Infertility

January 17, 2006 | 10 comments
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Infertility is a huge topic, as large in its own way as the topic of birth control. Unfortunately, I don’t have the time to do it justice. I fully recognize that this can be an extremely sensitive issue for couples for many reasons. I absolutely do not judge any patients for making choices in dealing with infertility that I would not recommend professionally. I also fully celebrate the life of all children of God, regardless of how they were conceived. With this background in place, I wish simply to make three points.

1) Couples who have infertility are often pressured into believing that their medical options for treatment are much more limited than they actually are. I don’t have any quantitative data on this, but I and my colleagues have heard countless stories from couples who are told that in vitro fertilization (IVF), or related procedures are their only option. In fact, there are few causes of infertility where IVF is the only option. These include tubal blockage that cannot be corrected by surgery, complete ovarian failure (in which case egg donation is required), or extremely low or zero sperm counts. In every other situation, including unexplained infertility, there are other kinds of treatments which have been shown to be effective. Now, they usually do not have as high a pregnancy rate as IVF does per cycle. (Depending on the type of infertility, the live birth rate per cycle of IVF treatment initiated ranges from under 10% to over 50%, on average about 30% per cycle.) But over time, the success rates for other treatments can be comparable, with far less cost and and substantially lower medical risk.

2) New options have been developed for infertility that are based on the principle of seeking to restore natural reproductive function, so that pregnancy occurs in vivo, from a natural act of sexual intercourse. The most advanced system is called natural procreative technology (NaProTechnology, or NPT). NPT was developed based on Creighton Model Fertility Care System (a natural family planning system), and incorporates medications and hormones that are also used in other infertility treatments. A strong foundation of medical evidence has been published for this option, and there are physicians throughout the United States and the world have been trained in this procedure. See http://www.iirrm.org

3) Finally, the mainstream of reproductive medicine has attitudes towards early human life and treatment that I regard as problematic. These include:

a) Treating human embryos as expendable and interchangeable building blocks for life, rather than as individual human entities. Among other things, this is evidenced by the huge number of frozen embryos in this country that have no prospect of being placed in a woman’s body for further development. Also in the current approach to create as many embryos as possible, use (imprecise) criteria to define which ones look like they are most likely to successfully implant, and then freeze or discard the rest.

b) Minimization of the potential risks of assisted reproductive technologies in the pursuit of the distorted goal of a high pregnancy rate per cycle (as opposed to high pregnancy rate over a reasonable period of time). A good example of this is the current craze over intracytoplasmic sperm injection (ICSI), in which a single sperm cell is injected into an egg. ICSI was developed as a method to get around severely low sperm counts, but within a few years of its development is now being used in over half of all IVF procedures in the United States, a level of use that goes far beyond its original indication. Some clinics do 100% ICSI, for all patients regardless of their reason for infertility, because ICSI seems to result in a somewhat higher rate of pregnancy per cycle. And we have no data on long-term safety for children born with this procedure. A number of large studies and meta-analyses have been published in the major medical journals indicating that treatment with IVF procedures is associated with higher rates of preterm birth and genetic abnormalities. The absolute rates are still low, but are still of a magnitude that warrants a genuine concern and more caution. See for example the statements near the bottom of this link

http://www.mayoclinic.com/health/infertility/DS00310/DSECTION=8

c) In January 2006, an editorial by one of the top journals in the infertility field made the following statements that accurately reflect where the opinion leaders of the field of infertility medicine think the field is going [Fertil Steril 2006;85:12-3]:
“Are we ready to be the genetic engineers of the future?… In just over two decades, IVF has evolved from a laboratory curiosity to a commercialized, industrialized technology responsible for millions of births worldwide. More than 45,000 babies were born in the United States as a result of ART procedures done in 2002, an increase of approximately 10% over 2001. Just as laparoscopy replaced laparotomy, so will all traditional treatments for infertility be rendered obsolete by advanced reproductive technologies. Patient work-up will be minimalized and will be primarily targeted toward whether the couple can produce reproductively competent [sperm and eggs] and then followed immediately by treatment with a course of IVF and ET [embryo transfer]. Frozen eggs, frozen embryos, frozen blastomeres, libraries of genetic stem cells, and embryo genetic engineering will be the tools of the future. Aldous Huxley was clairvoyant when he prophesied, ‘our civilization has chosen machinery and medicine and happiness.’ But what will be the role of the doctor then in the future? Will patients input their symptoms and their DNA samples into a computer and walk away with a printout of their differential diagnosis and treatment plan? Will procreation involve genetically engineering and choreographing the unification of a desired oocyte and spermatozoan?â€?
Thankfully, not all physicians in the field of infertility treatment would agree with these statements. But enough do that it is of great concern.

This is my last post as a guest blogger to T&S. I want to thank this community and all who have participated. I have worked in these issues for many years, but still your thoughtful comments have helped me explore angles that I had not fully considered before. It has been useful for me, and I hope it has been helpful for some of you.

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10 Responses to Infertility

  1. Michael L. Umphrey on January 18, 2006 at 1:40 am

    Thanks for contributing these posts. These are hard questions, and I appreciate your insights.

    I tend to think about situations such as these on two levels, which have different methods of analysis and different conclusions. On the practical level of politics and law, I tend to favor very conservative answers, leaning toward maximal definitions of life. We have too many horror stories already–surgeons harvesting organs from people who were healthy, because there was a market for them. We are a so often a crass and carnal people that we need strict laws and bright lines.

    But IVF for a married couple, using their own parts?

    At a moral level it doesn’t seem wrong to me. I try to discern the principles that give rise to what laws we have–such as don’t look on others with lust, don’t be angry with others. Most of the laws we have, I think, are schoolmasters to bring us to see prinicples that we don’t yet fully grasp.

    Make sure no children come into this realm unless there are people here who are fully committed to caring for them forever, is one such principle, I think. I can’t generate any real sense that a loving couple who have chosen IVF have done something wrong.

    Of course, if I or the prophet was given revelation that an embryo is a human soul and should be treated as such, I would change my mind at once, so that “leftover” embryoes aren’t put in storage or destroyed. But for now, I want to side with what is clear to me: the reality of a loving couple wanting a child.

    But I’m sure the realms we are entering are extremely dangerous and the utmost reverence will be needed to make our way–an idea hard to square with the practices in handling embryoes you describe.

  2. Russell Arben Fox on January 18, 2006 at 9:42 am

    Joseph, thanks for making the time in your schedule to bring all of these ideas and arguments before our audience; it’s pushed our boundaries, I think, and in a good way. I hope you’ll be able to stick around to respond to the many comments and questions which this last series of posts of yours is bound to inspire. And of course, I hope you’ll continue to comment in the future, as issues like these are likely only to become more pressing for Mormons to respond to in the future.

  3. Marc Bohn on January 18, 2006 at 11:05 am

    While I lean more Michael’s way on IVF(Comment #1), I too have greatly appreciated your posts. I think they’ve helped all of us to see the issues that are involved in this incredibly difficult questions. We hope you’re not a stranger to the bloggernacle in the future.

  4. Ariel on January 18, 2006 at 5:10 pm

    I have enjoyed your posts very much. I have to admit my disappointment, though, that there will not be one on the morality of NFP vs. other BC. Could I convince you to email me about it?

    Are there treatment options other than NPT and IVF that offer similar sucess rates?

  5. Adam Greenwood on January 18, 2006 at 6:01 pm

    Ariel,
    Check his first post and the First Things article.

  6. Heather O. on January 18, 2006 at 6:01 pm

    Thanks for your thought provoking posts. I would be interested in what you have to say, if anything, on miscarriage, and how your protocol and theories come into play with that complicated problem. It seems that natural planning treatment and other things you have mentioned might not really be all that helpful in such a situation, but it would still be interesting to know if you did have some insights on this very under-researched problem.

  7. Ariel on January 18, 2006 at 10:14 pm

    Adam, I already read them. What I’m really going for is this”

    Dr Stanford calls NFP “a spiritually healthy approach for family planning” and has said “If the woman has a contraindication to pregnancy, I believe there are reasons to encourage complete abstinence from genital contact or NFP.”

    What makes NFP more moral than, for example, a barrier method? I understand the relative benefits- honeymoon effect, an understanding of the woman’s cycle, easier to concieve when you decide to, etc. But why is NFP more “spiritually healthy?”

    Ladies and Gents, sorry for the thread-jack, please carry on.

  8. Nicole on January 20, 2006 at 10:58 am

    As one who is a member and currently undergoing Donor Egg IVF with ICSI, believe me when I say that if we did not undertake this procedure we would certainly never have any children in this mortality.

    Also, in regards to your comments about embryos, when they are replaced in the recipient woman’s body, they will not necessarily succeed and grow to be a baby. They *do* choose the embryos that have no (or few) fractures, and have the most successful rate of continuing the cell division – in fact they have a better chance of succeeding than the embryos that are put into freezing. I will also state that when you do proceed to use the embryos in freeze later on, a good deal of them will not become children either. To me this is no different than the millions of eggs a woman loses between age and menstrual cycles with every year that progresses. Perhaps if you actually underwent the infertility process and really understood the minutae from personal experience you would have a completely different feeling about it.

    And no, there is no other IF procedure that has the success rate that IVF or Donor Egg IVF does have.

  9. Ana on January 20, 2006 at 1:20 pm

    I was very frustrated when I realized that infertility treatments could only work around our fertility problem, not solve it. Even if treatment succeeded and we conceived, we would still be infertile. This seemed fundamentally unfair and sometimes I wondered if the fertility industry kept it that way on purpose. After all, if they could make us fertile and send us on our way, we wouldn’t have to keep coming back. In spite of the new treatments Dr. Stanford mentions, by the way, we still fit into the group that would probably need IVF to conceive, even 7 years after we ended treatments.

    This sentence was interesting to me:

    “But over time, the success rates for other treatments can be comparable, with far less cost and and substantially lower medical risk.”

    Time is what the infertile couple usually feels they don’t have. By the time they get to a reproductive endocrinologist, they’ve often been trying to conceive for two years or more. In our case, it had been four years of working with ob/gyns and a urologist before we got to a real fertility clinic. The doctor we saw recommended six cycles of unmedicated intrauterine insemination before we considered IVF. We wore out after cycle number three. We were emotionally exhausted.

    We moved on to adoption. For us it was a tremendous relief to know that there was another, more certain way. Thousands of couples undergo IVF and emerge from the experience financially poorer (if not financially destroyed) and without a child in their arms. Couples who pursue adoption almost never exit the process without adding a child to their family, unless they choose to end the process early. That contrast confirmed our choice. We were so tired of waiting. We wanted a guarantee that the tunnel we were taking really had a light at the end. IVF couldn’t offer that.

    I’d never call IVF morally wrong for everyone. But I think it’s not healthy when people believe it’s their only choice. Eleven months after our last infertility treatment we brought home a beautiful 8 week old son. We definitely found our light.

  10. Nicole on January 20, 2006 at 6:40 pm

    Ana – Adoption may have been a good route for you, but it isn’t for everyone – some people such as myself do not feel that adoption is an option. Everyone has to make the decision in their fertility treatment that is the best for them. And you should know as well as I that there really are some issues that can’t be solved, and have to keep bringing you back to the IF Specialist. For example, I have premature ovarian failure. No matter what they do to me, I just don’t have any eggs left, at the young age of 27. My ovaries are non-existent. Yet we know that we have a child that is at least half biologically ours, and the opportunity for me to carry for 9 months and have that bonding experience with our child will be worth it for all the injections. We will have to go through this every time we want another child. My condition will never change. And there are some women that have such amazing Endometriosis or Polycystic Ovaries, that, no matter how many times they have a lap to remove it, it just comes back.

    Granted, I will not have ever had to go through all the IUIs and IVFs that you have – I’ll get a donor, and all I have to do is be given daily injections to create a suitable environment for a fetus. It will almost certainly succeed on the first or second try. That is not to say that we are not tired of the tears and the heartache, but for us, adoption is not the way we want to go. Everyone has to choose the right path for themselves.

    To address the quotation about time that Ana addressed, the thing is, when you are going through treatments to conceive over a lengthy period of time, there is a time factor to consider because the older you get, the lower quality your eggs become. You are sort of racing the clock, especially if you start when you are a little older. 6 years of infertility treatments starting at age 25 can drastically reduce your chances of having a successful pregnancy with your own eggs. If you wait too long you wind up having to consider things like IVF or DE IVF because as you age, your eggs become less and less capable of becoming a sustained pregnancy. Especially after you hit age 30.

WELCOME

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