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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It’s another week and another “IVF linked to cancer” study: a recent study from the Netherlands has raised the possibility that in vitro fertilization may heighten the risk of ovarian cancer in patients who have undergone the fertility treatment. Obviously this is going to cause great concern in a large and growing population of patients who've accessed advanced reproductive care – but as always, I’m urging caution as you consider this study.

First, it is important to state that the researchers thought the results were preliminary only and recommended that much larger studies be done. In other words, there is no confirmation yet that this risk is in fact true. Secondly, it is important to remember that women who never give birth in their lifetimes (i.e. nulliparous) are at increased risk for ovarian cancer. Pregnancy, as well as birth-control pills, actually helps protect women from this deadly disease. In fact, women who have a strong family history of ovarian cancer are actually advised to be on birth control pills until they bear children. Once they are done having children, I usually recommend that these women undergo a preventative removal of their ovaries. 

So is there cause for concern? The first question to consider is if there is biological plausibility to the idea that IVF can cause ovarian cancer – and there is biological plausibility. The current thinking about certain types of ovarian cancer is that it occurs because of the “injury theory” – if the ovary is incessantly exposed to ovulation, it increases the risk of cancer. Again, birth-control pills help reduce the risk because most women don’t ovulate while on the pill, and pregnancy also helps for the same reason. With IVF, we put a needle into the ovary to retrieve eggs, which in theory causes an “injury” to the ovary. Does this mean we should stop doing IVF? And, does this mean that women who cannot bear children should stop the attempts to build the family? I don't think so.

In my opinion, we should do more research to see if this risk is real. If a concrete link is found, then current IVF protocols will need to adjust. There are some very simple adjustments that can be made, such as putting women back on the pill if they complete an IVF cycle and don’t get pregnant. Also, we can closely monitor women post-IVF for ovarian cancer with yearly ultrasounds and (although some disagree) the CA 125 blood test.  

My final thoughts on this topic are that, with anything in medicine, there is always the potential for side effects, and unfortunately sometimes those side effects can be serious. Diligent, ongoing study to continuously refine and improve our treatments, diagnostic tests and overall medical care are absolutely vital and must be continued around the world. I know I’ll be following ongoing studies very closely, but I certainly would not discourage anyone from pursuing their dream of having a baby because of one preliminary study.

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The best way to start managing fibroids is to have an ultrasound, preferably by a fertility specialist or a sonographer specifically skilled in assessing if and how fibroids may impact fertility. As the doctor who is potentially going to be operating on the patient, I always do my own sonograms – I truly believe it improves the outcome for patients. Doing my own sonograms, I can decide whether or not the fibroids are impacting fertility, whether they could impact pregnancy, and the best way to remove them.

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Having just had a number of patients with fibroids as their major cause of infertility, it’s the perfect time to talk about this frustrating and widespread problem.

First, we really do not have an accepted theory as to why or how fibroids come about. We know that they are more common in certain races (for example, as many as 40 percent of African-American women have fibroids) and can run in families, so there is most surely a genetic component. But while the researchers try to figure all that out, we practitioners are stuck with what to do about them. The answer lies in what the person with fibroids is experiencing and what she desires regarding her fertility. 

Fibroids are often present with no obvious symptoms, or the symptoms can be so severe they feel as if they are ruining one's life. They can cause heavy menstrual flow and clots, and consequently severe anemia. They also can put pressure on surrounding organs like the bladder, causing a frequent urge to urinate. A fibroid can grow so big that it outgrows its own blood supply and cause severe pain as ischemia ( lack of oxygen) will do – similar to a heart attack. 

With regards to pregnancy, fibroids can prevent an embryo from attaching and implanting in the wall of the uterus and also be a cause of recurrent miscarriages. As fibroids may grow during pregnancy, they can put a pregnancy at risk in its later stages by causing premature labor or even incompetence of the uterus.

Fibroids are classified by where they are attached to the uterus. From the inside out, they can be: 

• Submucosal - under the endometrium or lining, often extending into the cavity (think of a boulder emerging from your lawn). Submucosal fibroids will cause increased bleeding, a failure to implant or even miscarriages. 

• Intramural - in the wall of the uterus. These fibroids often cause no symptoms but can cause bleeding if close to the cavity/lining and can cause increased menstrual cramping. They also can become quite large and cause pressure or abdominal swelling. I have seen intramural fibroids compress the fallopian tube as it travels through the wall out to the ovary, possibly blocking transport of sperm and embryos.

• Subserosal - these are on the outside of the uterus and are also often without symptoms, but they can cause pressure on the bladder and abdominal swelling. Also if positioned near the side (i.e. the tubes and ovaries), they could interfere with the transport of the egg to the tube by pushing them apart.

• Pedunculated - (I know what you're thinking...Pe-what?) this means the fibroid is hanging on a stalk – think of a  mushroom. These fibroids are different in that they are at risk for twisting around on their own stalk, cutting off the blood supply and possibly causing acute pain - what I call "a fibroid attack." These fibroids can get quite big and can also displace tubes and ovaries, causing infertility. 

When you are attempting conception, and pregnancy is not happening easily, why not always start by removing fibroids? Fibroid removal is called "myomectomy."  We think carefully before moving forward with myomectomy because the surgery can cause new problems, including scar tissue and new "plumbing issues," so we must be convinced the fibroids are an issue before moving forward to surgery.

So how should you manage fibroids? Part 2 of my blog post, coming Sept. 1, will outline what you and your doctor need to do to manage your fibroids and - if at all possible - preserve your fertility.

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Let's be honest - if you're battling infertility, Mother's Day is probably a holiday you'd be more than happy to skip. You may have chosen to "skip" it by taking a vacation, doing something completely non-family-focused (skydiving, skeet shooting, etc.), or by just hiding away in your house and ignoring the phone, emails and Twitter. Or, you may have put on your "brave face" and survived a moms-focused church service, family lunch or other celebratory event, probably suppressing the urge to stick a fork in your leg for most of the day.

I'm not going to try to give you advice about how to survive days like this. A million other bloggers try to do that for Mother's Day. What I will say is simply this - don't give up. If you want to be a mother, you will find a way to someday be a mother.

It may not be by traditional means. You may need fertility medications or treatments. You may need an egg donor or a gestational carrier. You may need to find an embryo donor. You might even need to adopt. But no matter how you do it, you will achieve your dream. Stay focused on your goal, do your research and look for the best clinic, doctor, donor, attorney - whatever resources you need - to help you have a child. 

Stay focused, stay strong, ask for help when you need it, and - to quote a beloved family movie you'll hopefully enjoy with your child someday - "Just keep swimming."

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