- The Washington Times - Sunday, April 1, 2001

Robin, a 31-year-old Loudoun County woman who asked that her last name not be used, gave birth to her little girl last summer after nearly six frustrating years of infertility treatment.

Robin underwent seven months of ovulation-boosting drugs and intrauterine inseminations to no avail. She and her husband spent tens of thousands of dollars on in-vitro fertilization (IVF) treatments. Finally, the fifth IVF try after the couple had begun pursuing adoption resulted in a healthy baby.

"It was such a thrill, I cry when I think about it," Robin says of the first time she saw her daughter. "I went into labor on the anniversary of our first date and brought her home from the hospital on my birthday. The minute she was born, I said 'Let's do it again.' "

Assisted Reproductive Technology (ART) involves a mixture of hormonal stimulation, careful laboratory skill, timing and luck. When it works as it is supposed to, it pays off in a baby for thousands of couples who might have been unable to conceive.

It appears ART is getting more successful. The first IVF baby was born in 1978. Since then, about 140,000 babies have been born nationwide as a result of ART, including more than 80,000 from IVF.

In 1998, the latest year for which numbers are available, more than 28,000 babies were born nationwide through ART, according to the American Society for Reproductive Medicine (ASRM).

"Success rates have increased as lab techniques have become standardized and learning curves have been met," says Dr. Paul Gindoff, a reproductive endocrinologist at George Washington University Medical Center. "There have been improvements in lab equipment, technical enhancement. There are better drugs and easier ways of administering them."

As the baby boomers near the end of their reproductive years, the pool of patients for procedures has grown, Dr. Gindoff says.

Also, more insurance carriers are providing at least some coverage for IVF, which averages $8,000 to $13,000 per cycle. Twelve states, including Maryland, have mandated coverage of infertility treatments.

Adoption costs, meanwhile, typically range between $5,000 and $25,000, according to the National Adoption Information Clearinghouse.

Three hundred and sixty clinics nationwide performed 80,634 ART cycles in 1998, according to ASRM data. Those cycles resulted in 28,500 babies. That means a 25 percent success rate, which is an improvement from the previous year.

Though 25 percent may sound like a small percentage, it is a figure that pleases the doctors and the patients who are hoping for a baby.

"Twenty-five percent might sound like a shocker to some patients," Dr. Gindoff says, "but it is better than the percentage each month if you try on your own."

How it works

The prescription for each couple's fertility treatment depends on the couple's infertility factors, says Dr. Mark Perloe, an Atlanta reproductive endocrinologist.

If irregular ovulation is a factor, a woman could try the ovulation-boosting pill clomiphene citrate (Clomid) or a variety of stronger, injectable drugs.

Drugs in combination with intrauterine insemination (IUI) can be an effective treatment for some couples, says Dr. Suheil Muasher, medical director of the Jones Institute for Reproductive Medicine in Fairfax. In IUI, sperm is treated to sort out the strongest swimmers and then placed by catheter directly into the woman's uterus.

In ovulation induction and IUI, a woman must be monitored closely to prevent hyperstimulation, a dangerous side effect of fertility drugs. Doctors also must carefully monitor the number of egg-producing follicles In ovulation induction and IUI, a woman must be monitored closely to prevent hyperstimulation, a dangerous side effect of fertility drugs. Doctors also must carefully monitor the number of egg-producing follicles with repeated sonograms and blood tests as the cycle progresses, Dr. Gindoff says.

The cases of higher-order multiples such as quadruplets or even quintuplets usually come from this type of treatment, which is less precise than IVF because fertilization is taking place inside the body with an unknown quantity of eggs, he says.

"While there are a certain number of our patients who would be thrilled to be pregnant with triplets, that is not what our mission is," Dr. Gindoff says. "There can be huge complications with multiples."

IVF is more controlled because doctors put in a set number of embryos depending on a woman's age and fertility history, Dr. Gindoff says. Women who have blocked or damaged fallopian tubes, severe endometriosis, multiple factors or long, unexplained infertility could benefit the most from IVF treatment, Dr. Muasher says. In IVF, the eggs are removed from a woman and placed in a petri dish with sperm. If any of the eggs are fertilized, some of them are put back into the woman's uterus a few days later. If they implant successfully and become embryos, the woman will test positive for pregnancy about two weeks later.

An IVF cycle starts out similarly to ovulation induction, with the woman injecting medication nightly in the first part of the cycle.

"I did my own shots because my husband was squeamish," Robin says. "The first time I had to give myself a shot, it took 20 minutes. It was very weird, and it hurt when the medicine went in."

In the middle of the cycle, around the same time a woman normally would ovulate, doctors retrieve the woman's eggs with an ultrasound-guided needle placed through the vagina.

After the eggs and sperm are placed in a culture dish, technicians watch for development. About 12 hours after fertilization, a fertilized egg divides into two cells. The cells may divide several times in the 48 to 72 hours before the embryo is placed in the woman's uterus.

There are no laws in the United States that regulate how many embryos may be put into a woman. Most doctors usually place between two and four embryos.

The woman's age, previous treatment history and fertility issues all figure into how many embryos to place, Dr. Gindoff says. If there are additional embryos, they are frozen for future tries. Robin's successful pregnancy came from a frozen embryo.

Occasionally, all four embryos will implant. Because carrying higher-order multiples can be dangerous for both mother and babies, a procedure called selective reduction, in which some of the embryos are terminated, is available for some IVF and IUI patients.

Even more advances

There also are variations and additional treatments that can improve an ART cycle's success. One variation on the IVF procedure is gamete intrafallopian transfer (GIFT), in which sperm and egg are inserted directly into the fallopian tube, where they ideally undergo unassisted fertilization. Another variation is zygote intrafallopian transfer (ZIFT), in which eggs are fertilized in a dish, then placed in the fallopian tubes before they begin cell division.

For couples with severe sperm mobility problems, doctors can directly inject a single sperm into an egg. Donor eggs can enable a woman with egg deficiencies to carry a child.

Tina Campbell, a Rockville woman who went through premature menopause at age 23, used a donor egg to conceive her son, Nicholas, now 5.

"I was totally in shock," Mrs. Campbell says of the day she found out she would not be able to conceive on her own. "I was faced with the decision to use a donor egg or adopt," she says.

The Campbells chose an anonymous donor. The donor was given ovulation drugs, and her eggs were fertilized in a dish with sperm from Mrs. Campbell's husband, Doug. The embryos were then put into Mrs. Campbell. The procedure doubled the cost of the IVF cycle.

Mrs. Campbell gave birth to twins in November 1995. Her daughter, Natalie, died when she was 1 month old, however, of a heart ailment unrelated to the procedure. The Campbells eventually adopted a boy, Matthew, now 3.

After many IVF cycles with her own eggs, Robin also eventually used a donor egg combined with assisted hatching, in which doctors manipulate the outside coating of the egg to boost the chances of implantation.

"I was ready to do something that worked," Robin says. "It doesn't make any difference to me now that I used a donor egg. I have a baby. She is my child. I only got one cell from someone else. Everything else is from me."

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