Last month, Dr. John Waterstone addressed the Oireachtas Joint Committee on a new bill addressing assisted human reproduction.
There was a very positive reaction to his opening statement as Dr. Waterstone represented the interests of the patients he cares for.
You can now read his full opening statement here: Opening-Statement-by-Dr.-Waterstone
Save our Sperm
Environmental factors such as air- borne pollutants and pesticides in our foods are leading to a decline in the quality and quantity of male sperm, says Lorraine Courtney
Men’s sperm counts have fallen by almost 60% since the 1970s, according to major new research which cautions that our modern world may be prompting a male fertility crisis. Over the past few years, various studies have pointed to declining sperm quality and quantity. This latest research, and the first systematic review of trends, looked at 180 studies over four decades. It concluded that total sperm counts in Western countries have fallen by 59% since 1973, with a 52% fall in sperm concentration, or the concentration of sperm in a man’s ejaculate.
“Decreasing sperm count has been of great concern since it was first reported 25 years ago,” says Dr Shanna H Swan, a professor in the Department of Environmental Medicine and Public Health at the Icahn School of Medicine at Mount Sinai, New York and study leader.
“This definitive study shows, for the first time, that this decline is strong and continuing. The fact that the decline is seen in Western countries strongly suggests that chemicals in commerce are playing a causal role in this trend.” The chemicals he refers to range from everyday air pollutants to pesticides or even soap. So should the average man panic?
A first glance at the statistics suggests that we are faring well. Ireland had the highest birth rate among EU countries last year. 2016 saw 63,900 live births recorded according to figures from Eurostat, the EU statistics agency. That’s a super healthy rate of 13.5 births for every 1,000 of the population. Italy was the lowest with just 7.8 births for 1,000 of the population.
However, male infertility is a factor for half of the couples who seek fertility treatment here in Ireland. Azoospermia (absence of spermatozoa in the ejaculate) is a condition present in approximately 1% of males in the general population. Between 10-15% of infertile men who attend assisted reproductive technology clinics here have had a diagnosis of azoospermia. However, approximately 30% of couples present where there is suboptimal sperm count or reduced motility, impacting on the couples’ ability to conceive a child.
Dr Tim Dineen, head of laboratory services at Cork’s Waterstone Clinic, says the study draws attention to a trend that doctors and scientists working in reproductive medicine have been aware of for many years.
“The decline in sperm counts is very gradual and is unlikely to prevent any individual man fathering children naturally in the short term,” says Dr Dineen.
“It is also important to point out that if a man’s sperm count is so low that natural conception is impossible, intracytoplasmic sperm injection (ICSI) treatment is able to compensate for the problem very successfully.”
Treatments, in the form of ICSI, have been very successful in overcoming male subfertility and male infertility. In the Waterstone Clinic, for those couples where the female partner is younger with good ovarian reserve, a live birth rate of at least 50% (first fresh cycle) is expected.
ICSI costs €4,750 including blastocyst and embryoscope incubator culture at the clinic, which offers a range of treatments.
“It is reasonable to assume that environmental factors are to blame but no one knows exactly which factors are involved,” says Dr Dineen. “Research is urgently required to identify the environmental causes; only then can public health initiatives be undertaken in order to address the problem.”
With an eye on the future, Dr Dineen maintains that if the exact cause of the drop in sperm counts is not discovered and corrected soon, the decline will continue and major problems will arise with regard to the ability of men to father children naturally.
When you should start seeking fertility help?
With so much media coverage of celebrities seeking fertility treatment and documenting their IVF journeys, the anxiety around trying to conceive when nothing is happening can become amplified for women and couples.
If you and your partner have made the decision to have a baby, it’s good to know when you should and when you shouldn’t become concerned if that blue line is not appearing.
When not to be concerned
If you are younger than 35, have regular periods, no family history of fertility issues or early menopause, and no underlying issues such as Polycystic Ovary Syndrome or endometriosis, then there is no need to worry if you have been trying for less than six months. I would always recommend when someone is trying to conceive, that they keep a menstrual diary to track their cycle, so you have a good understanding of your pattern and know when you are ovulating.
If you find yourself anxious even if everything appears normal, then to alleviate stress I would suggest you (and your partner) avail of a simple and cost-effective fertility assessment. This will either reassure you that all is well, or inform you of an underlying issue, which you can take steps to correct. At our clinics we offer a self-referral fertility assessment service, My Fertility Check, which is a quick and straightforward test.
When to know it’s time to seek fertility help
If you are under 35 and have been trying without success for 12 months and there is no history of early menopause or known fertility issues with you or your partner, then it may be a good time to consider seeking help.
If you are over 35 and unsuccessful after six months, you should take action and make an appointment with a fertility specialist. Age is the single greatest factor affecting a woman’s fertility, which goes into decline at a faster rate after the age of 35.
It is more difficult for women over this age to become pregnant, even with assisted reproductive technology. The earlier an issue is identified, the sooner we can address it with you. Remember, one in six couples will struggle when trying for a pregnancy, so you are not alone.
Don’t forget the male factor
Of course, fertility issues also affect men. In fact in 30% of cases, a male factor is the reason why a couple has been unable to conceive, while in a further 10% of cases it is a combination of both male and female difficulties. So, if your partner has undescended testicles, had mumps when he was younger, or had any injuries to his testicular area, it would be a good idea to have an early assessment to ensure all is well, and if not, treatment is available to help you achieve your goal.
Advances in reproductive technology for men now mean that there are simple, effective and non-invasive procedures which can be very successful in overcoming some problems.
There Are Signs of a Decline In Male Fertility
Two weeks ago I wrote about a recently published large systematic review of studies examining sperm count and sperm concentration from 50 different countries between 1973 and 2010. In this large synthesis of previous studies, sperm concentrations in the ejaculate of men in Western countries had declined by 52 percent over the nearly 40-year period. The analysis was carefully done, and the authors attempted to address a number of pitfalls.
I emphasised the problems inherent in using results from studies conducted in different populations during different time periods and using different methods. I also referred to a careful study of sperm count in young Danish men over a period of 15 years (1996-2010), which showed no change in sperm count. I pointed out that opinion among scientists was divided regarding a previous meta-analysis published in 1992, which also appeared to show a dramatic decline in sperm count. Finally, I discussed possible causes that might account for a decline, if, in fact, it were real.
In order to make sure I was not overlooking important considerations on a difficult topic, I wrote to Professor Richard M. Sharpe of the University of Edinburgh, one of the foremost experts on male reproductive development and pathology. Professor Sharpe wrote back saying that he felt my piece was “accurate, fair, and balanced,” although he would “put a different spin on a couple of things” I mentioned.
First, he pointed out that the median sperm count across all years of the study of young Danish men was in the low 40’s x million/ml, which is at or below the 47.1 million value reported in the new systematic review for men in 2011. He added that “There is very good data historically for Danes showing much higher sperm counts [i.e., in the past – G.K.], plus they have the highest assisted reproduction rates in the world. I would agree that the Danish 15-year data (highly reliable and well-standardized) do not support the idea of a continuing fall in sperm counts, as implied by Levine et al., but they do not offer any support for ‘no fall.’ ”
Second, Professor Sharpe wrote, “I personally share your opinion on the evidence (or rather lack of) that endocrine disrupting environmental chemicals are an important factor in the apparent sperm count fall.” However, he questioned my argument that people in developing countries have higher exposures to chemicals in the environment, arguing that some exposures will be much higher than ours, but others will be much lower. “We would need to know which are most important in the present context before drawing any conclusions (and we clearly do not know which, if any, are important).” A valid point.
A third and related point is that the available evidence regarding trends in sperm count over time in developing countries is very limited and of poorer quality than in developed countries, and thus cannot support an argument that there is no decline in sperm count in developing countries. Sharpe did not comment on my point that, due to widespread environmental and occupational regulation in developed countries in the latter half of the twentieth century, any decline in sperm count would be difficult to explain by exposure to environmental pollution.
Finally, Professor Sharpe commented that the idea of conducting a prospective study to address the question of declining sperm count is unrealistic, given that such a study would require very large numbers and a span of 25 years or more. Furthermore, such a study would fail to answer the question whether sperm counts have fallen up until recently; it could only address whether they are continuing to fall. And this question appears to have been answered in the negative by the Danish study of young men over a 15-year period.
In closing, Professor Sharpe wrote, “Ultimately, the arguments can go back and forth and no amount of new data is likely to resolve the issue of a historical decline. So maintaining a balanced view (i.e., there is always uncertainty) is, in my opinion, all that the evidence allows.”
Several important take-home messages emerge from this discussion.
First, there is good evidence from the study of young men in Denmark that there has been a shift toward lower sperm counts in the period 1996 to 2010 compared to the 1940s. Recent studies in European and North American populations indicate that 20-30 percent of young men today have sperm concentrations below 40 x million/ml, which is associated with a reduced fertility, i.e., the ability to father a child.
Second, sperm number and quality are influenced both by exposures in utero and soon after birth and also by exposures later in life. For example, we know that maternal smoking during pregnancy can reduce testis size and sperm count in males. Other maternal behaviors and perhaps particularly medications taken during pregnancy may also have important effects. (In an earlier exchange, Sharpe told me that he had turned his attention to this neglected question). As for environmental pollutants, studies in animals show that exposure to chemicals at high levels can adversely affect sperm count, but these high exposures are not relevant to the general human population. A host of exposures associated with modern, urban lifestyle may potentially have adverse effects on sperm count and quality both in the perinatal period and in adulthood. These include sedentary lifestyle, obesity, stress, poor sleep, smoking, and nutrition. Because many of these exposures are correlated, identifying the key factors represents a daunting challenge.
A final point is that, as Richard Sharpe makes clear, in view of the difficulties of identifying trends in human reproductive function and possible causes, we need to resist embracing facile explanations that appeal to the public, journalists, and to scientists with an investment in a particular hypothesis, such as the endocrine-disruption hypothesis. Sharpe uses his extensive knowledge to describe what the firmest evidence suggests, but, at the same time, he is careful to delineate the limits of our knowledge. His skepticism regarding endocrine disruption as an explanation for the dip in male fertility is particularly noteworthy, since in the early 1990’s he was one of the first to formulate the hypothesis.
Geoffrey Kabat is a cancer epidemiologist at the Albert Einstein College of Medicine and is the author of Getting Risk Right: Understanding the Science of Elusive Health Risks
Impact of gene editing breakthrough will be muted
The work on the repair of a gene in human eggs, reported in the journal Nature, is an important scientific achievement. It made use of “Crispr” (clustered regularly interspaced short palindromic repeats) technology to make a single specific change in the three billion units of the human genome. The work is indeed a stunning application of Crispr, with some elegant and surprising results – and the publicity is good for my science – but it is not likely to change the way reproductive medical genetics is practised and it raises no new ethical problems.
The claims made for the work, amplified by the media, will raise expectations in families carrying genes with severe medical effects and has already excited the critics who fear that geneticists are busy undermining our society. So let us first look at what has been achieved in the science, and then tease out some of the implications.
Medical genetic disorders cause a great deal of suffering and affect about one person in 25. Genetic engineering and DNA sequencing invented in the 1970s led to a revolution in genetics. Mutant genes causing many genetic disorders have been identified. Advances in human embryology led to in-vitro fertilisation (IVF) in 1978, leading to the birth of more than five million children and untold happiness in their families. The question arose whether IVF could be useful in dealing with medical genetic cases.
Genetic defects
By the early 1990s geneticists could detect mutant genes in single cells taken from IVF embryos without harming the embryos. This led to the gradual introduction of preimplantation genetic diagnosis (PGD). Today parents who are concerned that they may conceive a child with a significant genetic disorder can produce embryos by IVF, these may be tested for the genetic defect and one or more unaffected embryos can then be implanted.
PGD requires a specific “probe” for each genetic mutation. Some mutations are common, such as F508 in cystic fibrosis, but for many families the mutations have to be analysed and specific probes prepared and tested. As many people know, IVF is itself complex – PGD adds another level of complexity, meaning that the number of successful clinical cases dealt with worldwide to date is still only a few thousand. PGD is in its infancy.
So what will be the clinical impact of the new method on PGD? In their experiments, biologist Shoukhrat Mitalipov and his fellow researchers treated 58 embryos in which about 50 per cent carried the normal and half the mutant gene. After treatment they found that 42 (or 72 per cent) carried two normal genes. The mutant gene had been repaired in an estimated 13 out of 29 embryos. Crucially, not all embryos were repaired, nor was it possible to say that Crispr did not cause other unintended, off-target damage to other genes. The embryos were not implanted.
The authors suggest that repair by Crispr will increase the efficiency of PGD. In fact it will have almost no practical effect on PGD services, for two reasons. First, not all of the defective genes are repaired, so after Crispr the embryos still have to be screened by standard PGD to avoid implanting mutant genes. Second, repairing is much more complicated than the current method, which is already complicated. Two Swedish commentators who work in the field note dryly: “Embryo genetic testing [PGD] during IVF remains the standard way to prevent the transmission of inherited diseases in human embryos.”
In contrast to its use in reproductive medical genetics, use of Crispr in repairing genes in body tissues is a really promising approach to treating genetic disorders after birth, but that is another story.
What do we really need to do in developing PGD? The technical priority is to make IVF itself more efficient. Then we need to refine the current methods of PGD and apply them routinely to a much wider range of genetic mutations. The social priority is to provide PGD on national health services to all couples faced with a high chance of conceiving a child with a major genetic disorder.
Ethics
Now what about the ethics? Since PGD, which is a medical procedure, is well accepted in international medicine there is nothing new on that front. If in the past, like the Catholic Church, you opposed IVF (and PGD), or the wishes of parents to avoid having children with genetic disorders, this work will not change opinions, and should not increase your concerns.
It is possible that the Crispr techniques of changing genes will be used for non-medical purposes in reproduction, for example to alter genetic qualities which have nothing to do with health. In the UK, such use is regulated by the Human Fertilisation and Embroylogy Authority, and might be made illegal (as for example is the non-medical use of PGD for sex selection). But it may be more difficult to make all applications illegal – for example, parents might wish to have a child with blue instead of brown eyes, and if so is foolishness something we should make illegal?
One thing is clear. It is long past time that we put into effect the recommendations of the Irish Commission on Assisted Human Reproduction of 2005 dealing with these issues, which are not new, and are well known to the Government. IVF is not regulated in Ireland nor is PGD, making it difficult for pioneers in the field such as Dr John Waterstone of Cork Fertility to provide a service that is badly needed in Ireland.
David McConnell is fellow emeritus of the Smurfit institute of genetics at Trinity College Dublin. He is a former chairman of The Irish Times Trust.
Tips for choosing a Fertility Clinic
Tips for choosing a Fertility Clinic
When choosing a fertility clinic, there are some important factors consider:
1. What services are offered at the clinic
Research the services the clinic offers and ensure the treatment options suit your requirements. Some clinics offer a full range of services and other clinics offer a limited amount of services. Some clinics offer additional services such as counselling, nutrition advice etc., if these services are important to you, ensure the clinic offers these and enquire about costs. Some clinic will offer these services at additional costs while others offer them free of charge.
2. What are the Success Rates
It is important to research the success rates of the clinic and how successful are they treating people in your age category. It is important to understand the data presented when comparing ‘success rates’ between clinics. Often pregnancy rates can be quoted and these will always be higher than live birth rates. ‘Live birth ‘ rate is the number or percentage of live births that resulted from the total number of successful embryo transfers. Because live births can be calculated as a percentage of cycles started, egg collections or embryo transfers, it is very important to compare like with like when reviewing results.
Reporting of annual statistics is mandatory in the USA and UK and unfortunately there is no requirement by Irish law to report annual statistics. You can benchmark the success rates of an Irish clinics to those in the UK and USA and compare the industry average. Success rates can be found on the clinics website, if they are not available you need to ask why they are not published.
3. How convenient is the clinic to where you work/live?
It is important that the fertility clinic you attend is accessible to where you work/live as you may require a number of appointments (approx. 6 per IVF cycle). Choosing an accessible clinic will reduce your travel times, cost of travel, leave from work and stress. As fertility treatment can be a stressful journey it is important to ensure you make the process as streamlined and stress free as possible. Also, be aware of the clinics opening times. Can you receive treatment early morning/week-end’s. A clinic offering a seven day service with extended opening hours can reduce stress, absence from work etc.
4. Patient testimonials
Are the patient testimonials available to read? These can normally be viewed on the company website. Visit fertility chat rooms and reputable blogging sites and ask people of their experience with the clinic and get a feel for what others are saying about the clinic. Ask the clinic do they have a former patient who is willing to talk to you about their experience. Also, if you know someone who has been through the journey, ask them about their experience.
5. Is the clinic routinely inspected by an authorized body?
Has the clinic been regulated and audited by the HPRA (The Health Products Regulatory Body)? What standards does the clinic adhere to? How often are internal and external audits carried out?
6. First Impressions
Did you speak to a member of staff at a clinic or meet them in person. What was your impression? Does the clinic offer a personal service focused on your needs? It is important you feel comfortable with the clinic and team prior to embarking on the journey. Ensure the clinic offers support via email/phone etc. should you have any questions during your treatment. You want to feel that you are important to the clinic and they are with you every step of the way.
7. Equipment and Facility
How dynamic is the clinic? Is their equipment up-to-date and are staff trained with latest techniques? What research and development is being conducted at the clinic or what studies/trials are being done?
8. Cost
Before choosing a clinic, it is important to be aware of the full cost of treatment. Some clinics have additional costs or add-ons such as blood tests and these can all add up to be quite expensive. Ensure that the clinic will only carry out necessary tests and treatment and will not perform or recommend unnecessary expensive tests. As this is both an emotional and financial journey it is important to be aware of costs so there are not any surprises.
Majority of ‘add-on’ fertility treatments not supported by science
There is no evidence the majority of “add-on” treatments commonly marketed by private fertility clinics improve chances of having a baby, a damning new study reveals.
An investigation by Oxford University found 26 of 27 routinely offered procedures, some costing more than £3,000, have no rigorous research justifying claims they are effective.
Investigators discovered that one popular treatment which purports to complement in vitro fertilisation (IVF), the recommended treatment for infertility, may even harm the likelihood of pregnancy.
The Human Fertilisation and Embryology Authority, responsible for regulating the sector, said it was concerned about the increasing marketisation of add-ons but admitted it has limited powers to intervene.
Professor Carl Heneghan, Director of Oxford’s Centre for Evidence Based Medicine, said “Some of these treatments are of no benefit to you whatsoever and some of them are harmful.
“I can’t understand how this has been allowed to happen in the UK.”
Approximately one in seven couples in Britain have trouble conceiving, with increasing numbers of people choosing to delay trying for a family until they are older a contributing factor.
Official guidelines stipulate that the NHS should offer three full rounds of IVF to women under 40 who have not conceived after two years of regular intercourse, although the reality is a postcode lottery and numerous areas only offer one.
The new study, published in the British Medical Journal, analysed claims made across on 74 UK fertility centres’ websites.
Of 276 claims relating to the benefits of fertility interventions, just 16 were accompanied by references citing corroborating scientific research, of which only five were rigorous systematic reviews.
Add-on treatments include blastocyst culture, the practice of waiting longer to transfer embryos from a laboratory to the uterus in the hope that they will be healthier and lead to a higher chance of pregnancy, which can cost around £800.
Assisted hatching, creating a hole in the outer layer of an embryo to improve its quality, which is offered for around £450, is also offered by private clinics.
Another commonly offered add-on which aims to test embryos for abnormalities, Preimplantation Genetic Screening, has in fact been the subject of papers which suggest it lowers birth rates.
The treatment is being offered for £3,500.
Professor Heneghan told the BBC’s Panorama, which collaborated in the investigation, that the exploitation of people hoping to conceive was “One of the worst examples I’ve ever seen in healthcare”.
“The first thing you would expect to happen is that anything that makes a claim for an intervention would be backed up by some evidence,” he said.
Approximately 98 per cent of women aged between 19 and 26 having regular intercourse will conceive naturally within 2 years, however this figure drops to 90 per cent for women aged between 35 and 39.
In around 25 per cent of couples, however, this is no identified cause of the infertility.
Earlier this year experts warned that half of all women prescribed fertility treatments do not need help getting pregnant and are at risk of exploitation by private clinics.
Dr John Parsons, founder and former director of King’s College Hospital’s assisted conception unit, said clinics were having a “free-for-all” at the expense of desperate.
He described a “perfect storm” as women delay getting pregnant to establish their careers, meaning they take longer to conceive naturally which can lead them to prematurely seek fertility treatment.
http://www.telegraph.co.uk/news/2016/11/28/majority-add-on-fertility-treatments-not-supported-science/
Fertility Hedge Fund? Pros and Cons of Egg Banking
Freezing and storing your own eggs when you are not trying to get pregnant used to be rare. It was something young women with cancer might do, if treatment could badly damage their eggs or ability to ovulate.
Not any more. Oocyte cryopreservation is now promoted as a “hedge” against declining fertility – called by some, anticipated gamete exhaustion (AGE). And if commercial egg freezing isn’t already a billion-dollar industry in the US alone, it might not be long till it is. Egg freezing is being heavily marketed, nudging women’s fears and aiming to make it trendy with slogans like, “Smart Women Freeze”.
Freezing eggs was never going to be as simple as freezing sperm, especially as there is so much liquid (cytoplasm) inside an oocyte. Although the first baby born using a frozen oocyte was in 1986, success rates for IVF with frozen eggs couldn’t compare to fresh eggs or frozen embryos.
It took 2 developments in the 2000s for oocyte cryopreservation to become widely accepted by reproductive specialists: a fast-freezing method called vitrification and an IVF method, ICSI (intracytoplasmic sperm injection) Vitrification had less impact on embryo development and was much more effective than previous slow freeze methods. And ICSI is thought to improve chances of fertilization, because sperm are injected directly into the cytoplasm. That might reduce the impact of changes in the oocyte’s outer membrane caused by freezing.
The egg freezing process is basically half an IVF cycle. There will be a couple of weeks of ovarian stimulation – hormone injections to get the ovaries to ripen a bunch of oocytes. Alongside, there is monitoring for adverse effects of these fertility drugs, and to determine the timing of the next step.
That next step is more hormones to trigger ovulation. Then comes oocyte retrieval: eggs are picked up with a needle through the vaginal wall into the ovary.
The costs of this could be from $12,000 to over $20,000, including medications and annual storage costs – more, if it takes more than 2 cycles or there are medical complications. If eggs are later used, there will be further costs for one or more ICSI cycles, along with more rounds of hormones and procedures.
In 2012, the American Society for Reproductive Medicine (ASRM) issued a statement that egg freezing was no longer experimental. Pre-emptive egg freezing “just in case” was already driving an increase in partial IVF cycles by then. It’s not the only reason for freezing eggs, though. It’s an alternative to freezing embryos for some women who are currently trying to get pregnant, too. The latest available figures from the CDC for the U.S. go up to 2014.
In 2013, debate began about law firms offering the cost of egg freezing as an employee benefit. 2013 was also the year that Sarah Elizabeth Richards’ book on egg freezing was published amid a blaze of promotional publicity, including her piece in the Wall Street Journal, “Why I froze my eggs (and you should too)”.
Since then, there have been high profile announcements by Facebook (in 2014) and Apple (in 2015) that $20,000 a year towards covering the cost of egg retrieval and freezing was now an employee benefit. The U.S. defense forces included it as a benefit for active duty servicewomen in 2015.
Richards reported that she spent nearly $50,000 on egg retrieval and freezing over 2 years – between 36 and 38 years old. The age women are doing this is getting lower, though. Egg freezing is now being marketed to women in their 20s, and you don’t have to look far to find people arguing it should be discussed with all women in their early 30s if they don’t already have a child (example). That’s a no-lose business proposition for reproductive services.
But the American College of Obstetricians and Gynecologists (ACOG) has issued a statement saying that there was not enough data to recommend egg freezing “for the sole purpose of circumventing reproductive aging in healthy women”.
There is a core problem here. The younger women are when they freeze eggs, the less likely it is that they will ever want to use them. They will be infertility patients without ever being infertile. The older women are, the less likely it is that their frozen eggs would make a difference.
The ASRM has said there is a “relatively high likelihood” that women who freeze eggs before the age of 35 will never use them. Women’s fertility declines gradually from 20 to 30 years of age, then more steeply somewhere around 35, and ever more steeply from about 38, before ending at menopause (on average, around 50).
The rate of infertility is over 60% between 40 and 44, but the rate of infertility is still only 30% between 35 and 39 [ASRM]. Pregnancies over 40 carry higher all-round risks, even for the healthiest, fittest women. And by 45, it’s very unlikely a woman can have a baby – with or without IVF.
Of the women who had a baby over the age of 40 in 2011, only about 6% got pregnant using assisted reproductive technology (ART – any IVF technique) [PDF]. (I didn’t find data on how often pregnant women over 40 were having their first baby, and planning to.) For the women who use ART, most will use their own, “real-time” eggs. At 39 years old, about 10% will use donor eggs, rising to 50% of women around 44 [CDC data].
Let’s step through how that might change if a woman whose fertility isn’t immediately threatened decides she would like to freeze eggs in her 20s or 30s for her own use. This is when we should start calculating the odds of being more or less likely to have a baby: life choices, health, emotional wellbeing, and chances of being a mother (and how) could all be changed after taking the first step down this road.
1. Consultation and testing
There will be history-taking, blood, and ultrasound tests. This is to see if (a) there are any conditions that increase the risks of ovarian stimulation, and (b) to try to estimate ovarian reserve (whether there are enough oocytes that could be ripened). For (b), the evidence for the value of these tests is not strong at all, although there is plenty of marketing hype around them. There could be genetic testing, too.
I didn’t find good data on how many women don’t move past this first base, either because they are not accepted as candidates or they change their minds.
This step is a no-lose business proposition for a service provider. From a consumer choice point of view, though, it is fraught with complexity. The bases for the choice that a future self would make in choosing an IVF service provider might be very different from the choice of an egg-freezing option. Years later, another clinic may be having far better outcomes. Yet, the choice of oocyte cryopreservation provider might pre-empt or constrain those later choices.
2. Fertility drugs for ovarian stimulation and ovulation induction (ripening and releasing eggs)
This step involves daily hormone injections for a couple of weeks and frequent monitoring, including vaginal ultrasound.
Like all major hormone treatments, adverse effects are common. A recent systematic review of hormones for triggering ovulation estimated the rate of adverse effects at about a third of women. That includes injection issues and effects of hormones on the body and emotions.
The most serious risk is ovarian hyperstimulation syndrome (OHSS). The review said that moderate to severe OHSS is expected in 3 – 10% of ART cycles. The risk of OHSS is higher for young women. OHSS can be fatal, so women with serious symptoms will be hospitalized.
The rate of canceling a cycle because of adverse effects, or the cycle not resulting in enough eggs, varies a lot. Anywhere from 2 – 30% of women on ART cycles have been estimated to cancel the cycle or have a low success rate at this point. In the CDC’s national data for 2014, about 10% of cycles were canceled. A study on one clinic’s results for women starting cycles for egg storage reported a 21% rate of too few eggs – and most of those women still had too few eggs after multiple cycles. (The women in that study were all over 34.)
There are big question marks here, because most of the data about ART comes from women who are trying to get pregnant. That might mean a greater willingness to tolerate adverse effects and plough on than a young woman for whom this is not a last chance.
After so many years of IVF, you would think we would have conclusive data on all the key long-term health questions for women and children, but we don’t.
There is more longer term data for women, but it is in mostly older, infertile women having infertility treatment, not young, healthy, fertile women. The data suggest ovarian stimulation doesn’t increase the risk of breast cancer (see here and here), although there is not enough data to put other reproductive cancers in the clear for fertile women using fertility drugs (here).
There are still open questions about the longterm health of people born after IVF (here and here). A systematic review in 2009 found no longterm health data in children or adults born after oocyte freezing, and non-systematic reviews in 2013 and 2014 didn’t either.
3. Oocyte retrieval (egg pick-up)
The success rates for this aren’t separated from the data in the previous step. The common issues here are pain during, and for 1 of 2 days after, the procedure, plus adverse effects of the anesthesia/analgesia.
The less common adverse effects are bleeding, damage to organs, pelvic infection, and serious anesthetic complications (from less than 1% to 2 – 3% per type of complication).
4. Repeat cycles
I didn’t find data on how many cycles women have, or how many eggs women store.
Around 90% of eggs will survive the freezing/thawing process in the short-term at least [ASRM], but those won’t all successfully fertilize. And only a minority of embryos lead to a live birth [CDC]. So 1 egg is a very long way from 1 baby.
There isn’t very strong data on how many eggs to store. Rosalie Cabry and colleagues refer to studies suggesting at least 12 are needed for 1 pregnancy, with others suggesting 22 for women 37 years old or younger and 55 for women over 37. On average, Cabry wrote, that means 2 – 3 cycles per hoped-for birth.
5. How likely are the eggs to be used?
It’s unlikely women will use their frozen eggs (unless perhaps they are donated/sold to others), but I didn’t find much data to narrow this down. In 1 study, where 505 women had frozen eggs across a 5-year period, only 20 had come back to try for a pregnancy at that point (4%). Kevin Doody from the Society for Assisted Reproductive Technology (SART), which maintains a national registry of most ART data, reported to Time magazine that there were 176 babies born after egg freezing in 2012 and 2013 in the U.S. nationwide. (There are tens of thousands egg freezing cycles each year.)
The majority of women who set out down the egg freezing path are likely to have some eggs. But most of them – and almost all younger women – may never have infertility problems, either because they will get pregnant without medical help, or they let go of the idea of pregnancy.
6. The chances of having a live birth because of stored eggs
Here the issue isn’t the success rates for stored eggs: it’s whether the success rates are higher with stored eggs than starting from scratch.
ART data is complicated. The numbers – for example at a single clinic – can be too small to be a reliable gauge of what might happen to others. There is often no good comparative data. And apparent success can be exaggerated by measures like embryo transfers or clinical pregnancy, not live birth. The miscarriage rate, including of the earliest chemically detectable pregnancies, can make quite a bit of difference, especially in older women. Both early and late pregnancy loss can be devastating, and that has to be taken into account.
What you select as the denominator makes a big difference. For example, the later down the line you start the clock ticking – say, only after eggs are already frozen – the more unsuccessful outcomes you leave out from the calculations. And that inflates the success rate. That’s called selection bias. This hypothetical example shows selection bias in action:
For women who start an ART cycle with their own “real-time” egg(s), the live birth rate is about 35% in the mid-30s, dropping to 16% at 40 years of age [CDC data]. With embryos from donor eggs from younger, highly selected egg donors (usually in their 20s or early 30s), the rate is close to 45% even at 40 years.
But there don’t seem to be any direct comparison studies with a woman’s younger self being her donor, so we can’t be certain at all how using stored eggs stacks up. The rates reported so far with autologous oocyte cryopreservation (freezing your own eggs) are closer to using “real-time” eggs than donor eggs from selected young donors. Those SART figures reported to Time showed a 23% live birth rate – but we don’t know anything about age (of oocytes or the women) or whether vitrification was used, so it’s not very helpful. It’s not encouraging, though.
Aylin Pelin Cil and colleagues pooled data from 10 studies with 1,805 women. Using a statistical model, they estimated live birth rates of around 20 – 30% in women below 30 and half that in older women. Again, no higher than ordinary ART. They suggested 36 as a cut-off age for egg freezing.
Neelam Potdar and colleagues take issue with some aspects of Cil’s modelling. They analyzed 17 studies, but decided live birth rates couldn’t be estimated. Potdar concluded the rate of pregnancies lasting longer than 20 weeks was around 7% per thawed egg – and somewhat lower for women using their own eggs.
The success rates represent enormous joy. The high rate of pregnancy loss only hints at the emotional burden. Pamela Mahoney Tsigdinos writes in “The sobering facts about egg freezing that nobody’s talking about” in Wired:
“We’ve…been led to believe that science has mastered Mother Nature. This is not true. I know. I am a former patient of three clinics in the Bay area, all of which were happy to sell me services as long as I could pay the bill. I had multiple fresh and frozen embryo transfers. Instead of taking home a baby, I came away with tremendous heartache…
The emotional toll associated with family-building failure can be crushing. The scientific fascination with the latest protocol and the marketing of fertility procedures as a lifestyle enhancer the past few decades has unwittingly led to a disregard for the emotional responses of these medical procedures, which creates a different kind of health concern – one involving mental health.”
With the medical uncertainties about egg freezing, comes the uncertainty about whether having “banked” eggs changes women’s life decisions.
Some are encouraging egg freezing as a way to lessen anxiety about loud biological clock ticking. It’s not the only option for coping with anxiety or regrets, though. And we can’t yet rule out that a sense of reassurance because of the backup plan means some women delay childbearing longer than they would have – increasing the chances of exactly the outcome they are worried about.
People talk about “egg banking” as though it’s insurance. I think both “banking” and “insurance” are misleading ways to look at this. This language gives an impression of more security than freezing eggs can deliver. And it doesn’t convey the health and emotional risks.
Egg freezing is important for women whose fertility is threatened by something other than age. It’s hard for me to see it as a step forward for others, though. There is no strong data showing important benefit, set against high physical, emotional, and financial costs. Even knowing that, it will still be seen as worthwhile to some women, of course. But it’s arguable how well-informed women are at this point. The promotional hype and service provider advocacy look more exploitative than empowering to me.
http://blogs.plos.org/absolutely-maybe/2016/11/01/fertility-hedge-fund-pros-and-cons-of-egg-banking/
Whats the reality of going it alone through sperm donation?
Cork woman Maria O’Sullivan (41) is the mother of two children conceived through a sperm donor, Zavier (5) and Aurora (20 months). Her eldest daughter, Freya (all pictured), who was conceived naturally, had just turned nine when she decided to look into sperm donation.
Despite massive changes in Irish society in recent decades, most young women still envisage a future where they will meet Mr Right, get married and have children (not necessarily in that order). However, more and more women who have not met a potential life partner by a certain age and whose biological clocks are ticking louder every year, are now opting to go it alone through donor conception.
Angela O’Mahony, counsellor at Waterstone Clinic, says most of the single heterosexual women she meets who are considering sperm or egg donation have had a long desire to have a child, but have either not met anybody or were in a long-term relationship that did not work out.
“It’s a decision that does raise a lot of ethical and emotional issues for some people, the greatest of which is very much around the implications for the child into the future. Science has made so many amazing advances, but it also throws up challenges on so many levels.
“Counselling is an invitation to explore some of these complexities and challenges, to facilitate the woman making a decision that feels right for her and her potential child,” she says.
Once a woman has made the decision to go ahead and try for a baby through donor conception, the next major challenge facing her is whether to go for an identifiable (known) or anonymous donor. There are no sperm donation facilities in Ireland, so most Irish fertility clinics use sperm banks in Denmark where the law allows for donors to be identifiable, which means a child could contact their donor at the age of 18 if they chose to do so.
Dr John Waterstone, medical director of Waterstone Clinic, says that while the number of single heterosexual women attending the clinic for donor conception is small, it is increasing. Three-quarters of women in this situation who attend his clinic are over the age of 37, and all clients considering donor conception at the clinic must undergo free mandatory counselling in advance of treatment.
“The donation co-ordinator then sits down with the client and goes through the list of available donors. Some donors will provide an extended profile with more information on their background, maybe a baby photo and even a voice clip, which is more expensive than a basic profile.
“Once a client chooses her donor, she needs to decide how much sperm to import. If she is planning to extend her family in the future, she might bring in more sperm so that all siblings come from the same donor,” he explains.
The sperm is deep frozen and imported in straws, one straw containing one unit of sperm. The cost varies depending on the number of straws purchased and whether the donor is anonymous or identifiable. For example, four straws from an open donor will cost about €3,350, and four straws from a closed donor will cost about €1,900.
Clients can opt for intrauterine insemination (IUI), a simple procedure that involves placing the donor sperm inside the uterus to facilitate fertilisation, or in vitro fertilisation (IVF), a more invasive procedure that involves combining the egg and donor sperm in a laboratory dish and transferring the embryo to the uterus. IVF is much more successful, particularly for women in their later 30s, but also about four times more expensive than IUI. The typical cost of one cycle in an Irish clinic is about €750, while the cost of a cycle of IVF is about €4,250.
Maria’s story
Cork woman Maria O’Sullivan (41) is the mother of two children, Zavier (5) and Aurora (20 months), conceived through a sperm donor. Her eldest daughter, Freya, who was conceived naturally, had just turned nine when she decided to look into sperm donation. She had been been in a relationship with a man who already had children, and did not want anymore. With the support of her GP, she decided to go ahead with treatment at Waterstone Clinic Clinic.
“I opted for an open donor as I wanted my child to have the choice of contacting the donor when he or she was 18. I had a choice of five donors and chose somebody I felt I would have sparked with if I was to meet him. It was like a blind date without actually meeting the person.”
After only one cycle of IUI, Maria was fortunate to get pregnant and her son Zavier was born at home in October 2010. She had some sperm from the same donor frozen at the clinic and, four years later, she decided to try for another baby. Aurora was conceived in March 2014, again through IUI and born at home in December that year.
“Freya is now a teenager and Zavier is starting school in September. Aurora is just a dote; she really completes our family. I had been parenting Freya on my own from the start so I knew I would be able to cope. I don’t have a lot of family around, but you make your own family. I have made great friends and have great support, it’s true that it takes a village.”
Maria has always been very open about how Zavier and Aurora were conceived and talked about it with Freya before they came.
A former kindergarten teacher, Maria is now at home with her children full-time. She also finds the time to volunteer as a doula, supporting other women through pregnancy, and with Le Leche League.
“I do worry about the financial side of things. I’m renting and the rental sector is a bit crazy at the moment, but I tell people not to let finances stop you from having a baby. There’s not much you need in the first couple of years, apart from your arms and boobs. I would definitely recommend sperm donation to other women. You can have a relationship any time in your life, but you can’t have babies any time. I’m so glad I had my babies, they’re amazing.”
Alison’s story
Alison (40) had been in a long-term relationship on and off with a man who had been married before and had two teenage boys. He had always been honest about the fact that he did not want any children, but she was convinced she would change his mind.
“I was 36 heading for 37 and the pressure was building. I went to the US for work, and was involved in a very serious head-on collision. That was a wake-up call for me. I loved the guy, but he was not prepared to have more children so we split up. It was a difficult decision but the right one.”
Six months after the breakup, Alison made the big decision to try for a baby alone through sperm donation. Two close female friends encouraged her on her journey, while her mother and sister attended appointments and supported her along the way.
“I was 37 heading for 38 when I made the decision. I had a voice constantly in the back of my mind saying you can’t not be a mum and that voice got louder every year. My friends and brother were on their way down the traditional life path of marriage and children that I had always thought I would follow. My family were not staunch supporters of my decision at the beginning but, to be fair to my parents, their concern was coming from the right place. They knew how hard it was raising kids with two parents, let alone one.”
Alison was referred by her GP to the Clane Fertility Clinic (since acquired by Instituto Marques). It took two rounds of IUI and one round of IVF before she became pregnant with her daughter Katy, now two years and 10 months old.
She is open about how she had Katy and intends to be open with her daughter in the future. For now, she explains to Katy how every family is different and while she doesn’t have a daddy, she has a mummy who loves her very much.
“Katy is not three yet but she says “Mammy, I have no Daddy” She sees the dads collecting other children from her childminder’s house. She has my dad and brother as male role models and if the right person comes into our lives, I would like him to adopt Katy, but I would need to be 150 per cent sure about him.”
A communications manager, Alison has a busy career and, as the sole provider for her little family, bears all the responsibilities for her daughter’s care. There is nobody to help her in the middle of the night when Katy is sick, nobody to help her with drop-offs and collections and it’s simply not an option for her to be sick herself.
Despite all of the challenges though, she says the decision to have Katy was the best she ever made and she will never forget the day her daughter was put into her arms for the first time and describes motherhood as “incredibly rewarding”.
As an administrator for the Single Mums by Choice and Single Mums By Choice in Waiting private Facebook groups, Alison explains that the groups are strictly for women either trying to or who have conceived through sperm donation. Anybody who wants to join can send a request via email to [email protected] which will be reviewed by the administrators. Members of the group come from all over Ireland, but are mainly concentrated in the Dublin area and they meet up for regular coffee mornings and days out.
Counsellor Angela O’Mahony says one of the biggest challenges for women considering donor conception tends to be about how to deal sensitively with questions from their child about the identity and whereabouts of the donor.
She encourages women to look for as much non-identifiable information as possible to help give their child a better sense of who the donor is, such as what kind of music they like or whether they are into football. This may also help the child to identify where his /her particular interest or talent originated.
“Women who opt for sperm donation on their own often have made a safe and conscious choice about how to have their baby. The sharing of the genetic narrative with a child is part of that decision-making process. While this can be daunting for some, keeping it age appropriate and honest tends to work well for most mothers,” O’Mahony.
Michelle McDonagh
http://www.irishtimes.com/life-and-style/health-family/parenting/what-s-the-reality-of-going-it-alone-through-sperm-donation-1.2768318
Tips on choosing the right fertility clinic for you
When the time comes to choose a clinic, there are a number of factors to consider, with one of the most important being success rates.
Pregnancy rates will often be quoted on a website, but you also need to look at the live birth rate – the number of babies born per completed cycle of treatment. Pregnancy rates are usually higher than live birth rates, but it’s the chance of having a baby from treatment that you are actually interested in. A call to the clinic should give you an indication, for your age of how likely it is that you would have a baby from one treatment cycle.
It is really important that you trust the clinic and get a good feel for the team. If you have an opportunity to visit a clinic or attend an information evening, you should get a good sense of the clinic and its ethos.
Consider the opening times and the location of the clinic. It is important that the clinic is within reasonable distance of your home or work. It’s best to avoid long journeys as they will result in added stress, time off work, expense etc.
The cost of treatment is a very important factor to consider. Enquire if there will be additional costs involved or added extras, as you do not want to be faced with an unexpected bill at the end of your treatment.
You also need to be sure that the clinic offers the full range of treatment options. In addition to offering IVF, the clinic should also provide the less invasive treatments. If you are aware of a specific problem that is causing your fertility issues or contributing to it, it is always best to make a phone-call and ensure they are the best clinic to treat your concern.
http://www.her.ie/health/start-seeking-fertility-help/309081