Recently it was calculated that approximately 125 IVF cases per 1 million capita are performed in in the USA during the course of a year. In most of the major westernized countries in Europe they are performing between 400 – 500 cases per 1 million capita. That is just one fourth of the cases that are done in these other countries! Despite the fact that on average USA IVF success rates are higher than those countries, we do not help nearly as many people. Why? The answer is obvious. IVF is not a covered medical treatment in the USA and so, the overwhelming majority of Americans just can't afford the procedure. In many European countries there is generally some form of coverage, but  if the family has to pay out of their own, the costs are less than half than what they are in this country. With one in seven couples in the USA struggling to build their families, that leaves many people left to fend for themselves.

Two and half years ago, we opened the Fertility Partnership with the goal of providing state-of-the-art reproductive health care in a caring and compassionate environment. As we opened our doors in the heart of the worst economic crisis in 70 years, it was clear that the best way to be compassionate was to make it as affordable as possible. In August 2010 the Fertility Partnership was featured in  Newsweek Magazine describing our efforts to lower the cost of Advanced Reproductive Technology. It was a fascinating article that stirred up some controversy. For example, it touched upon some difficult topics such as the "economic selection" that created by the high cost of fertility procedures . That is to say, only infertile couples with economic means will be able to reproduce. We have learned a lot since we've opened, and so I thought it appropriate in honor of National Fertility Week to reflect on what we've learned during our quest to provide the best care at the most reasonable cost.

The fact of the matter is that the materials and equipment needed to run and maintain an IVF laboratory, staff an IVF clinic, and all that is needed to maintain state-of-the-art clinic in full compliance with all regulatory statutes is just very expensive. So how do you bring the cost down? Some clinics have tried what are called "shared risk programs". That is where you pay for more than one round of IVF upfront and are given certain assurances that there will be a successful outcome. There are even promises or guarantees to return money if all attempts fail. We initially considered pursuing this at Fertility Partnership because there is something to be said about calming the frightened couples with guarantees and opportunities to try more than once. What eventually dissuaded us from pursuing this practice is the simple fact that some of the companies that provide these services are publicly held and annual profits are visible to any and all. They are apparently doing quite well financially with these programs and post millions of dollars of gains each year. This somehow seems too businesslike to us and not in the spirit of practicing medicine. Also, typically patients can only get in on these "shared risk" programs if they meet certain criteria which in fact make them very likely to be successful at IVF, ad so they are "safe bets". I like to use the metaphor of throwing darts at a balloon. IVF is like paying thousands of dollars for a dart to hit a balloon and win the most wonderful of prizes. But, there are no guarantees. I believe that you have to keep your darts very sharp, that is to say the best science and medical/clinical care. You have to engage your patients and keep them focused and calm as they take their shot at being successful. Also, our philosophy has been to provide each dart at the lowest cost possible. We are not going to “sell” you two or three darts at a time with guaranteed results. In the end, we believe that works out better for the patients.

So what about "low intensity" in vitro fertilization? It comes under various names such as "low dose", "micro", and other names that are in fact trademarked and so I will not mention them. It is my understanding that these protocols for IVF were developed with the idea that there are women who would benefit from lower doses of fertility medications during their cycles. Unfortunately it has not panned out. In a recent publication Dr. Norbert Gleicher reported on their results. He states that "with an identical number of embryos transferred, after adjusting for age, patients using standard IVF demonstrated a 7-fold better odds for pregnancy and a cumulative pregnancy rate that was more than six times higher than that achieved in patients using low intensity IVF cycles". He also calculated that the average cost to bring a baby into the world from these technologies i.e. live birth, was “$23,100 when low intensity IVF cycles were used and $20,333 when standard IVF cycles were used (these are cumulative results, meaning multiple attempts may have been necessary). Dr. Gleicher concluded from his research that "low intensity IVF currently lacks clinical and economic foundations, and therefore should be offered only under experimental study conditions". Unfortunately, there are some clinics that are marketing these protocols as low-cost alternatives to standard IVF. I feel certain that there are some couples who could benefit from this approach; however we do not know who these couples are at this time. At Fertility Partnership we don't provide low intensity IVF, but, it's in fact quite easy to do and we are ready to implement these protocols once we are convinced that is beneficial for a particular couple.

So what's the answer? How do you lower the cost of in vitro fertilization? The answer is by doing just that, lower the cost of in vitro fertilization. I believe that physicians need to lower their expectations of what they will ”earn"  from each cycle and be prepared to provide care to the increased number of couples who will come seeking care because it's less expensive. We are only taking care of one fourth of the patients in the USA who require in vitro fertilization and all that goes with it. Clinics need to just lower their prices and roll up their sleeves to work harder and provide good care for more people.

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Unexplained infertility is by far the most frustrating of all conditions I see. To get this diagnosis, all the testing patients have undergone show that everything is normal. There are adequate sperm for the male, and female patients seem to be ovulating or “making eggs.” The “plumbing” has been checked through an ultrasound and hysterosalpingogram, or “dye test,” and there are no abnormalities. We cannot find a medical reason for failure to conceive. 

I have sat before many patients with this diagnosis, including many that are in the medical profession, and the look of utter frustration is intense. They say “Everything checks out, so why won’t it all work?” The fact is that as many as 20 to 30 percent of all the patients we treat for infertility are not truly explained. The patients look to us for a treatment plan, but what are we treating? Doctors, as a general rule, like to know what and why they are doing things before they do anything. But unexplained infertility defies that rule because the lack of a plan of action is unacceptable. So, we need guidelines.

Clearly, if you do not know what you are treating then anything you do is empiric. In other words, we will rely on observation and experience rather than clear cut science. The general rule is if the woman is 35 or younger, and there is a normal semen analysis, doctors should provide Intrauterine Insemination (IUI) three times. That yields about a 30 to 35 percent overall pregnancy rate after three attempts. 

If IUI fails, you move on to IVF for 3 attempts. The combined IUIx3/IVFx3 yields between 85 and 90 percent success rate. But, if the semen analysis is significantly abnormal, or if the woman is older (or there is evidence of a diminished egg reserve), you should recommend going straight to IVF. 

Obviously, patients have choices. There have been many patients who have insisted on trying IUI first, and some who wanted to skip the IUIs and go straight to the most effective tool we have, In-Vitro Fertilization. Medical ethics dictate that the choice must be made by affirming “patient autonomy” and the “Doctor’s Beneficence.” That means the patient should be involved in making the choice, but the doctor can only do what has a real chance of working.

Before I initiate a treatment plan, I review the history closely, especially the family history. It is my experience that many unexplained infertility patients are in fact getting pregnant, but they are miscarrying and do not know it. Incredibly, a study showed that probably 70 percent of all pregnancies never make it. The woman may get her menstrual cycle on time or may not. It may come a few days late, the patient may feel that the breasts are tender and may think to themselves that it doesn't come tomorrow I will run out and buy a pregnancy test. Then the menstrual cycle starts. 

In other words, I believe that many of these patients are in fact getting pregnant but repeatedly losing pregnancies. Recurrent pregnancy loss, however, is the subject of an entire different blog. Regardless, I very often if not always look at the possibility that the patient is experiencing recurrent pregnancy loss. It’s extremely important - imagine finding out you have a treatable recurrent miscarriage condition after losing viable IVF pregnancies. 

Unfortunately, no doctor can find answers for every patient. Sometimes unexplained infertility, despite our best efforts and the use of the latest technology and tests, stubbornly remains unexplained. For those patients, gestational carriers or adoption may be their best paths to parenthood. As disappointing as this can be, the good news is that more than 50,000 people in the U.S. every year become parents through these methods. The path to parenthood can be a rocky one, and those who battle unexplained infertility certainly have among the rockiest of journeys, but in most cases there can be a happy ending.

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Recently, yet another major article was published in the fertility literature that demonstrates the negative impact of being severely obese on infertility treatment outcomes. Piggybacking on that, Canada is currently debating whether obese women should even be allowed to undergo In Vitro Fertilization (IVF). As we have long known, being extremely obese (i.e. a BMI over 50) greatly impacts a woman’s chances to conceive. Obesity reduces the body’s ability to respond well to fertility medications, can make egg retrieval a nightmare, reduces the pregnancy rate after IVF, and increases the possibility that the woman will miscarry. 

So now what? Do we just tell overweight women that they are out of luck unless they can diet and exercise, throwing guilt into the frustration and sadness that they already have regarding their inability to conceive? The reality is that most of these women have dieted and tried to control their weight for many years. In fact, many have a metabolic condition that makes it extremely hard to lose weight. 

So what is the best way to help these heavy ladies? Weight loss, exercise, and diet plans work for some, but even with the motivation brought on by their desire to have a baby, they rarely can acheive the goals. It also takes time to institute lifestyle changes, which is a big problem when you’re talking about having a baby. In many cases, time is of the essence, since egg quality and quantity decline so rapidly after age 30. How do we get these patients to lose weight quickly in order to proceed to fertility management? 

There are number of approved prescription medications available that currently are in use. Some have been used and reported in the fertility literature, but the only drug I have found useful is phentermine, of Phen-Fen infamy. Go with me for a moment on this. In the Phen-Fen debacle, the treatment regimen included two drugs: fenfluramine which tragically caused some fatalities and is rightfully off the market; and phentermine, which has been on the market for over 40 years and has been shown to be very useful with rapid weight loss. 

Unfortunately for patients, however, the use of phentermine is largely vilified in the medical community. Why? In my opinion, it is frowned upon because it is perceived as a quick fix and, while results will include rapid weight loss, the dependence on a drug rather than lifestyle changes virtually guarantees the weight will go right back on post-medication use.

Most doctors probably think, “What's the point of using a weight loss drug if the patient will gain it all back right soon after?” But in the field of fertility, that’s really exactly what I’m trying to achieve with my patients. I want my patients to lose enough weight to successfully and safely get pregnant, then gain weight (albeit carefully and by making healthy choices) as their baby grows. 

Under the watchful eye of a careful doctor, phentermine can work very well. A well motivated patient who exercises 3 times a week for 30-40 minutes, watches carbohydrate intake and takes the prescribed dose of phentermine daily can lose 40 pounds or more in six months. Many patients who typically do not ovulate on their own will start to do so after losing that much weight, and some even conceive spontaneously. 

Is phentermine safe? Yes. I have now had over 500 patients on a regimen that included phentermine and have found many of the bad press the drug has received to be unfounded. Other than the annoying side effects of “cotton mouth” and constipation, my patients have done extremely well with short-term, carefully monitored use of the drug.

There is no doubt that if you are very overweight, your fertility journey is going to be harder and less successful. Instead of turning you away, however, as some other infertility clinics do, Fertility Partnership will work with you to safely and effectively manage your weight and help you get pregnant. We have seen great results from our philosophy that well-supervised weight loss programs - which include the short-term use of medications like phentermine - are very successful in getting the weight off quickly in preparation for achieving the dream of having a baby.

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Earlier this month, the Society for Assisted Reproductive Technology (SART) published 2009 statistics - the latest available - for in vitro fertilization (IVF) success rates. (Side note: Since Fertility Partnership opened in December 2009, our clinic is not included in these statistics.) There were a number of interesting findings in the report that I’ll be blogging about over the next few weeks, but what really caught my eye was the statistic that ovulatory dysfunction (i.e. Polycystic Ovarian Syndrome [PCOS]) accounted for only 7 percent of all infertility diagnoses among member clinics.

I’m not entirely sure what accounts for it, but at Fertility Partnership, fully 30 percent of the women we see have PCOS. It could be that, since our practice is based in the St. Louis region, we simply see more overweight women – a common symptom of PCOS. According to CalorieLab’s 2010 Obesity Map, Missouri is the 11th “Fattest State,” and the states that border us all rank in the top half of “Fattest States.” (Given our reputation for delicious toasted ravioli and the great food they serve at Busch Stadium, I can understand how we earned that ranking.)

It also could be that we’ve become somewhat of a magnet for PCOS patients, and that’s just fine with me. Having cared for PCOS patients for more than 20 years, I’ve developed an unofficial specialty in the syndrome. My PCOS patients have had great success getting pregnant, bucking the trend and the general thinking about this special patient population. In fact, a number of fertility clinics will refuse treatment to PCOS patients if they are “too obese.” 

I say, “Bring ‘em on!” Fertility Partnership works with everyone who comes to us for help, working together to develop a treatment plan that meets each patient’s unique situation and needs. Our success rates for PCOS patients undergoing IVF at Fertility Partnership are actually better than our success rates for the under 35 age group. (Our success rates in all age categories are above the national average.) In fact, the older our PCOS patients are, the better they do with IVF at our clinic.

So the moral of this national statistical report is…don’t let national statistical reports get you down. In your search for the “best” fertility clinic, look for the one that best meets your needs and has experience and success treating your particular infertility issue. And, if you’ve been told you wouldn’t be successful with fertility treatments because of PCOS or some other issue, don’t let that shut the door on your baby dreams. Give Fertility Partnership a call and give us an opportunity to help you overcome that opinion and have a baby.

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Once again, Fertility Partnership is thrilled to report that our patients are dreaming, believing and conceiving well above the national average. Our January success rates topped 50 percent, and we are beyond excited for each of our newly pregnant patients. Congratulations to each of you and enjoy every moment of your pregnancy – don’t forget to send us photos!

And for our patients who are still waiting for their dreams to come true, we hope you’ve already felt and continue to feel our ongoing support for you. Every member of our staff is committed to doing everything we can to help you, so please don’t give up on your dream – we never will.

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