This is the machine that we use to actually freeze the embryos and
they're stored at minus 298 degrees ... it's passed through a series of
solutions that allow it to be frozen. You can't simply freeze and thaw a cell
or an egg, or else it will essentially explode when you thaw it ... various
substances have to be put inside the egg or the embryo before it can be frozen
and thawed successfully.|
So that's all done in this machine?
That's right ... and these are just liquid nitrogen tanks here and we're just
beginning our pre-implantation genetics program and ...
Pre-implantation genetics is kind of a new way, where you take an embryo and
you biopsy it. You check it out genetically before you put it in. This is
something that is going to be very commonly done over the next five to 10
What's that let you do?
It lets us evaluate whether or not it has Down's or other chromosome
abnormalities, whether it's male or female. In the future we'll be able to look
at even finer details of the baby ... that's going to emanate from that
This is mind-boggling to people, right? Here you can take an embryo and you
can do all this analysis on them, freeze them and pick out the goods ones. Does
this seem other worldly to you at all?
No, it's a natural progression of the knowledge we have of how this works and
the next step is going to be, make sure you know what you're putting back in.
In the step after that I'm sure it's going to be, can we modify it? Can we
correct problems in the embryo before we put it back in? It's going to be a
fairly contracted period of time before we get to that.
So what does that mean? That we'll be able to eliminate certain genetic
I would think specific diseases that are due to some single gene defect are
probably the most likely thing to be corrected first, and, hemophilia. Sickle
cell, that's a bit down the line, but I don't think it's that far down the
line. We just need to learn how to incorporate the correct gene into the DNA
without causing any problems in that embryo.
... This is where we do hormone [testing on] each patient going through an IVF
[in vitro fertilization] cycle ... Each [patient] going through a cycle is
evaluated both with ultrasound to make sure their follicles are growing
correctly. We also do a variety of hormonal test to make sure that not only the
follicles are growing as they should, but they're functioning as they should.
By looking at ultrasound as well as hormone test, we have a good idea of
whether or not the eggs ... are likely to lead to a pregnancy. So it's all the
monitoring process. Each time a woman comes in, she has an ultrasound and she
also has blood drawn.
Is this like a medical procedure where it's sort of down to the mechanics
and in eight days she's going to take this pill or that pill. Is it sort of
routine at this point?
Most patients are routine, but probably one out of every five does something
unusual and that's why this monitoring is critical to make sure that you adjust
what she does.
Just tell me how much monitoring you have to do to make the cycle [work],
how delicate it is and how much attention?
These cycles take three weeks. Patients come in six to eight times over the
three weeks. They have an ultrasound each visit and they have a blood test most
visits. It's not uncommon to need to make adjustments in the medication
protocol, and it's a very important decision when to actually remove the eggs,
when to retrieve the eggs. You do it too early, you have immature eggs that
aren't going to fertilize. If you do it too late, you get what we call
post-mature eggs, they're of low quality and unlikely to implant.
... It's like you have your own hospital here.
That's right. With an operating room and the ability to evaluate blood test, do
ultrasounds, do procedures. It's an accredited operating room ... This is an
andrology area, where various tests are done on sperm. Everything from semen
analysis to sperm survival to antibody testing and a variety of other things.
So this is more a diagnostic area and we try to separate the diagnostic area
from the treatment area, which is in back.
So here you're trying to figure if there's something wrong with the
That's right. A couple comes in, and roughly half the time [it's] the sperm
factor and roughly half the time it's primarily something going on with the
female. So this is the area that we use to evaluate the male's fertility.
Are there new things you do in terms of treating male fertility?
Well, one of the things that happened in IVF over the last 20 years--probably
the most important thing is the ICSI [intracytoplasmic sperm injection]
procedure. Now that we can inject single sperm into eggs, unfortunately, a lot
of the research in this area has fallen by the wayside. You just pick a sperm
up, you stick it in an egg and it fertilizes. People aren't that concerned
about why it wouldn't have gotten in there if you hadn't stuck it in there. So
it's just changed the face of male fertility.
It's truly amazing to look back, six to eight years ago, very low fertilization
rates, very low pregnancy rates for male factor infertility and now, it's easy.
In fact, virtually no couple will fail to become pregnant because of a sperm
problem. It all boils down to the egg. If they're good eggs and we can find
even a few sperm and we have many ways to find those few sperm, they're going
to have an excellent chance of getting pregnant.
It's extraordinary that you're doing all these things that nature can't do
... how many [babies have you had here]?
Well, I know it's many hundreds, but I don't really keep track. Because to me,
once the patient's pregnant, I'm not involved anymore, in a sense. I love to
see them back and keep in contact with them, but ... as soon as you have a
positive pregnancy test, there's another patient there who's trying to get
pregnant. So it's a constant battle against fertility and infertility. Thinking
about all the babies you helped someone have doesn't matter when you have
someone new to deal with who's not pregnant. So it's not something I even think
So do you not think about the fact that you're making babies here?
Yeah, I think about the fact about making babies. But the fact that I helped
someone have the baby last week, is not nearly as important to me as the person
that's sitting in front of me right now trying to have a baby. So that's why I
don't focus on that. Some clinics have long lists or pictures of everyone
they've helped have a baby. To me that gives me a sort of false sense of
security. I want to be a little on edge. I want to be out there helping the
next one and not thinking about the last success that I have.
... What variety of walks of life and family dynamics do you see come
through here? Doesn't that strike you?
Oh, absolutely. So many different kinds of parents. So many different kinds of
relationships. So many people involved. Sometimes five or six different people
have to be coordinated to make a family. It's amazing.
What do you mean five or six people?
You can be getting eggs from one or two different people, putting them into
another uterus, using sperm from a husband but also having donor sperm back up.
So you can have a ... number of gametes and uteri coming from here to there and
you have to coordinate it all and make it all happen on the same day and make
it happen in a successful way.
Does it seem like some sort of genetic grab bag?
No ... it seems well planned and it has to make sense to me. I do have people
that come in and have ideas that just simply don't make sense to me. I don't do
those. For example ... we had a couple and the wife had lost her uterus because
of cancer. So they were going to use a surrogate along with her eggs to try and
have a baby. Well, they were so distraught of having gone through this
procedure that they wanted to make absolutely sure that it worked the first
time. So their plan was to use three different surrogates at once. Given three
shots at having a child. So things can get a little too complex and you have to
look at the overall picture and what's in the best interest of the children as
well as the couple.
How do you decide?
I think it's experience and really getting to know the couple and always
keeping in mind the best interest of everyone involved. But, in particular, you
have to think about the baby. So they're being brought up an optimal
environment and a good environment. That's the thing that most ethical
decisions really hinge on in this field.
Is it your job that ...
I don't know if it's my job, but I can't do something that I don't feel
comfortable at. It's very clear if you talk to different fertility specialists
that different ones have different views on these things. In fact, in the case
I just mentioned, the couple I didn't feel comfortable working with, they went
somewhere else, and somebody did feel comfortable working with them. There is
not a very tight set of ethical guidelines in this field so sometimes it's just
a case of finding the right fertility specialist.
It's such a personal process.
It's so personal that ... I don't feel that the infertility specialists should
interfere in it in any substantive way, unless it transcends his ethical
boundaries. Most of our ethical boundaries are rather wide, because we do feel
that the couple should have wide latitude in determining how they have a
A key point is that you don't judge fitness of people that are trying to have a
baby naturally. We don't say how much money do they make? What kind of house do
they have? Do they have a good extended family? How much education do they
have? We don't make those kinds of decisions of society for them, so we have to
be very careful about making those decisions for people that happen to need
help to become pregnant.
You were talking earlier about how it's the egg, the uterus, the sperm. How
do you decide what the problem is, in a fertility situation?
There are diagnostic tests that are helpful in each of those areas. But that
being said, there are certain times when the sperm looks fine, the eggs look
fine, both if you looked them directly as well as the blood test, and the
uterus looks fine--an unexplained infertility--you're not sure what's wrong.
In cases like that, you have to decide what's most likely to help. What can I
change? What can I switch out? Would using a different uterus be better? Then
you would go to surrogacy. Would using a different egg be better? Then you go
with egg donation. And I mentioned, it's very uncommon for sperm to be the
limiting factor, because if you can pick a sperm up and force it to fertilize
the egg, that's very unlikely to be the reason that that couple doesn't get
Do you find that couples start thinking they're just going to do a little
and [then] they're using eggs from someone's sperm, from someone's uterus, from
Absolutely. Couples come in with the conception of how they'd like things to
be. Many of them, particularly early in the process, just want to know, "Is
there something we can do, just the two of us to help improve our chance of
becoming pregnant," and when that doesn't work, it antes up a little bit.
Something else is done and then another step. Then it's the eggs and you have
to consider another egg and soon things may be far different than they expect
it. But at the beginning and at the end, they have the same goal--have a baby.
There are many couples that fall out along the way, and say, "I don't want to
do it if I have take drugs," or "Okay, I'll take drugs, but I don't want to do
it if my eggs are going to aspirated," and so each couple has some limit.
... once couples get involved in the process, there's a tendency to make it
want to happen and they continue to do more and more aggressive procedures
until it does happen. The truth is that with current technologies absolutely
every couple could have a baby, there is no doubt about it. If you think about
it, if the womb could use another egg or another uterus, it's going to happen
for them. It's just a question what procedure it's going to take to accomplish
it, and whether or not they're willing to do that procedure.
Are we doing something different than traditional infertility treatments?
Well, we're progressively taking care of different kinds of problems. We've
largely eliminated, at least, male factor problems with ICSI, and then with
newer procedures in which we take sperm from the testes, or procedures in which
we activate eggs after a sperm is placed in the egg. [There's] almost nothing
in the sperm area that we can't deal with. Most of their problems are also
eliminated through the use of in vitro fertilization and other techniques. So
we're down to just the last few things that keep us from succeeding on a
... It's a personal thing, maybe. I like being able to help couples that no one
can help or very few other centers can help. I like to see a progressive
chipping away at the number of couples that we can't help have a baby. So each
new technique, depending on it's importance, may get rid of another 10% or 15%
or 2%, but in each case, that's another one or two out of 100 babies that
wouldn't have been born if that technique wasn't there.
What are these techniques? What are you doing?
Well, the ICSI procedure, in which a single sperm is injected into an egg,
probably eliminated 30 or 40% of couples from the group that couldn't get
pregnant, no matter what you did if you exclude using donor sperm.
Cytoplasmic transfer is a very useful technique for women whose eggs are not
very good quality, who consistently fail because their eggs and their embryos
just aren't good enough to implant. Right now, that's the biggest area that
needs work. It's not the final procedure for that. We have a lot to do in that
area, but it helps us do something for those couples, the most desperate kind
... What happens in cytoplasmic transfer ...
We take some of the fluid from inside the egg of a young, fertile woman and
inject that fluid into an older woman or a woman whose eggs aren't as good a
quality as those from whom we're getting the fluid to begin with.
Some people would say, why? That's it's engineering ... how do you feel
about that response?
I don't understand the criticism.
Everything we do is engineering. It's trying to change something. If there's
something wrong with the fallopian tube, we reengineer the fallopian tube, the
ovary, the uterus. The egg is just one more element in the process, just as the
Do you think there's any place that we can stop?
We shouldn't do procedures that cause more harm than good. That's a very
difficult definition to really pin down.
You see a lot of couples in here that have failed before. What is your
approach to them?
When couples fail before, sometimes it's because the previous fertility center
missed something. So the first thing you have to do is go through every record
and try to find some clue as to why they failed before. Sometimes, they just
failed because their prognosis is very poor and then you have to apply some of
the new technologies that you have in an attempt to move them from the group
that's not getting pregnant into the group the can get pregnant. That's the
key, just getting someone into a group that can get pregnant. You can't
guarantee anyone a pregnancy, you can't cause a pregnancy, but you have to put
them into a position to succeed. Many of the patients I see who have failed
before never had a chance.
They didn't have a chance, because?
They had no embryos to transfer or the embryos they had to transfer were very
poor quality. They didn't even have a crack at it and that has to be your first
goal. If someone has a legitimate chance at it and they're willing to work at
it hard enough, the vast majority are going to succeed.
What are they like when they come to you?
Most of them are very tired of the process by the time they've come to me. It's
extremely rare that I'll see anyone who's been trying for less than a couple of
years, and usually, they've tried many different treatment techniques. They've
all failed. In some way, they may be hopeless. At least, they've given up hope
in those intermediate or beginning techniques. So you see a lot of fatigue from
But there's some excitement, too, because everyone knows, in reading magazines,
there are many people who have succeeded with these advanced techniques, so
there's an excitement, fatigue, a wariness. It's a combination of different
emotions and different couples have these emotions to varying extents.
Some people we've talked to just cannot understand peoples' desire for a
child of their genetic heritage. Do you?
Absolutely. The desire to have a child is one of the most basic instincts that
humans have. It's a lifelong dream for many people. When you're a child, you
visualize what your future's going to be like. I'm sure there are some people
whose ideal vision doesn't include a child, but the vast majority of people do
have a child in their future. When they've accomplished even everything else in
their life and that one little piece isn't there, isn't incomplete and they're
incomplete as people until they accomplish that.
Are you seeing a lot of people that have put off child bearing?
Absolutely. It's one of the reasons that the number of couples seeking
infertility care has gone up because the woman has waited until her fertility
has significantly diminished. It's important to remember that at the same time,
men's fertility also is reduced as they get older.
I remember one couple in particular, they came to me and said, "We both have
the jobs we want. We're in the positions we want, we have the house we want, we
both have these great cars, now we're ready to have a baby." I said, "How old
are you?" She said, "I'm 46." He said, "I'm 48." They got everything in their
life ready, but they waited too long to get one piece that they wanted and that
was to have a biological child together.
What happened to them?
They ended up getting pregnant, but using donor eggs.
Is that fairly typical ...
Any woman who waits until she's 42 and then needs to see a fertility specialist
has a very high probability of ending up with donor eggs.
And so, all of a sudden, you have one of the genetic [links
That's right. If you put everything else first, that's the thing you end up
sacrificing. The female partner's genetics aren't going to be there if you wait
to long, if you make sure you have everything else first that's what you give
What do you say to those people who say, "Why don't you adopt? There's
thousands, millions of children in the world?"
Adoption is an extremely difficult process, time consuming, expensive. Perhaps
many of the things you could say about what we do, but the loss of any genetic
contribution by either partner is very devastating and the effect on the
children in the two situations is very different.
When someone finds out they're adopted, by definition, it meant that someone
rejected them. When they get pregnant, even through egg donation, sperm
donation, it means somebody really, really wanted them and that's why they're
there. So it's a lot easier for the parents and the children to deal with
With regard to adoption, also, one of the problems is you really can't select
those characteristics that you want when you adopt. If you get picky at all in
adoption, you're going to end up without a baby. But the beauty of egg donation
is that you can select characteristics that are important to you. You can
select someone who has similar interests to the female partner. You can select
[someone] who looks like the female partner. She also gets to carry the baby
and that's a tremendous factor in bonding that you miss if you do adoption
You told us a story about a person that was a backup singer for rock band.
Could you tell us that story.
We've seen the role of surrogacy expand over the last several years and one
couple we worked with, the female partner was a backup singer in a rock band
and she was getting later in life. As I recall, she was 39 or 40 and was very
concerned that she would lose the chance to have children that were hers
biologically, so she chose to use a gestational surrogate in which her eggs and
her husband's sperm were placed, after fertilization, into a surrogate. She
could continue her career; yet, maintain her ability to have a biological
What do you think of that?
Couples should have a right to choose their method of reproduction and that
unless it's outside the bounds of ethical and legal behavior, they should have
the right to do that.
What is outside the bounds to you? Could you give us another example
... The ethical boundaries are indistinct right now and so each fertility
center, each fertility specialist will probably give you a different answer to
where those boundaries are. My boundary is, if I believe that a procedure may
harm the baby or one of the participants is involved ...
Arguably, inserting donor eggs and eggs that have been substituted by
cytoplasmic transfer could create a somewhat complex social situation. What do
you think of that ...
Under circumstances, in which it's necessary, it's very helpful to mix donor
embryos and the mother's embryos because I believe that there is evidence that
the donor embryos may assist the mother's embryos in implanting and it enhances
the overall probability of pregnancy. In the end, it's not known which actually
implanted and subsequently led to a baby. It's been my experience the couples
doing that always believe that at least one of the babies born under the
circumstances is theirs biologically. It's a way of allowing them to achieve
their dream, isn't it?
What do they say to you?
What I'm told is that at least one of these children looks exactly like I did
when I was a baby. I'm certain it's mine. I don't need to do any genetic
testing. I know.
What do you think about them doing genetic testing?
I don't favor it. I think genetic testing in that situation really shouldn't be
done. The fact is, those babies are their children at that stage, it really
doesn't matter where they came from biologically and I'm concerned that finding
out may affect how that child is treated.
In what way?
In a situation where one child is theirs completely biologically and the other
is only half theirs biologically, they may treat those two children differently
and that concerns me. That child is 100% theirs regardless of the paternity and
maternity of it.
Do you think they would always be looking?
That's not my experience. My experience is that they look carefully after birth
and for perhaps some months after that. But with time, that really becomes a
secondary issue. The same is true of egg donation. By a year or two, the
thought that an egg donor was involved just simply doesn't enter their mind.
Where do you think all of this is heading for? Are we on the cusp on
anything new ...
... Here's my thinking. What is going to happen in the future is that embryos
are going to be evaluated before they're transferred into the woman. Within
five to 10 years, virtually no couple will just put random embryos into the
uterus. As the technologies are available to assess them, they're going to
insist that they be assessed.
Why put in an embryo that would be a Downs syndrome, for example? It's
pointless. So they're going to select among their embryos and place those that
are healthy in the uterus. So that's going to be one important step.
Another is that we're going to understand implantation better so that we can, I
believe, greatly increase the probably that those embryos will stick. So,
ultimately, you'll have a situation where you know the embryo's okay and you
can make it stick, except in very rare circumstances and that's coming in the
next 20 years ...
What is the step after that ...
Well, somewhere in that process, maybe after, maybe while this is going on,
couples are not going to be content with simply assessing the embryo, they're
going to say, "Can I take care of problems within the embryo? Can I enhance the
embryo?" They may be looking at specific genetic problems within the embryo
that can be corrected at that stage. They may be looking at enhancing areas of
the embryo that are a problem for the parent.
Where do you think the areas are that they most likely enhance?
Well, it may be, for example, identification of a gene or genes that predispose
to alcoholism or depression. A couple wants to have a child that's theirs
genetically, but if it's caused them a great deal of problems in their life,
they may not want to pass on that particular aspect of themselves to their
children. This would be an opportunity to go in and correct a genetic problem
that they have, to make things better for the next generation, which is, I
think, every parent's dream.
What about the likelihood that their male child will be very short?
It becomes more difficult when you look at other things. For example, height.
It's say that a couple was, for genetic reasons, very short. Then it would be
legitimate to make alterations that give them a normal height child. On the
other hand, a couple who's normal, who has normal height, but feels that their
children would have an advantage if they were considerably taller than other
children, that's an ethical area that I probably wouldn't want to get into.
You probably wouldn't want to get into or you think that the sands will
Well, ultimately, what a reproductive endocrinologist does is dependent on the
available technology, their personal ethics, and then the social milieu. Any
one of those three things can limit what's done. It's almost certain that
things are going to be done in this area 50 years from now that society
wouldn't accept now ...
What sort of things ...
I'm thinking, in particular, of enhancing characteristics that children have
that are average or above average to make them exceptional. That's an area that
I'm not ready for, society's not ready for and the technology is not there.
However, the technology will be there soon, and then it's going to depend on
the individual specialist in this area and what society will allow.
Your attitude right now is on the cutting edge of the technology? You're
quite willing to do as much as you can in terms of these technologies. Where do
you think you will stand in 25 [years] ...
Right now, the benefits of going forward with these technologies vastly
outweigh risks. It's hard to say where anyone is going to be on an issue in the
future. Every ethical decision has to be made in its proper context, religious,
socio-ethical and societal and so it's very difficult to make that assessment
this far in advance.
... this history of infertility treatment, in fact, is it always an
experimental technique? Has it been a grand experiment ...
Absolutely. IVF, from the beginning, has been one experimental technique after
another and what happens is, after five, seven years, it's no longer
experimental, but there are two or three other experimental techniques and
that's how it's going to continue to go until this problem is completely
solved. It's an amazing area of medicine in that way.
From the beginning, no one really knew if any of these techniques were going to
prove to be effective or safe, so there's a grand leap of faith each time
because the goal is so important, we feel like it's like worth that leap, but
they are progressive leaps to achieve each new goal.
Is it unique medicine in that way?
This one area of medicine may be unique in that nothing seems very certain in
advance. It's very difficult to test these ideas on other animals because other
animals have different reproductive systems. What works in a mouse may not work
in a human and what works in a monkey may not work in a human. You really have
to try it in a human to be sure. That is one of the unique aspects of this
Does it draw a particular kind of person, because you see a lot of
It's an area where you can become a star very easily. There's no problem when
you have new technique with getting it on TV and that's unlike most area of
medicine. So it does draw the kind of physician who wants to have a big impact.
If you think about it, how can you have a bigger impact on someone's life as a
physician than to create a family, than to give them new children. Something
that affects everything they do, every day for the rest of their lives ... So
many fertility specialists share that characteristic. They want to do something
that matters, something that's important, something that's lasting.
When you see all these little babies, these couples come in ... you see them
all the time at clinics ... how does that make you feel?
It's tremendously, tremendously satisfying. That's what's it's all about. The
thing that I like best are cards we receive on the holidays and I look at these
cards. What used to be a husband and wife is now a husband, wife, child and a
dog. It's a family now and to create a family is much more than simply creating
a baby. It has a tremendously positive impact on the live of the parents and
can you imagine how well those children are taken care of by those parents?
It's an extremely positive situation for all of them ...
People say that this is also a grand experiment on women with high-powered
hormonal drugs. A lot of treatments that come and go and that we should sit
back and evaluate ...
There's really no way to evaluate it more than to do it. If you stop doing a
procedure to evaluate it, you can't evaluate it anymore. When you're in a
largely experimental field, some things are going to work and some things
aren't going to work. Certainly, women have gone through procedures that we
subsequently learned were ineffective. But that's the price all of us have to
pay, the specialists, the couple, in trying to reach our end goal, which is to
wipe out infertility altogether.
... Do you think more studies should be done?
The only advantage to a trial is that the patient is well informed, ultimately.
There are ethical questions about entering patients in trials in which they
won't receive what might be a new effective procedure. Is it fair to them not
to receive a new technique, not become pregnant and subsequently lose their
chance to become pregnant altogether? So there's a price to be paid to be in
the placebo group, in the no treatment group.
That's why it's very difficult, in this country, to do good trials. Couples are
not going to allow themselves to be randomly assigned to any treatment group or
a lesser treatment group. It doesn't make any sense to them to do that,
particularly if they're paying for it, which is a requirement in this
What would they say?
When we tried to set up trials before, they'd say, "Great, I'd love to be in
your trial, as long as I'm in the treatment group ... You want to put me in
that other group, I'm not interested." So you can begin a trial and once they
see that they're assigned or even if they suspect they're assigned to the wrong
group, they just simply won't continue in the study.
I'm not sure it's really fair to them to put them in that kind of situation if
there's some good evidence, either on an animal basis or in pretrial studies
that it may be effective for them. You have be very careful of any patients
you're going to put in a trial. You don't want to put a 42-year-old woman, who
may only have three months of fertility left into a trial in which she receives
sub-optimal treatment. It's simply not fair to her. So there are many ethical
issues about trials and to simply say we should do more trials ignores
practical aspects of it and ignores ethical aspects of it.
... To get back to the industry as a whole, you say this is a very
Extraordinarily competitive industry and getting more competitive ever year ...
In most areas of the country, there are simply too many reproductive
endocrinologists for the needs present in that area.
What are they using to compete against each other ...
Specialists in the field use three things to compete. They use success rates,
they use the availability of new procedures and ... they use price.
Talk about success rates. What success rate [does your clinic have]?
Our overall success rate last year was 47% clinical pregnancy rate per cycle.
Patients will frequently call a series of fertility centers and say, "What's
your success rate?" If the fertility center gives a success rate considerably
lower than others, they're simply not going to get a visit from that patient.
That's probably the most important factor that fertility centers use other than
generating the usual referral sources and things like that.
Do you have a problem with that?
Success rates are extraordinarily misleading and extremely easy to manipulate
and the information that many couples are given over the phone is simply
inaccurate or even when they visit, it's inaccurate because there is inadequate
standardization as to what a pregnancy rate is, who's included in that
pregnancy rate and over what time period that pregnancy rate was generated, how
were patients selected to create that pregnancy rate? It's an almost useless
A 42-year-old woman comes in and says, "What's your pregnancy rate?" And
someone says, "47%." That number has nothing to do with her. That number
included women who were 21 years old, it included women that had gotten
pregnant many times, and then lost their uterus due to surgery and subsequently
used a surrogate. It includes so many different things that these overall
statistics have noting to do with the person that you're talking to.
So I object to the overuse and the misuse of statistics, but it's absolutely
rampant in this field because it is the main way that fertility centers
You also raised [the issue] when I spoke to you a question about donor eggs
One of the easiest ways to manipulate the statistics, if you choose to, is to
push women who are poor prognosis into using an egg donor. These are women who
are unlikely to get pregnant if they use their own eggs and hurt your
statistics; and very likely to get pregnant if they use an egg donor and help
our statistics. So this inherent conflict in the mind of many fertility
specialists about this situation. They don't want her to fail, in part, because
of their statistics.
The question is: What does she want? What does she want to try? This is not
You also talked about people being drawn into IVF itself ...
Another way that centers can manipulate their statistics is to encourage
patients that don't need IVF to do IVF. These patients that could get pregnant
with much simpler, less expensive techniques. Thus, if they do IVF, their
pregnancy rate is going to be extremely high and if a situation is set up where
they're induced to do that, it's another way of making your statistics look
better. These are not really infertile patients, in the sense that most of the
patients that come to an IVF center are infertile. They really haven't tried
the conservative things before they go to the more advanced techniques.
What do you think about the financial plans, in particular, the money back
The money back guarantees, the so-called shared risk plans are of great concern
to me, because they're an indication for fertility specialists to do the wrong
thing. If a fertility specialist stands to lose money if someone doesn't get
pregnant, it can alter their behavior in several way that are not in the
patient's best interest. In and of itself, I don't think the money back
guarantee, is unethical, but it provides so many ways for unethical conduct to
occur that I personally am against it.
What kind of ways?
One thing that it can induce a center to do is to place more embryos back into
a patient then they desire. In fact, some of these plans specifically indicate
that the center, not the couple, decides how many embryos to replace. It can
also lead to problems with inducing patients to do IVF that don't need to do
IVF. And they're so financially complex that it's a rare patient who really
understands that it's unusual for the patient to benefit from a money back
Most of the centers that have money back guarantees specify what type of
patient can be in their money back program. And what type of patient is that?
The very patient who could have an outstanding chance of getting pregnant
without a money back guarantee.
What do you think is the main problem in infertility medicine today?
One of the main problems in infertility medicine is an excessive number of
multiple pregnancies. An important question to ask is: Why is there such a high
incidence of multiple pregnancies? The reason is that centers are trying to
maximize their pregnancy rate. It's one of the outgrowths of focusing on
pregnancy rate itself and not focusing as much on the consequences of that
In addition, by the time a couple gets to a fertility center, they want to get
pregnant and for many of them, they're not concerned about whether it's one,
two or three. They don't believe they can get pregnant at all and so they're
not concerned if a fertility specialist says, let's put in six or seven.
They've been trying for 10 years and couldn't get pregnant. They just want to
see any kind of pregnancy ...
Do you think something should be done about this?
... it would be a big mistake to limit the number of embryos that are placed
into a woman by legislation or any other regulatory body. Some women need large
numbers of embryos before they can become pregnant and if you set the cutoff at
three or four or five, some couples will not be able to have a child because
you did that. That's unfair to them.
Ultimately, the problem is not the number of embryos that are placed in the
uterus, it's the percent multiple gestation. The center should be evaluated on
how they do in limiting that ...
But do couples ... know about the problems of [prematurity]?
Infertile couples probably minimize the significance of complications that come
from multiple gestation. They do so because they're so desperate to have
children that I don't think they pause very long to think about that. They have
in their mind a certain view, a certain vision. When they think of twins, what
they see are two toddlers running about in a room with their parents. What they
don't see is a trip to the neonatal intensive care unit when those twins are 28
or 30 weeks and all the sleepless nights that they might spend worrying about
what problems are going to result from that prematurity, that hospitalization
and the costs and other problems that are associated with it.
So it's very important for the fertility specialist to let these couples know
that these problems are real and are serious. The fertility specialist has to
have a lot of input on the number of embryos that are [re]placed, so that
they're not putting large numbers of couples at risk for multiple gestation
simply to help them have one.
Do you talk to your couples about prematurity?
Absolutely. Before a couple decide on the number of embryos to replace, we tell
them our impression as to their chance of pregnancy, their chance of multiple
gestation. The effects of multiple gestation are significant. We discuss with
them the problems associated with multiple gestation, including prematurity, so
that they can make a decision, because we know that they're in a vulnerable
position where they may or may not fully realize that problems associated with
that, we limit the number of embryos that they can replace to some range.
I normally like to say, we'll put in two or three, for example, with two being
conservative and three being aggressive. I feel their input is important in the
decision, but I don't want to put them in a position where they have a serious
pregnancy complication because they were so desirous of having a pregnancy that
they overdid the number of embryos that they replaced.
A client of yours is 29, 30 years old, had four embryos put in fairly
recently. Why did you do that?
I'd have to know who it was ... If a woman had a history of poor quality
embryos or has a history of failed in vitro fertilization in the past, then one
of the right things to do, is to increase the number of embryos that you
replace. That's exactly a situation that legislation or limiting of number of
embryos to be transferred would harm. Some women aren't going to succeed when
you put two in, when you put three in ... You may have to put five in before
they're going to succeed. They have a right to succeed just as much as the
woman who's going to get pregnant when you put two in.
You're lucky ... in a way, that she ended up with two healthy babies.
Whenever you put in more than one embryo, you're taking a risk of a multiple
gestation. And no center has a 0% multiple gestation rate. If they did, they'd
have a very low pregnancy rate. So there are definitely risks in putting in
multiple embryos and the methods we have right now to assess the quality of
embryos are incomplete or inconclusive in some ways. Sometimes you look at an
embryo, look at set of embryos and you put too few in and sometimes you put too
In a neonatal intensive care unit we ran into a couple who had four embryos
put in. One of the embryos did not [make it], so they had triplets. At 14
weeks, they reduced the triplets to twins ... at that point, the woman's uterus
had stretched so much, she was threatened with miscarrying all of them at 19
weeks ... she had those babies at 26 weeks and they're very ill. What do you
think about that ...
The important question is: Are you doing the right thing? You can't always tell
if you're doing the right thing by the outcome. You can choose to go to a
restaurant, not drink and get killed in an accident on the way home. Does that
mean it was wrong not to drink any more than it means it was right to drink if
you did drink and got home safely? You have to use criteria other than outcome
in any individual case to decide whether or not the right thing was done.
By necessity in this field, because there are so many unanswered questions,
sometimes you're going to miscalculate and put too few in and cause a couple
that could have gotten pregnant not to get pregnant; or put too many in and
cause a couple that would have gotten pregnant easily with fewer to get
pregnant with a multiple gestation.
It's something that you have to accept in this field. It's a difficult part of
the field. None of us wants these couples to have premature children or to do
reductions or to do a reduction and lose the entire pregnancy. None of us want
that, but unfortunately, it's a chance you have to take in order to help them
have a baby at all.
The obstetrician who was looking after this woman said it was a very
depressing day for him when those babies were born at 26 weeks. He tried so
hard to keep them in, but he said, "... We [the doctors] need to get together
and confront this problem because the infertility specialist may not even know
that this problem is happening."
It's very important that the infertility specialist follow up with the couples
and find out what happened. I personally have gone to intensive care units on a
number of occasions. You can lose contact easily. You can feel that your job is
done once there's a positive pregnancy test and not even learn what happened.
To the extent that there's a disconnect between ones' actions and the
consequences of ones' actions, I think that's a negative thing.
Some people would say ... we are getting quite close to the time when
cloning will become an option.
These techniques, particularly nuclear transfer, are closely related to
cloning. The technology to at least attempt cloning in humans is readily
available. That's not what's keeping it from happening. Right now, society
isn't ready for it and fertility specialists are unwilling to do it in a face
of society's resistance to the procedure. But it's not really a technological
problem to begin to do human cloning. It may or may not work. There may need to
be many adjustments in the protocol, but somebody could tomorrow attempt to
make it work. So I don't think that these techniques by any stretch of the
imagination will cause cloning to occur. But they'll further the technology
that will be necessary to do cloning in the future.
Is there interest amongst you and your colleagues ...
Much of it's probably good-natured chatting, but at meetings there's certainly
those that indicate they wouldn't have any aversion to being a first person
cloned and suggested other people think that that would be a waste of the
cloning technique. That sort of banter.
So it would actually be a perfect thing for a ...
I have no doubt after talking to others in the field that there is a temptation
to do it. But the cost is so high and the ethical questions are so large that I
don't think that any of the well established [clinics] are likely to try that
type of technique.
But there's a point, let's say 25 years from now, where it's more accepted,
where a couple pays you and this is really the only technique that would give
them a baby. Can you see yourself saying this is a technology that you wouldn't
Cloning is really not a very useful technique to treat infertility. It's hard
to imagine a situation where that would be the optimal choice. And couples, I
don't think, at least I've never run across one that came in and said, "We'd
like to clone me, or clone her." That's not why they're there. They want to do
something unique with each other. They want to create some new being that is
the result of their union. So I really don't see the utility of cloning in
To get back to an issue ... do you think you're crossing natural boundary
[lines]? There is some concern. We interviewed a couple ... the husband was
infertile because of [Kartagener's syndrome] ... What do you think about
possibly passing on a genetic syndrome to his child ...
Couples in this country have a right to reproduce under natural circumstances
without regard to their genetic component. For example, if a woman has adult
onset diabetes, there's a considerably higher chance that their child will have
diabetes. Society doesn't say, "No, you can't have a child because there's a
higher than usual chance you're going to pass on diabetes to that child." I
don't think that it's fair to these couples to place restrictions society
doesn't place on them in a natural setting, in this more artificial setting.
So here we're creating children. It's something slightly different than
normal reproduction. People would say there's needs to be some regulation and
debate, and some following of these children in this situation, because it's
not normal reproduction. That sperm would have not gotten to the egg without
It would be irresponsible for a couple or for fertility specialists to help
create a child that would have some serious medical problems for which there is
no treatment. Most are not that clear cut. They may cause some disability, but
it may not be a serious illness or they may not cause it in all children who
are born under those circumstances. These are ethical issues that have to be
dealt with on an individual basis and I could certainly see that in some
situations there should be overall ethical guidelines about helping couples
that are very likely to pass on significant medical problems to the children.
But this needs to be viewed in an overall societal concept. If we're going to
do that with these couples, we also need to do it with couples in society, in
general, who have a chance of passing on other types of disorders. But the mere
fact that they're infertile, I don't think should cause them to be treated
differently from other people in society.
A doctor said to us that there is such enormous amount of money and care
going into treat infertility ... should we be raising questions [such as] the
money should be going to prenatal care for poor people ... It is quite
staggering ... the amount of care and the amount of money in this specialty.
What do you think of that?
Without a doubt I'm biased about this issue, but it's hard for me to imagine
anything more important to spend resources on than to create the very backbone
of our society, which is healthy family. People like to talk about how much
money spent on infertility. How much money is spent on treating colds every
year? Colds never caused a marriage to break up. Colds never caused someone's
career to go down the drain, caused anyone to commit suicide, caused all the
problems that infertility causes. Yet, I'm sure the same amounts of money are
spent on that.
Nothing affects quality of life like infertility of those couples that want to
have a baby. There's nothing better to spend money on then something that
that's positive. Something that generates good for the society. Rather than
eliminating a cold, you're actually doing something that can have a great
benefit to society for many years to come. So, yes, we need to prioritize
healthcare dollars in this country, but infertility healthcare dollars, you
need to be near the top.
But people who are proponents in strong family values, religious
[organizations like] the Catholic Church, say we're fooling with nature and
we're fooling with God's design.
Medicine itself is fooling with nature. When you take an antihistamine, you're
fooling with nature. The essence of nature is that something went wrong,
someone got an infection, someone got a disease and you're attempting to cure
that. It's absolutely no difference between a diseased ear drum that needs an
antibiotic and a diseased fallopian tube that needs to be either fixed or
circumvented with in vitro fertilization. It's baffling to me that people
don't seem to understand that infertility is just another medical problem.
Something is wrong, and the body of one or either of those two individuals, and
if it didn't relate to infertility, no one would have any problem treating it.
But because it's related to that, it's considered to be of less importance.
It's just nonsensical.
But treating disease is treating disease. This is creating life and this is
where these religious observers have a real question that we are creating life
Why do we treat disease? We treat disease to improve the quality of life for
that individual. Having children, creating a family is the ultimate improvement
in the quality of life. If treatment of disease results in a child, does that
make it any less valuable than treatment of a disease that doesn't result in
anything except the absence of disease?
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