to get our book higher up the best-seller list but she was at a loss….Oh well.

What does all this have to do with infertility? Nothing. Just thought my patients may want to know where I was on a rainy Friday in Virginia. If you don’t care where I was then please accept my apologies but no one’s forcing you to read this blog anyway (although I pay my kids 5 cents per click to help my Google ranking).

This has been a week full of third-party reproduction questions. Egg donation, sperm donation, embryo donation, gestational carrier, gestational carrier with egg donation vs. embryo donation….etc, etc. If you can think of an usual way to have a child, chances are that someone has already tried that. Every year I get a couple of questions regarding daughter to mother egg donation. Adult daughter from first marriage wants to help mom have a baby with 2nd husband. If successful this makes husband #1 the grandfather of baby born to patient and husband #2. This is not as newsworthy as Octomom but most clinics will not perform this type of egg donation. The reason usually given (and I concur) is that children wish to please their parents and that makes Informed Consent without coercion impossible. Plus it just seems “yucky.”

So how do we even do egg donor IVF in the first place? This is the topic of today’s excerpt from 100 Questions and Answers about Infertility (which could use some more positive reviews on Amazon.com BTW!).

82. What are egg donors, and how is donor egg­ IVF performed?

Donor egg-IVF involves the use of healthy female egg donors who are usually in their twenties. Most donor arrangements are anonymous, although known donor egg IVF is possible. In the latter case, the known donors are usually family members or friends. In our experience, most of our patients prefer to use an anonymous egg donor to avoid family and interpersonal conflicts. Most medical practices recruit egg donors for their patients, but third-party agencies are also available that act as brokers. The American Society of Reproductive Medicine (ASRM) has developed a set of egg-donor screening guidelines, which most practices utilize for screening donors. The guidelines encompass comprehensive screening for infectious and genetic diseases, physical examination, and psychological testing.

Since May 2005, the U.S. Food and Drug Administration (FDA) has mandated extensive infectious disease testing while screening all anonymous egg and sperm donors. The actual treatment cycle for donor-egg IVF essentially combines a fresh IVF cycle (the donor) and a medicated FET cycle (the recipient). The two treatment cycles are synchronized by using GnRH analogs. Usually, the recipient begins estrogen therapy 5 days prior to the start of the egg donor’s stimulation so as to provide an adequate time frame for the recipient’s endometrium to grow and thicken. After 10 to 14 days of stimulation, the donor receives an injection of HCG (Pregnyl, Profasi, Ovidrel) to mature her eggs. On the same day, the recipient starts progesterone therapy to create a receptive endometrium.

Because most egg donors are young, they tend to respond very well to the ovarian stimulation drugs, producing many high-quality eggs and embryos. Implantation rates with these embryos are also very high, so that usually only one or two embryos are transferred to the recipient. Pregnancy rates usually exceed 50% per initiated cycle, making donor-egg IVF the most successful therapy currently available for infertile couples. Usually, extra embryos that were not transferred can be frozen and stored for later transfer, with excellent pregnancy rates achieved in subsequent conception attempts.

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