ASK THE DOCTORS

Will infertility treatments (specifically male factor) become sufficiently economical so that getting a second mortgage on your home isn't the only option?

Depending on the problem, there are some problems that can be treated at low cost, but there are others that can only be treated with a high-tech procedure, like invitro fertilization. Those will remain costly. An example of a low-cost treatment would be somebody who has obstruction of the male tube. That can be dealt with surgically, which insurance would cover. The cost is not the problem of technology or techniques; it's a problem of insurance coverage. If you look at Europe, many of those procedures are covered.

We had a wonderful child 7 years ago but we have been unable to conceive since. All tests show normal for my wife and myself. I am 40 and she is 37. We have tried various methods and are about to try IVF. Has there been any progress in the diagnosis of "undiagnosed" infertility?

Unexplained or idiopathic infertility is what you're talking about. There hasn't been too much of a change in terms of diagnostic procedures in the absence of any obvious problems. But I can tell you that there is always a subtle problem that can sometimes be easily missed. For instance, it's more than likely that the woman's age is the problem. That could be the only thing preventing you from achieving pregnancy. IVF and related procedures could increase your chances. Our own data on unexplained infertility shows that intra-uterine insemination (or IUI) after controlled ovarian hyperstimulation has achieved very good results in couples. Our own data is 50% success rate per cycle, compared to about 2-5% per cycle when it is a natural cycle. Our own data has shown as well that if you do gamete intra-fallopian transfer (GIFT) the chance of success is 70%. There are techniques available to overcome the problem, even though there hasn't been much of a change in the diagnosis.

What progress is being made in research and treatment for Polycystic Ovarian Syndrome? There's been a good deal of new research going on, with some success. What do you think is the prognosis for the average patient?

It depends on what symptoms the patient has. If we focus on infertility, there haven't been tremendous changes. However, the changes that happened more than 10 years ago were new medications to stimulate ovulation. Lack of ovulation is the main problem. New medications like Lupron and Synarel (GnRh analog agonists) suppress the pituitary gland and suppress a hormone that is markedly elevated in these patients, that hormone can cause lack of ovulation.

Is there a way to stimulate sperm in a man with no sperm count due to overdosage of testosterone?

Yes, it depends. Many men have used testosterone for bodybuilding. There is an element of damage in the testes. If that damage is reversible, then the use of gonadotropin hormones may then stimulate the tubes in the testes to produce sperm again. You can see a urologist to assess the damage to the testis. The majority of cases will be reversible.

Is it really a "miracle" when a woman has 7 or 8 babies?

It's a miracle in a sense because the human uterus usually is meant to carry a single baby. If somebody carries twins or triplets, that's unusual. When it comes to sextuplets or more, delivery of such a number is considered a miracle that she could carry them to a stage of maturity that allowed them to be healthy. So yes, it is.

Why is there very little (government) regulation, if any, in this area? I am not for regulation in general, however; it seems that if regulation is to occur at all it definitely should be in this area.

I'm not sure that you're correct completely. There is a 1993 or 94 law passed by Congress enforcing that every unit providing IVF and related procedures comply with certain regulations, that the lab be inspected every year. Also, every unit is supposed to make the results available to the public through the CDC since 1995. The public now has the ability to look on the Internet and find results. They don't go to orthopedic surgeons and ask for that kind of information. The more regulation, the more difficult things can be. For example, I was trained in Great Britain and the regulation there is that you cannot transfer more than three embryos to the woman, to reduce the chance of multiples. But when you have somebody who is 42 and all the data shows that multiple pregnancy is low in that age group, if you transfer 5 or 6, you may boost her chances. If you were the physician, you would advise a procedure that gives her a better chance of success. Rules are good, but rules that are too rigid ca jeopardize the chances of certain age groups.

Is there technology currently available to fuse two eggs, use NO sperm, and still create a viable fetus?

Not to my knowledge.

Is there a procedure available now that will allow a man who's had a vasectomy to have sperm withdrawn without having the procedure reversed to impregnate his wife, and if so, is it as costly as the reversal and does it seem to be successful?

Yes. We’re very fortunate because we were one of the very first groups to have a successful pregnancy with that technique. If you don't want a vasectomy reversed, or if it happened 10-15 years ago, the treatment would be to retrieve sperm and fertilize eggs retrieved from the female. Unfortunately the woman would have to be subjected to IVF then. You retrieve the sperm through percutaneous sperm aspiration (done under local anesthetic) the needle goes into the male tubes. Or there is testicular sperm aspiration. That's a tiny biopsy from the testis. You can search for sperm in the tissue. These kinds of sperm are very weak, and the only way they could fertilize an egg is through ICSI, or intra-cytoplasmic sperm injection. The likelihood of success is, in general, in the range of 35-40 percent.

Do you think it is un-ethical of fertility doctors to not insist that patients consider selective reduction prior to fertility treatments, which may result in pregnancies with multiple babies?

I'll tell you what we do: Education and counseling to couples. Part of that is to tell them the chances that multiple pregnancy will occur. By the same token, you try to explore the religious and social background of the couple. Can they cope with a multiple pregnancy? If they understand everything and they are willing to take the risk, maybe you can transfer four embryos if the situation calls for that. If their religious background indicates they wouldn't even consider selective reduction, maybe you should transfer only three. You know that at least the maximum is triplets. It's basically understanding the couples and their needs. It's a matter of judgment and counseling.

Do you see the possibility of being able to take chromosomes from a non-sperm cell and/or a non-egg cell and creating a zygote from that? Remember that some men fire blanks.

It sounds like you're talking about cloning. I think theoretically the idea may be feasible but practically, there is tremendous controversy over whether this is something that should be tried or even looked at.

Is there any treatment for someone prone to ectopic pregnancy?

Nothing will change that, unless the person undergoes laproscopic tubal surgery, in an attempt to free any scar tissue around the fallopian tube. That may reduce the chances, but it will never eliminate it. Whatever damage caused the scar tissue to begin with may have damaged the inside of the fallopian tube. Patients who are at risk, when they conceive, they need to be followed up with very early on. Even if you implant embryos directly in the womb with IVF, there's still a risk for ectopic pregnancy because they don't implant right away. With IVF, though, you can either remove the diseased tubes completely or you interrupt the connection.

Regarding the woman who had eight preemies in critical condition: I understand that many people do not feel morally comfortable with selective reduction, even when it's very likely that many of the fetuses will die. However, isn't it possible, before fertilization, to determine that an unusually high number of eggs are developing, and simply drop that cycle? Then the woman could have started a new cycle at a lower dosage of fertility drugs, and attempted to have triplets or something.

Absolutely. I want to make sure the message is clear the role of the physician is to help the couple achieve their dream. But you have to avoid risk and complication, one of which is multiple pregnancy. If you have somebody who is producing many eggs, it's far better to cancel and try again. The problem is when you have somebody who's been through many cycles without getting pregnant, and everybody's pushing for something to happen. That’s when disaster happens.

Having tried IVF unsuccessfully, I was wondering if there are new variations of IVF which will reduce the amount of injections (and pain) required before aspirating the eggs. Also, being in my late 20's, how do my chances of getting pregnant via IVF decrease as I get older?

In your late 20s, your chances of getting pregnant are very high. When you reach 35, 38 or 40, the chances are lower. Unless there is a strong family history of early menopause, I'm not sure you need to worry. Yes, there are new techniques. Most of the medications available now can be given subcutaneously, or under the skin, rather the intramuscular. It's a very small needle and reduces the discomfort.

What do you see as the major advances we can expect from the field of fertility in the new millennium?

Obviously, one would expect a lot of advances in the future. Some of that I may not even imagine. If we take what's available and being tried, one procedure that may be a clinical practice in the future is cytoplasmic transfer for aging eggs. That would be eggs we retrieve from women over 40. Since we know the results of IVF are much lower in this age group. The ongoing research is to exchange the cytoplasm is these eggs with the cytoplasm from younger eggs from a donor. This may increase the success rate of IVF in the older age group, without the need for using donor eggs with all its religious and legal implications.

Please submit your questions to the Doctors of IVF Michigan.