How to Get Pregnant with the New Technology : A World-renowned Fertility Expert Tells You What Really Works, What Doesn't, and Why

CHAPTER 1

How Does the New Technology Work?

In the mid-1980s I saw a lovely woman who had undergone surgery by a well-meaning gynecologist for severe pelvic adhesions (scarring) caused by previous infections. (Nowadays if I were to see a woman with such severe adhesions in the pelvis, I wouldn't even attempt to try to solve her problem surgically, but would go straight to in vitro fertilization [IVF], a relatively simple, outpatient procedure.)

At the time, the surgeon who explored her felt that her only option would be an effort to free up the adhesions to her fallopian tubes and ovaries. Unfortunately, the doctor performing the surgery got into some problems with bleeding that were beyond his ability to handle and the only way he could solve the dilemma was by removing the woman's uterus (she was only twenty-five years of age). The doctor who removed her uterus did not feel the sense of tragedy he should have, because he was not aware that this lady could have gotten pregnant with in vitro fertilization without ever attempting the hopeless operation to open her completely cemented-down tubes and ovaries. If he had only known that all this lady needed was a uterus in order to get pregnant with the new technology, he might have avoided this foolhardy operation, sent her to a proper IVF program, and she could have had her baby. Now she could not even get pregnant with IVF.

Miraculously, four years later, I called this lady back to tell her what seemed absolutely incredible, that she could have a baby after all even without her uterus. She had to find a close friend who would be willing to carry her baby for nine months and then return her baby to her. Her own eggs and her husband's sperm would be used to get her friend pregnant using IVF or GIFT. Then, nine months later, her friend would give her baby back to her.

This is not the same as the infamous "surrogate motherhood" cases that have appeared in the media. "Surrogate motherhood" involves no medical technology whatsoever and is a procedure of highly questionable ethics. With the "surrogate motherhood" case you may have popularly read about involving "Baby M," a volunteer is artificially inseminated with sperm from a couple's husband and then paid to carry a baby who is genetically the surrogate's (not the infertile wife's). Nine months later the surrogate is required to give this baby (which is hers) up for adoption to the couple.

What I am referring to is something entirely different. A friend would simply voluntarily carry the genetic baby of the woman who has no uterus. The friend, who would be paid nothing other than normal medical expenses, would then return the baby to her infertile friend.

Couples who wait too long can even get pregnant after menopause. The only problem is it will require the donation of an egg either from an anonymous donor or from a good friend or younger sister, or even a niece, who has not yet gone through menopause herself. Most women go through menopause between the ages of forty-five and fifty-five but about 5 percent will run out of eggs well before the age of forty.

What about Paulette (to whom I referred in the Preface), who wrote the stirring article in the New York Times Magazine? Her biological clock is ticking and she's going to run out of fertilizable eggs fairly soon. That does not mean the end of her chance to get pregnant. A proper lining of the womb (endometrium) can easily be created by giving her the right hormones in the proper sequence to simulate a normal cycle, and put her husband's sperm along with one or more eggs from a good friend (or anonymous donor if she so prefers) into her fallopian tube at exactly the right time of her artificially induced cycle, and quite amazingly, she can still get pregnant and carry and deliver a normal baby, virtually at any age!

Speaking of getting pregnant at an older age, the first case of a grandmother giving birth to her own grandchildren, using her daughter's eggs and her son-in-law's sperm, was reported in 1989. This procedure was necessitated because her daughter had no uterus. The grandmother was forty-eight years old, and her daughter was twenty-five. Their cycles were synchronized with hormones quite easily (as will be described in later chapters), and her daughter's eggs with her daughter's husband's sperm were used to create three embryos in a culture dish. A11 three embryos were then placed in the uterus (womb) of the grandmother-to-be and she got pregnant with triplets. Thus, in one delivery the grandmother gave birth to her own three grandchildren.

Because of pioneering research by Professor Roger Gosden, at the University of Leeds in the United Kingdom, we can now successfully freeze the eggs of young women before they undergo cancer chemotherapy and/or radiation (which would otherwise most likely destroy their fertility). This approach may also help women who feel a need to delay childbearing until their late thirties and forties, when their eggs will very likely have been depleted. This technology is also an option for the woman who wants her own genetic child, but does not anticipate starting a family for many years. As women get older, a thousand of their eggs degenerate every month, and the eggs which do not degenerate are less fertile with each succeeding year because of the aging process. By age 40, the likelihood that a woman can produce eggs capable of resulting in a baby has decreased significantly because it is very likely that she has run out of most, if not all, of her fertile eggs. Therefore, women who find themselves not yet married at age 35, but who still want to have children in the future, all feel the relentless ticking of the biological clock. Ovarian tissue freezing is a new solution for these women who feel that by the time they do get married, or are otherwise ready to start a family, they will have lost all of their fertile eggs due to the aging process.

For the last ten years, we have known that although human embryos can be successfully frozen and thawed, and can result in happy, healthy babies, unfertilized eggs cannot be successfully frozen and thawed (see page 304 in Chapter 11 regarding "embryo freezing"). A great deal of research has demonstrated that the reason for the poor success of egg freezing is that the eggs we retrieve through normal IVF-type processes are undergoing chromosomal division. The chromosomes of retrieved eggs are highly organized, on a complex "spindle," which is very susceptible to minor crystal damage from freezing. However, "resting" eggs in primordial follicles within an unstimulated ovary are undergoing minimal cellular activity and have no such complex spindle formation. Therefore, these immature, "resting" eggs are not easily damaged during an appropriately administered freezing procedure.

In women who are not yet married but who need to put off childbearing, and whose ovaries may be destroyed by cancer treatment, we can remove portions of ovary, or the entire ovary, perform bench microsurgery to create microstrips of tissue (to allow successful diffusion of the cryoprotectant), and successfully freeze this ovarian tissue with a well-controlled computerized methodology (see Figure 1). All of a woman's eggs can be found in the thin 1mm outer layer of the ovary, while the inside of the ovary is just pulp and blood vessels with no specific organization or function other than to feed the eggs and follicles that are located in the periphery. This structure makes it possible for an entire ovary to be removed and the periphery dissected off microsurgically. The ovarian tissue is then put through a computer controlled, gradual freezing process. At least 70 percent of the ovarian follicles survive this freeze/thaw process without damage. Transplantation of this tissue back to the patient in a relatively simple fashion can result in normal egg development and ovulation.

In the future, patients will have the option, depending upon the opinion of their oncologist, to have either transplantation of the ovary back to them, or in vitro maturation of the eggs contained in that ovarian tissue, followed by a standard ICSI-IVF procedure. Ovarian transplantation is already well established, but in vitro maturation of ovarian tissue still requires ongoing research. In either event, ovarian tissue freezing now offers a woman an opportunity to achieve motherhood many years after she will appear to have been cured of her cancer, or perhaps later in life, when she finally meets her permanent partner.

Some types of infertility require very tricky technology and micromanipulative skill. One example is men who are born with completely absent sperm ducts. For almost twenty years, I had been bombarded by couples from all over the world for a solution to the problem of the male being born with completely absent sperm ducts. This had been a particularly frustrating condition because the man's testicles are making perfectly normal sperm, but the sperm just can't get out and there are no ducts available to connect microsurgically. These cases had previously been completely hopeless. Now, however, we have an extremely delicate method for microsurgically extracting sperm from right near the testicle, and getting the wife pregnant with it. Such sperm normally should be unable to fertilize because they have not gone through the normal pathways which are necessary for the sperm to mature and develop the ability to fertilize. However, now it is

possible to inject those microsurgically extracted sperm directly into the wife's eggs, and thereby get normal fertilization and, nine months later, happy, normal babies.

Advances like this seem to come when you least expect them. Several years ago, I had just finished telling my friend Dr. Richard Amelar (a fertility expert in New York) that a couple he had known for many years with congenital absence of the vas (and with whom he had become very close) should just give up because I didn't think the efforts in solving their problem were going anywhere. On that same day I had sent letters off to two similar patients in Colorado and Missouri, who had been repeatedly bugging me about why there couldn't be a "simple" solution to their problem. I told them that the complex requirements for maturation of sperm are beyond our understanding and that simply extracting them from near the testicle would not be of any benefit in getting the wife pregnant.

With these three patients (who were only a small number of the thousands with whom I had corresponded over the previous years) freshly in mind, I pondered how we might be able to use the new in vitro technology to approach this problem. The result was the beginning of a methodology that now allows us to successfully treat every single case of obstructive sterility, and most cases of "absolute" sterility caused by what would appear to be a complete lack of sperm production. These couples from Colorado and from Missouri were our earliest such pregnancies. Now there are thousands like them.

Surgically retrieved sperm from sterile men previously had a terribly low fertilization rate because the retrieved sperm were so weak. They looked like they were hobbling around on crutches, with big cytoplasmic blebs in their necks, all caused by the fact that they hadn't matured completely in their passage out of the testicle. Nonetheless, the DNA within all of these immature sperm was completely normal, and all that was required for these men to be able to have their own genetic offspring was the technique of IC SI, which in the early days I liked to jokingly call "fertilization by brute force."

Seven years ago, I wrote the following paragraphs in the first edition of How to Get Pregnant with the New Technology: "Another new development for otherwise impossible cases which requires great technical expertise is what scientists call 'micromanipulation,' but what perhaps the layman might understand better simply as 'fertilization of the egg by brute force.' The way this works is that some men have sperm counts that are so low, and motility so poor, that the sperm are incapable of penetrating the egg on their own even in the best quality laboratory setting. With ultramicromanipulative instruments that can be attached to special microscopes, the wife's egg can actually be held secure with a microholding pipette (scientific word for eye-dropper), and another micropipette can be used to literally inject a sperm through the hard outer shell of the egg (what is called the 'zona pellucida') so that this otherwise 'dead' sperm is now able to fertilize the egg.

"Can you imagine the dexterity involved in this type of manipulation? The sperm head is no more than 4 to 6 microns in diameter (that's approximately i/4,000 of an inch), and an egg is approximately 100 microns in diameter ( I/200 of an inch). Thus, 'fertilization by brute force' is indeed a highly delicate procedure." It took years of painstaking research in Brussels, Belgium, and in St. Louis, Missouri, to perfect it. We called this perfected technique of sperm injection ICSI.

In November l992,in the remote town of Adelaide, Australia, a small but historic meeting of a few sperm scientists, was put together by Dr. Colin Matthews, the head of the IVF program in this relatively remote spot in Australia, to determine by consensus whether we had finally achieved a solution to the enigma of male infertility. This meeting included everyone who was feverishly working on the micromanipulation of sperm including Dr. Jacques Cohen from New York, Dr. Alan Trounson from Melbourne, Australia, Dr. Bob Edwards from Cambridge, England (the inventor of in vitro fertilization and who helped create the first IVF baby in 1978, Louise Brown), my self from St. Louis, and a rather shy, self-effacing doctor from Brussels, Belgium, Dr. Andre Van Steirteghem. It was at this meeting that a consensus was reached and spread throughout the world that with ICSI, a new era for treating infertile couples had arrived.

One of the biggest fears of those of us who were working on microinjection of sperm was that if the sperm can't get into the egg because of poor numbers or poor motility, abnormal shape, or poor maturation, then perhaps they weren't meant to get in. Perhaps it was naive to think that if such a poor sperm were injected into the egg that the chromosomes would be normal and that a normal baby could be obtained from such a procedure. Those fears proved to be completely wrong.

What is becoming apparent now is that even poor sperm have normal DNA sufficient for making a normal baby and the only thing wrong with poor sperm is simply that they cannot get into the egg. The incredible complexity of sperm physiology with enzyme production and motility, which will be discussed later in this book, appears to serve no purpose other than to mechanically get the package of DNA which the sperm contains into the egg. Once that package of DNA is inserted into the egg, all the processes of fertilization and embryo formation leading to a baby can take care of themselves.

It was Alan Trounson who brought up the startling notion that perhaps one could even take the DNA from Egyptian mummies, or frozen ice-age men, preserved for many thousands of years; inject that sperm into a modern-day woman; and have a normal baby. This was a crazy idea that would never be attempted, but Dr. Trounson's first bringing that concept to our attention at this meeting underscored how powerful this technology is.

Less than one year later, Dr. Paul Devroey and myself, working with Dr. Andre Van Steirteghem, took a St. Louis couple and a Dutch couple, and achieved twin pregnancies using sperm retrieved from a simple testicle biopsy procedure in a man with complete absence of all sperm-transferring ducts. It had been thought for many decades that testicular sperm has barely any motility whatsoever, is completely immature with amorphous blebs around its head and neck, and could never result in fertilization, even with the most advanced in vitro fertilization culturing techniques. Yet with ICSI, this was no problem.

This first St. Louis patient, Mr. Hunter, had been calling me for ten years, every year, to find out if anything new was available, and I consistently told him incorrectly that he should give up because there was no hope. Finally, in July 1993, he proved me wrong. The St. Louis couple, and a Dutch-Spanish couple with the same problem as Mr. Hunter's, had no sperm whatsoever in any of their sperm ducts. We had no way of knowing whether seemingly nonmotile testicular sperm, extracted from testicular tissue itself, not released in any normal fashion, could result in normal fertilization and pregnancy. These two courageous couples were the first to demonstrate that normal babies can result from testicular sperm. Both couples now have happy, healthy twins. Mr. Hunter brought his babies to my office three months after the delivery, and showed me the letters that I had sent to him in previous years telling him to "give up hope." That convinced me that I was correct in 1990 in warning that we should be skeptical only of skepticism.

In 1985, a young religious couple, both twenty-two years of age, from New York, came to see me in St. Louis because he had azoospermia (no sperm in the ejaculate) and needed a testicle biopsy to see whether possibly he had an obstruction that could be corrected with microsurgery. In those days, we always prayed that the biopsy would show normal sperm production, because our success rate with microsurgery to correct obstruction in male infertility was over 95 percent. Of course, we could do nothing at that time for couples in whom the men weren't making sperm at all.

His biopsy in 1985 demonstrated what we call "maturation arrest." This simply means that the early precursors for sperm production were present in the testicle, but there was no continuation of sperm production beyond these early precursors. This man was by all definitions 100 percent sterile, and it was my unfortunate job to have to explain the bad news to this otherwise wide-eyed, cheerful young couple (who were looking forward so much to having a family) that they couldn't have children. But this couple never gave up hope. Ten years later, they came back because we had a new experimental approach to try on them. By now we were having exciting success in using ICSI for men with extremely poor sperm counts, and in men with irreparable obstruction requiring retrieval of testicular sperm from an otherwise normally functioning testicle. But how could it work on men who were not making any mature sperm at all? We were about to embark upon a new theory with startling consequences.

When I had looked back to my quantitative testicle biopsy research from the early 1980s, I discovered a phenomenon that had eluded my attention sixteen years earlier. Even in men with zero sperm in the ejaculate, and apparently no sperm production in the testicle, if one looked carefully throughout the testicular specimens, an occasional early spermatid (sperm precursor) could be found that had the same haploid number of chromosomes as a normal sperm. This couple was our first case of a man who appeared to be making no sperm, in whom we explored the testicle microsurgically and were able to find five such sperm precursors. We injected these sperm precursors into his wife's eggs, normal fertilization occurred, and they now have a happy baby girl, despite the fact that he was a man who apparently wasn't making sperm.

Another patient treated around the same time had undescended testicles as a child that were brought down surgically into the scrotum very late in childhood. As is usually the case with such men, he was clearly producing no sperm. When we operated on his testis to see if any sperm could be found (under the same theory, that any man with a testicle has some sperm somewhere), indeed we were able to find twenty-one sperm precursors in his testis. We injected his wife's eggs with those sperm precursors and again obtained normal fertilization and pregnancy. This young man had been known to be sterile ever since he was a teenager. Yet, during extensive exploration of his testicle, we found sufficient sperm to perform ICSI.

We also found an early malignant tumor that never would have been picked up so early were it not for this treatment, and he wound up having to have this testicle removed to save his life, but not before the few sperm precursors present within it were successfully used to allow him and his wife to have a baby. We now know that in most men (not all) who appear to be making zero sperm, with completely sterile testicles, there are a few early sperm precursors present, and that the fertilization and pregnancy rate using those precursors are no different than they are with a man who has a normal sperm count.

There was a tremendous furor of early skepticism and outright criticism of the new technology in the early 1980s. Dr. Ruth Hubbard, a Harvard University biology professor, warned the American Association for the Advancement of Science, "As a woman, a feminist, and a biologist, it is not worth opening a hornet's nest of reproductive technology for the privilege of having one's child." She continued, "How can we claim to know that the many chemical and mechanical manipulations of eggs, sperms, and embryos that take place during in vitro fertilization and implantation are harmless?" She was also concerned that in vitro fertilization required extremely costly and prolonged experimentation with highly skilled professionals and expensive equipment, "distorting our health priorities and funneling scarce resources into a questionable effort." She urged a complete halt to in vitro fertilization in the United States, and she was not alone.

Our government ordered a complete freeze on any support for medical research on the subject in the United States. In England, the originators of the procedure, Dr. Patrick Steptoe and Dr. Robert Edwards, had to perform their research and their first procedure in a sleepy little cottage because they could not get any government support or approval. In the United States, it took several years before the first private in vitro fertilization program was able to get through the legal, emotional, and religious barriers to be overcome in Norfolk, Virginia. The Department of Health, Education and Welfare in the United States received petitions with 30,000 signatures protesting any federal funding for in vitro fertilization work, and so our government completely shunned any research support.

Interestingly, an advisory board commissioned by the Department of Health, Education and Welfare to study the ethical aspects of the procedure reported that this technology, which originated in England, should be employed in medical institutions in this country, and the same advisory board concluded that government financing for such research was "ethically acceptable." Nonetheless, the Department of Health, Education and Welfare of the United States never allowed any funding for this procedure and, as often happens best in this country, the technology developed quite well on its own on a private basis funded simply by patients who wanted to give the procedure a try. The enormous growth in this technology to the point where we know so much more about fertilization now (resulting in simpler and cheaper methods of helping hundreds of thousands of couples get pregnant who otherwise couldn't) came strictly from laissez-faire private enterprise research and development without any government plan and without any overall supervisory direction from any organization. In the first half of the 1980s, most of the new developments in the field represented technology imported from England, France, and Australia.

By 1982, four years after the birth of the first test-tube baby by Steptoe and Edwards in England, one hundred more babies had been born throughout the world through in vitro fertilization. The procedure became so popular and ubiquitous that the original clinic started by Steptoe and Edwards by 1990 had been responsible for well over 1,000 healthy babies, and throughout the world every year thousands more healthy test tube babies are being born.

Still it was a very experimental, very expensive, and highly unsuccessful procedure at this critical time in the early 1980s. That was when Professor Ed Wallach wrote a prophetic editorial in the journal Fertility and Sterility predicting many of the advances in the future that would make in vitro fertilization simpler, more cost-effective, and have a pregnancy rate high enough to merit its serious use on a large scale. He outlined future research in stimulating the ovaries to get more eggs, determining when to give the ovulatory triggering hormone HCG, monitoring the growing follicle with ultrasound, retrieving the eggs without surgery simply by ultrasound-guided needle aspiration, placement of multiple embryos instead of a single embryo to increase the pregnancy rate, and even freezing of extra embryos. He argued persuasively that if we are going to worry about the ethics of in vitro fertilization, there are a lot of things we do in medicine that ought to cause us to worry a great deal more. The next boost to the popularization of IVF technology for routine cases of infertility was GIFT.

The idea of the GIFT procedure is enticingly simple. In 1985, when GIFT was first suggested, the success rates with in vitro fertilization were still so low that IVF was considered an absolute last-resort alternative and an exotic procedure performed only by a few centers with very low pregnancy rates. GIFT changed all that within a period of only a few years. Instead of taking the egg from the woman and the sperm from the husband and fertilizing the egg in a culture dish (in vitro) in an incubator over a forty-eight hour period, one simply held the eggs and sperm in culture long enough to prepare for loading them into a small little catheter and placed them directly into the woman's fallopian tube where fertilization normally takes place naturally.

"GIFT" is simply an acronym for G–gamete, I–intra-, F– fallopian, T–transfer, which means transferring the sperm and the eggs (the "gametes") into the woman's fallopian tube. Instead of waiting forty-eight hours for the fertilization process to take place in an incubator, that step is bypassed. Sperm and eggs are simply placed directly into the fallopian tube and allowed to fertilize naturally. Then, at the right time, they travel on their own to the uterus as would occur in a normal fertile woman.

This simple idea literally tripled the pregnancy rates of standard in vitro fertilization, and set the stage for its massive popularization. Of course, GIFT couldn't replace IVF. They each have their separate places in the new technology for different types of patients. But the vast majority of infertile women in the mid- to late 1980s had the highest chance of pregnancy (reproducible among many clinics around the world) with GIFT, assuming the wife has normal fallopian tubes. If, however, the fallopian tubes are diseased, then putting sperm or eggs into these diseased fallopian tubes is an error, and standard in vitro fertilization must be resorted to. The advantage of GIFT is a very high pregnancy rate and a very minor surgical procedure, whereas the advantage of IVF, despite a lower pregnancy rate, is that it can be used in any patient whether she has normal fallopian tubes or not, and it requires absolutely no surgery at all.

There is some controversy at present about the relative indications for IVF versus GIFT. IVF in good centers now gives a much higher pregnancy rate than it did ten years ago. The pregnancy rate in a very good IVF center should be at least 30 percent per treatment cycle. This pregnancy rate will be higher in younger patients and lower in older patients. This is dramatically better than the pregnancy rates achieved using IVF in the mid-1980s. Therefore, it is a common view that GIFT should be abandoned because IVF now gives almost equivalent results, and is non-surgical. Nonetheless, huge studies with large numbers of patients, validated by the Society of Assisted Reproductive Technology in the United States, as well as similar concurrent studies in Australia, still consistently demonstrate higher pregnancy rates with GIFT than with IVF. Just as IVF pregnancy rates have improved in the last ten years, so have GIFT pregnancy rates improved.

So we come back to the original question, "How do you decide where to go?" When our U.S. Congressional Advisory Panel met during the years of 1987 and 1988, we amassed figures which showed that of 150 IVF clinics in the United States, half of them had never achieved a pregnancy at all. Furthermore, of those that achieved pregnancies, the success rate varied from extremely low (less than 5 percent) to reasonably high (greater than 30 percent). Evaluating the quality of the clinic and the chances of getting pregnant from that clinic was an extremely muddled mess at that time. In 1984, it was reported at the World Congress in Helsinki, Finland, that of over 10,000 women entering (IVF) cycles, there were only 600 live births, for a success rate of only 6 percent. In the United States in 1987, out of a total of 12,000 women undergoing (IVF) cycles, there were a little over 1,000 live births for an overall success rate of about 9 percent. Such a low success rate would hardly be encouraging to a couple.

It was for this reason that the congressional bureaucrats who reported on the discussions of our advisory panel promulgated the publicity that the success rate with this new technology is too low and the cost too high to consider it anything other than a last resort and that more resources should be spent on the "conventional" therapy for infertility. The bureaucrats also failed to accept the recommendation of the advisory panel that infertility was a medical condition or an illness, which would give strong weight to forcing insurance companies to pay for infertility treatment without the need to come up with a specific and usually erroneous pathological diagnosis.

The fact is that nowadays if you choose your in vitro fertilization program carefully, you have a chance of pregnancy and live birth of 35 percent per cycle, and if your fallopian tubes are healthy (which is usually the case), you can undergo GIFT with the prospect of over 45 percent of having a pregnancy each cycle you attempt. Furthermore, we now have very good evidence that if you continue to go through multiple attempts, your chances remain just as good with each succeeding attempt at in vitro fertilization or GIFT for at least up to the seventh try. Thus, your odds are very good that eventually you'll get pregnant with this technology. But you must choose the right doctor and the right program. This is a free enterprise, laissez-faire system, and it is very clear to most of the experts in this area that no government "regulation" is going to help you.

Even if "honest reporting" of results were mandated by all clinics with their books open to review by auditors (a regulation that I would certainly support), this would still not give you a simple answer of where to go, for the following reason: Some clinics might have a bad pregnancy rate simply because they restrict their attention to the most difficult cases with the longest duration of prior infertility, the greatest amount of scarring, the oldest women in their mid-forties, or couples in whom the sperm quality is miserable. If the clinic had the kind of expertise that encouraged these most difficult cases to be in preponderance at their doorstep, they could easily have a lower pregnancy rate than a clinic which takes on more routine cases.

Some clinics have become so commercialized that they publish misleading advertisements in local newspapers, magazines, and even in the New York Times and the Wall Street Journal. These advertisements promise progressively higher pregnancy rates based on carefully selecting only the youngest, most fertile cases, and offer money-back guarantees after surreptitiously overcharging for every cycle to cover the cost of rebates. Indeed, many unnecessary and expensive tests, which can total as much as $10,000 or more, are sometimes insisted upon before the first IVF, thus guaranteeing hefty revenue exclusive of any potential rebate. This commercialized "Kentucky fried" IVF franchising has become a cause of great distress and confusion for patients trying to figure out what to do. Many clinics make false claims of exaggerated pregnancy rates by selecting younger patients (with a short duration of infertility, and large ovarian reserve). Therefore, the patients' only resource in deciding where to go for treatment is to understand fully how the reproductive system works, and to learn in a detailed way what the new technology is all about.

That's one of the reasons why you must study this book and become a knowledgeable patient. It will help you choose the right doctor or the right clinic. It'll make you savvy about how to get this paid for by your insurance company. It will give you the depth of understanding which you need in order to go through the many preliminary steps which are part of every IVF or GIFT cycle.

This book will review the basic How to Get Pregnant principles from 1981, but will debunk some of the terrible myths of conventional treatment, like endometriosis, varicocele, treatment of men with low sperm counts, among others. This book will encourage resorting earlier to IVF or GIFT technology as a way of getting more infertile couples pregnant more cheaply and quickly and with less pain. But understand that a couple shouldn't undergo this treatment without a full understanding of how it works. Otherwise there are too many steps and it's too intimidating.

This technology is certainly more cost-effective than so many of the treatments that insurance companies routinely pay for, but a couple is still going to need the savvy to figure out how to get the insurance company to pay for this procedure. The insurance company needs to understand that it will save rather than cost more money. This book will explain the differences between in vitro fertilization and GIFT with its variations, why such high pregnancy rates can be obtained, and what kind of clinics are able to obtain these pregnancy rates. Additionally you will learn how to watch carefully and pick the right place by interviewing the doctors and the nurses who are directly involved, so you can evaluate their results realistically.

A "list" of "specialists" or "clinics" is never going to be reliable. I can assure you that anyone and everyone who says that they are "fertility specialists" gets on such a list. There is no list of recommended doctors or clinics that any author will publish which will be reliable for you. In an effort to maintain neutrality and avoid libel suits, organizations such as the American Fertility Society, the American Medical Association, RESOLVE (a lay organization of infertile couples), county medical societies, and various books and manuals can never do a frank job of discerning and deciding which clinic is the one that is right for you or is most likely to give a successful result. For the energy, the time, and the money that must be put into this effort, you must make a good choice. For that, you must understand the new technology.

© 1998 by Dr. Sherman Silber
Excerpt posted with permission from http://www.twbookmark.com

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