New Hope Fertility

Welcome

I'm Dr. John Zhang, Founder and Medical Director of New Hope Fertility.  As the field of reproductive endocrinology changes rapidly, I have decided to start a blog in order to create a dialogue with my patients, prospective patients, and the community about fertility and related issues.  I hope this will be a place to find helpful information, and to ask questions and add your comments.  You can also find more material and contact information at our website:  www.newhopefertility.com.

Please bear in mind that the information here is intended as educational and is not a substitute for medical or other professional advice and services from a qualified healthcare provider familiar with your unique issues.  Always seek the advice of your physician or other qualified healthcare provider regarding any medical condition and before starting treatment.

ASRM's New Guidelines

As some of you may have heard or read about, the ASRM (American Society for Reproductive Medicine) has recently issued new guidelines with regard to the number of embryos that should be transferred in fresh and frozen cycles. The new guidelines are as follows:

 

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For patients under the age of 35 who have a more favorable prognosis, consideration should be given to transfering only a single embryo. No more than two embryos (cleavage stage or blastocyst) should be transferred.
For patients between 35 and 37 years of age who have a more favorable prognosis, no more than two cleavage-stage embryos should be transferred. All others in this age group should have no more than three cleavage-stage embryos transferred. If extended culture is performed, no more than two blastocysts should be transferred to women in this age group.
For patients between 38 and 40 years of age who have a more favorable prognosis, no more than three cleavage-stage embryos or two blastocysts should be transferred. All others in this age group should have no more than four cleavage-stage embryos or three blastocysts transferred.
For patients 41–42 years of age, no more than five cleavage-stage embryos or three blastocyts should be transferred..
In each of the above age groups, for patients with two or more previous failed fresh IVF cycles or a less favorable prognosis, one additional embryo may be transferred according to individual circumstances. The patient must be counseled regarding the risks of multifetal pregnancy. Both the counsel- ing and the justification for exceeding the recommended limits must be documented in the patient’s permanent medical record.
In women >43 years of age, there are insufficient data to recommend a limit on the number of embryos to transfer.
In donor egg cycles, the age of the donor should be used to determine the appropriate number of embryos to transfer.
In frozen embryo transfer cycles, the number of good-quality thawed embryos transferred should not exceed the recommended limit on the number of fresh embryos transferred for each age group.

 

 

We commend the ASRM for issuing these guidelines, and hope that clinics all over the country will adhere to them, without regard for statistics.  At NHF,  we have followed even stricter parameters since we opened our doors in 2004.  Our focus is on producing few embryos of the highest quality,  with the hope of reducing multiple pregnancies for women in all age categories.

 

Please read our post from October 12 with regard to reducing multiple pregnancies:

 

http://newhopefertility.typepad.com/my_weblog/2009/10/twin-pregnancies-and-how-to-avoid-them.html

 

As always,  your comments and questions are welcome.

 

 

Clomid Challenge Test and its Limitations

 

The Clomiphene Citrate Challenge Test (CCCT) is used to predict how a woman is likely to respond to ovarian stimulation medication.  Many clinics using conventional IVF use it as a way of predicting success in response to high doses of gonadotropins.  If a woman “fails” this test,  many clinics give a poor prognosis because it is likely that she will produce on a few eggs despite high doses of medication.   Women are then discouraged or even disqualified from cycling.

Insurance companies use the CCCT in order to determine eligibility for coverage.  If a woman “fails” the CCCT,  an insurance company may deny coverage because she is unlikely to “succeed” based on their definition.

At New Hope Fertility,  our approach is very different.  The CCCT test may predict response to stimulation medications,  but it is not necessarily an indication of egg quality.    We do not select patients based on a prediction of response – we believe that women should have a chance to try with their own eggs,  even if they can only produce a limited number.  Mini-IVF^TM focuses on creating embryos of the best quality – not on quantity. 

After all,  all it takes to make one healthy baby is one healthy embryo.

 

As always,  your comments and questions are welcome.

 

High Resolution Sperm Selection (HRSS)

Here at New Hope we emphasize quality over quantity – we work hard to create the best quality embryos for our patients. There are two parts which contribute equally to the quality of an embryo; a sperm (male) and an oocyte (female).  We routinely perform Intra-Cytoplasmic Sperm Injection (ICSI) during almost all fertilizations, meaning that our embryologists pick which sperm to use in order to fertilize the oocyte.  The oocyte is large enough to see in detail under an ordinary microscope (100-200X magnification), therefore we can easily identify the quality of its features.  Sperm cells, on the other hand, are much smaller than oocytes.  While the sperm can be seen under an ordinary microscope, they are far too small for details in the physical appearance of the surface structures of the sperm, or the morphology, to be seen. Traditionally, embryologists randomly pick the “best looking” sperm to inseminate an oocyte.  At New Hope our embryologists use a state of the art technique called High Resolution Sperm Selection (HRSS) in which the sperm is viewed at 6000X magnification using DIC (Differential Interference Contrast) microscopy. The embryologist views the details of the sperm including shape, size or any defects. Sperm quality is based on what is referred to as the “Kruger standard” morphology. When a sperm has a good morphological appearance it is more likely to have normal chromosomes and less fragmented DNA, two factors which play a huge role is embryo quality, embryo implantation and growth. Studies have show that with the use of HRSS, successful pregnancy rates are increased. HRSS has also been shown to decrease the rate of spontaneous abortion during IVF pregnancies. By using HRSS we inject only the best quality sperm into the oocyte,  one more step toward ensuring that our patients receive the best quality embryos possible.   As always,  your questions and comments are welcome.

Twin Pregnancies and How to Avoid Them

Many of you have probably have read the first piece in the New York Times series,  which discusss issues surrounding twin pregnancies.  As many of you know,  the risk to the mother during pregnancy and delivery,  as well as the risk to the babies,  can be very serious.  Twin pregnancies often result in premature birth and low birth weight.  Many premature babies need to be hospitalized,  and suffer long term consequences, which carry enormous financial consequences.  These risks are unnecessary when ART is practiced responsibly.

At New Hope Fertility, our first priority is the health of our patients.  Our goal is to help our patients deliver one healthy baby at a time.  Because we focus on Mini-IVF^TM we avoid many of the risks involved with conventional IVF.  With conventional IVF,  in order to create multiple embryos to transfer, large amounts of stimulation medication must be used in order to produce a greater number of oocytes.  This not only raises the cost per cycle,  it also takes a toll on the patient’s body.  There is a risk of hyperstimulation (OHSS), and there are increased side effects and long term risks from some medications. 

We are often pressured by our patients to transfer more than one embryo,  but the risks to both the patient and the baby are too high to allow for compromise.  At New Hope, we strongly believe in quality over quantity.   By using Mini-IVF^TM we cut the costs of medication,  the risks associated with conventional IVF, and we reduce the twin rate.  We also take very seriously the need to educate our patients about the risks that twin pregnancies pose.

Furthermore,  with vitrification,  a state-of-the-art freezing technique with a 95% survival rate,  we are able to freeze our patient’s embryos with no effect on the quality of embryos for future frozen transfers.  This allows us to perform multiple SETs for our patients without affecting the cost of treatment, and without reducing the chances for success.  Since we opened our doors in 2004,  we have focused on SETs for our patients under the age of 39.  Our twin rate is one of the lowest in the U.S.,  and there have been no triplets born as a result of our treatments. 

Unfortunately,  in the U.S., multiple-embryo transfers have become common practice.  The only federal regulation in place today with regard to fertility clinics in the U.S. provides incentives to physicians and clinics to transfer multiple embryos, and to withhold IVF treatment from patients in lower success rate categories based on factors such as age. The Fertility Clinic Success Rate and Certification Act of 1992 requires clinics to annually report their success rates for pregnancies and births. The lack of alternate regulation, coupled with failure by the insurance industry to cover IVF treatment in the U.S., has encouraged patients to insist on multiple embryo transfers to get the most out of the enormous out-of-pocket fees they incur per cycle. And, because patients frequently choose clinics based on their published success rates, the emphasis moves from quality to quantity so that clinics may boost their success rates despite potentially dangerous and expensive health complications.

 

If IVF were more accessible and reimbursed by health insurers, and if embryo transfers were regulated, there would be consequences for clinics and physicians who practice irresponsibly. Patients would have access to multiple, single-embryo transfer cycles and insurers would save money they now spend on the health complications the current situation precipitates. In other words, if IVF were covered and regulated appropriately, it would be nearly impossible for IVF to lead to multiple pregnancies with their attendant risks.

New Hope Fertility believes in patient education and advocacy, and we are active in legislative efforts to responsibly increase insurance coverage for fertility.  We strongly believe that a combination of education, legislation, regulation,  and responsible ART practices such as Mini-IVF^TM can dramatically reduce the rate of multiple pregnancies without affecting successful live birth rates.

As always,  your questions and comments are welcome.

 

 

 

 

 

Our Statistics - A Different Perspective

The congressional mandate which requires clinics to report their success rates to the CDC currently looks at pregnancy rates per cycle via the SART reporting system.    However,  with advancing techniques in IVF,  especially with the advent of vitrification,  it is more appropriate and useful to look at pregnancy rates by patient.  It is extremely common for women to require multiple IVF cycles to achieve success.  At New Hope Fertility, our cycles are either Mini-IVF^TM or  Natural Cycle IVF.  We focus on embryo quality rather than quantity, and we encourage single embryo transfers (SET).  We do not excluse patients based on age or high FSH,  so most of our patients tend to be what other centers consider difficult or impossible cases.

 

2008 pregnancy rates by patient

 

Total patients cycling:                                                733 (excludes donor cycles and freeze-only                                                                                                                 banking cycles)

 

Total number of pregnant patients:                            255 (34.79%)

 

Average number of cycles per

 pregnant patient:                                                        2

 

Average number of total embryos

transferred per pregnant patient:                                1.86

 

Average number of embryos transferred

 per cycle per pregnant patient:                                   1.21

 

As always, your comments and questions are welcome.

Obesity and Infertility

Many of our patients ask how obesity affects infertility.  Obesity increases the body’s production of estrogen,  and this excess estrogen frequently interferes with ovulation and often results in irregular menstrual cycles.  Without regular ovulation,  successful conception becomes difficult.  Obesity is also common in women with PCOS (polycystic ovarian syndrome), a major cause of infertility.

 

Obese women do not only have problems with fertility,  they are also at greater risk for pregnancy complications,  such as having a Caesarean section,  giving birth to a large baby,  gestational diabetes,  and miscarriage.

 

IVF can help with conception,  but does not reduce the risks face by obese women during pregnancy and delivery.  We encourage our obese patients to lose weight before attempting to become pregnant.  Even a 10% loss of excess weight can make a difference.

 

However, age is still the most significant factor in infertility.  If you are 38 or older,  you may not have time to lose weight before your infertility declines dramatically due to the aging process.   We will discuss the pros and cons of your individual situation,  and help you make a decision about your timing.

 

As always,  your questions and comments are welcome.

NSAID Update

In my post on August 17,  I discussed the use of Indocin in our protocols.

We have switched to Ibuprofen from Indocin,  for most of our patients.  We have found that with Ibuprofen we get the same results,  but without the side effects were were seeing with Indocin (dizziness,  nausea, lightheadedness,  stomach upset).  With Ibuprofen,  we are seeing very few patients with stomach upset. 

As with all NSAIDs,  it must not be taken on an empty stomach,  in order to decrease the risk of stomach upset.

As always,   your comments and questions are welcome.

Diagnostic Blood Tests

Lately I have been asked by patients why we do not use AMH (Anti-Mullerian Hormone) as part of our diagnostic workup.  Although AMH can be a helpful indicator,  age plays the most important role in infertility.  Checking a patient’s ovarian reserve through FSH testing and antral follicle count examination provides a better indication. 

 

Unlike at many IVF centers,  at NHF we do not deny treatment based on low ovarian reserve or age.  Therefore,  using AMH,  which is expensive and requires an outside lab and a waiting period,  doesn’t make sense. 

 

FSH is adequate to determine how we will proceed with treatment – whether that’s Mini-IVF^TM or Natural Cycle IVF.

 

With conventional IVF,  using AMH along with FSH and AFC may be helpful in determining the level of stimulation used in a conventional protocol,  and may be the basis for rejecting or accepting patients.

 

At NHF,  those issues simply do not exist.  Women with traditionally poor prognosis or women of advanced maternal age are given a chance to try with their own eggs at NHF.  That’s what our approach is all about.

 

As always,  please keep your questions and comments coming.

 

 

Ovarian Tissue - Cryopreservation and Transfer

Ovarian tissue cryopreservation and transfer overview

 

The ovaries are home to a woman’s lifetime reserve of eggs.  By the time a female begins her menstrual cycle, her egg reserve has shrunk to about 400,000 eggs from several million at birth.  As a woman ages, her egg reserve continues to diminish and by menopause, her reserve is depleted.  Ovarian tissue transfer and cryopreservation present an alternative to egg freezing for women unable to produce viable eggs or those who wish to extend or preserve their fertility. This outpatient procedure involves removing an ovary, microsurgically dissecting the tissue, a computer controlled, gradual freezing process and subsequent preservation for future transplantation.

 

Early ovarian tissue transfer attempts date back to the 1950’s, with the procedure becoming commonplace for cancer patients in the 1990s.  The procedure’s advances and increasing success rates are largely attributed to advancements in tissue cryopreservation.  To date, five successful live births have been reported following ovarian transplantation in patients from Sweden, Belgium, Spain and the United States. 

 

At New Hope, we preserve reproductive tissue using a flash freeze method called vitrification.  This technique involves initially freezing tissue in a low concentration of anti-freeze solution with physiological buffers, which draws water out from the cell.  The tissue is then placed in a high concentration solution that instantly freezes the tissue without ice crystal formation. 

 

New Hope’s Founder and Medical Director, Dr. John Zhang, began his ovarian tissue cryopreservation research nearly 15 years ago.  His colleague Dr. Sherman Silber was one of the first doctors to publish on a live birth resulting from an ovarian transfer.  Dr. Silber has also performed numerous frozen tissue transplantations to restore normal menstrual periods.  Together, Drs. Zhang and Silber are recognized globally as leading experts in ovarian tissue transfer and cryopreservation.

 

Why choose ovarian tissue transfer and cryopreservation?

 

Ovarian tissue transfer and cryopreservation offers several advantages over freezing eggs.  Egg collection and preservation requires the retrieval of mature eggs at a specific time during the menstrual cycle.  This process requires the woman to undergo hormone treatment and it only yields one to six quality eggs per treatment cycle.  Ovarian tissue cryopreservation and transfer, on the other hand, circumvents these low retrieval rates by preserving a woman’s entire ovarian reserve, which contains potentially thousands of eggs. 

 

Benefits Overview

·       Many eggs can be preserved at one time

·       Ovarian tissue can be extracted at any time during the menstrual cycle

·       Allows reproductive function to be restored after cancer treatment

·       Minimally invasive and simple procedure

·       No hormone treatment required

·       Ovarian extraction and preservation can be done in one treatment rather than several

·       Decreases chance of multiple pregnancies

·       Cost effective

 

Success rates

 

At New Hope Fertility, Drs. Zhang and Silber have successfully achieved six spontaneous pregnancies and deliveries after fresh ovarian tissue transplantation.  We have also achieved one of the first live births from Natural Cycle IVF following a fresh ovarian tissue transfer.

Frequently Asked Questions

 

How long does the procedure take?

The procedure lasts 30-60 minutes.

 

Is it a complicated procedure?

It is a minimally invasive procedure done by laparoscopy.

 

Are there any known complications?

The complications are general laparoscopic complications, which include minor bleeding and bruising around incision site.

 

Does it leave any visible scarring?

No.  Only two 5mm incisions are made below the bikini line.

 

How much does the procedure cost?

The cost is approximately $6,000-$10,000.  As an outpatient procedure performed in a hospital, costs include hospital and freezing fees.

 

Is Mini-IVF an option immediately after the procedure?

Even with one ovary left, Mini-IVF is still an option.

 

Can the procedure be performed on women in their early 40s?

Yes.  However, it is most effective in women in their 20s and 30s.

 

If the ovarian tissue is transferred back several years following extraction, can it delay the onset of menopause?

There is a 10% chance that menopause will be delayed a minimum of one to two years.

 

Does the ovary function normally when it is re-implanted?

You should gain full ovarian function within two to three months following transfer.

 

Which doctors at New Hope perform the procedure?
In New York, Dr. Zhang will carry out the procedure.

 

 

Indocin

Many patients have asked why and how we use Indocin in conjunction with a Mini-IVF cycle.  Indocin is in the category of drugs called NSAIDs (nonsteroidal anti-inflammatory drugs). NSAIDs work on a chemical level. They block the effects of  enzymes which play a role in making prostaglandins. By blocking these enzymes, NSAIDs reduct the production of prostaglandins. This means decreased inflammation and less pain.

Some commonly used over-the-counter NSAIDS are:

*  Aspirin (Bufferin, Bayer, and Excedrin)

* Ibuprofen (Advil, Motrin, Nuprin)

* Naproxen (Aleve)

Used in the fertility setting,  the reduction of inflammation can make follicles less sensitive to rupture,  therefore helping to control the timing of ovulation when low doses of other medications are used, or during a natural cycle when no medication is used.

As always,  your questions and comments are welcome.