Part 1
Modern Fertility Medicine: The Risks and Overuse of (Sometimes) Terrific Technologies
Pamela had been through ten cycles of in vitro fertilization (IVF) at three different centers but had never been pregnant. Some of the best fertility doctors in New York had told her she was too old (39) and probably had “bad eggs.”
Over the course of ten years of trying to have a baby, Evelyn’s doctors had pumped her up with a total of fifty cycles of fertility drugs, really strong ones. She’d made hundreds of eggs, but still she wasn’t pregnant. Not one of the four doctors she’d seen had ever stopped to ask why she wasn’t getting pregnant.
Stephanie took high doses of fertility drugs in preparation for her first IVF cycle at the best clinic in the city. The doctors harvested lots of eggs, made nine embryos, and discovered on testing that every single embryo was genetically abnormal. Although they’d been willing to give IVF a try with her, they now told her there was nothing more they could do because of her age (41).
The good news is that, in the end, all these women got pregnant and had babies. The bad news is that they underwent difficult, unnecessary, and futile treatments before anyone figured out why they weren’t getting pregnant and what to do about it. The worse news is that these women are not exceptions to the rule. The way fertility medicine is practiced today routinely generates stories like these.
Reproductive technologies also create a lot of expanded families, and we never want to discount the blessing that can be. What we long for is a new era in which technological successes will be unadulterated blessings, because the technology will be offered and used only when it is necessary. Everyone else will be able to get the appropriate help they need to conceive and bear children as naturally as possible—because that’s what’s gentlest, safest, and often most effective, even in the face of some serious fertility issues.
One in 100 babies born in the United States today was conceived with the help of assisted reproductive technologies (ARTs), according to the American Society for Reproductive Medicine (ASRM). Worldwide, more than 3 million babies have been born who were conceived through IVF—more than 400,000 of them in the United States. Each year in this country, 250,000 families consider IVF, and about half of those give it a try. They do so at their pick of 461 clinics nationwide.
The numbers have skyrocketed since IVF technology was introduced three decades ago. The number of ART births more than doubled between 1996 and 2002. A Centers for Disease Control (CDC) report from 2004 counted almost 50,000 babies born after ART interventions in this country that year. Just six years earlier, the figure was 28,000—and that was announced as evidence of the rapid growth in the use of these technologies. Over time, the nature of the industry itself has changed as dramatically as the number of babies born as a result of it, with ART morphing from an option of last resort, available to only a few, to the first choice for every player in the game.
We both celebrate regularly with patients who bring home babies thanks to amazing technological interventions, and we are always glad to do so. And we are both grateful, professionally speaking, to have something to refer patients to when our areas of expertise can’t address their needs. But the sad truth underlying the good news is that ARTs, and in particular IVF, are frequently misused, grossly overprescribed, and too aggressively administered. We’ve arrived at this place because of a culture, both in society at large and in reproductive medicine in particular, that always goes for the quick fix regardless of other options or possible consequences, emphasizes personal gain, and values technology for its own sake. Added to that grim picture are the risks and side effects of the procedures themselves.
Based on our experience with thousands of patients coming to us in various phases of fertility treatment, as well as on what we hear from our colleagues, we estimate that as many as half of all women who receive IVF could conceive naturally or with minimal medical intervention. This is not just a theoretical best-practices argument. The consequences of fertility treatment for women, couples, and families are immense—even when they succeed. When they don’t succeed, that failure adds another layer of heartbreak to an experience that is already extremely stressful physically, emotionally, and financially. Proud parents of babies born thanks to ARTs will say that it was worth everything they went through. But the more important point is not whether it is ultimately worth it, but whether it was necessary.
These technologies can be miracle makers, but they must be used wisely to be used well. As a society, we are not yet applying that wisdom. There is a better way, modeled by the Making Babies program. This is it in a nutshell: use all options available in their proper place and time, with a preference always for what’s closest to the way nature intended and what’s best (and most likely to work) for the patient. The truth is, with careful diagnosis, basic fertility education, and simple but detailed diet and lifestyle advice, many women using ARTs could conceive much more naturally. If any drugs or other interventions turn out to be necessary, minimal doses and least invasive procedures can be used, minimizing risks as well as unpleasant side effects—all while increasing success rates.
The stories that opened this chapter ultimately illustrate the possibilities.
Pamela, who’d had ten IVF attempts and a diagnosis of “bad eggs,” also had scar tissue from having fibroids removed, which was effectively keeping her eggs from getting into her fallopian tubes. She’d started IVF to get around the scar tissue—a common approach. But clearly something about the IVF wasn’t working for her, even if it was circumventing the obvious roadblock. When she came to see me (Sami), I couldn’t find any other issues to explain her problem, so I recommended surgery to clear away the scar tissue. (The same laparoscopic procedure can diagnose and correct this problem all at the same time.) Two months after I performed the surgery, Pamela was pregnant, with no drugs and no IVF.
Evelyn, who’d been treated with fertility drugs since before her 30th birth-day, finally became pregnant at age 40 after a single course of antibiotics cleared up a mycoplasma infection in her cervical mucus. Two years after her daughter was born, she went on to have a son with no treatment and no delay.
Stephanie, all of whose embryos had tested genetically abnormal, fit into a pattern we have seen all too often: high doses of injectable fertility drugs predisposing eggs in older women to develop chromosomal irregularities. Stephanie had been given too many fertility drugs for a woman of 41. My (Sami’s) approach was to recommend a much lower dose of essentially the same drugs. This time, her eggs and embryos were perfectly normal—and so is her young son.
It is not our intention to set anyone’s mind against IVF or any other ART. But we do want anyone who goes that route to do so with eyes wide open—and to know, before he or she heads down that road, that there are many other ways through the forest that are easier, safer, quicker, and cheaper. They all end up in the same place, so the difference between what exists now and the world you envision is understanding that you have a choice, including, but not limited to, ART.
So before we get into the details of how to do this right, let’s take a bit of time to look at what’s wrong with the way it’s done now.
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