Chat transcript: In-vitro fertilization

November 24, 1999
Web posted at: 3:28 p.m. EST (2028 GMT)

Chat Moderator: Welcome, Dr. Jones and Ernesto Bertarelli.

Mr. Bertarelli: Thank you.

Dr. Jones: Thank you. I am glad to be here with Mr. Bertarelli, and I hope that we can be useful in answering any questions in our area of knowledge.

Mr. Bertarelli: I am very honored to be here with Dr. Jones, who is a pioneer in reproductive health. I represent the Bertarelli Foundation and my late father, who worked with Dr. Jones to bring this technology to the United States.

Question from Milkman_Dan: Why is in-vitro fertilization so controversial?

Dr. Jones: There are two reasons. One is that it was a new technology. I think people in general are always concerned about anything that is new. But we are talking 20 years ago, so the newness aspect has disappeared.

Secondly, I think we need to realize that there are certain segments of the population that will object to things they think are unnatural, and we understand that. Those of us who practice IVF think we are assisting nature and persist with this technology.

You have to remember that at the very beginning, IVF was designed as a method of bypassing tubal problems, that is, the tube that transports the egg. I felt that if it had been called a bypass procedure, it would have been more accepted. In the beginning, it was done for a specific problem. It was successful and so was applied to other problems.

Chat Moderator: What scientific advances have been made in in-vitro fertilization?

Dr. Jones: One of the great advances was the introduction of products that made it possible to harvest more than a single egg during a single menstrual cycle. This way the pregnancy rate was greatly increased. Incidentally, Mr. Bertarelli's father and grandfather had a great deal to do with these advances.

There have been advances in the technical aspects of harvesting eggs and in the culture medium used to incubate the eggs and the sperm. One of the more spectacular advances was the acquisition of knowledge that made it possible to pick up a single sperm to inject into the egg.

This process is called intra-cellular sperm injection, or ICSI (pronounced ICKSEE). The significance of this is that it became possible to treat males who had a great deficiency in their sperm count. It has to be realized that infertility in general is due to the male in 40 percent of the cases, in the female in 40 percent of the cases. In the remainder, there are usually bilateral causes.

In summary, then, there has been a wonderful evolution and advance since IVF first became available.

Question from Mags: Is the process of in-vitro painful?

Dr. Jones: It is interesting that pain is perceived by individuals on a sliding scale. What may be painful to some is not to others. Some patients can undergo the procedure without any medication at all. Other individuals benefit from local anesthesia. Some prefer general anesthesia, the type you would have for a major operation.

There seems to be a social component to pain, and the physician has to make an estimation of this situation in arranging for the patient's treatment.

Chat Moderator:How is the procedure performed?

Dr. Jones: It is easy to say, more difficult to do. It is necessary to harvest eggs from the woman, as I mentioned before.

After having stimulated the patient and making an estimate by hormonal measurements from the patient and by visualization of the follicle, which is the name of the little sac in the ovary in which the egg develops, the eggs are secured from the follicle with the benefit of an ultrasound. This is usually done through the vagina.

Once the eggs are obtained, they are turned over to the embryological laboratory, and it is the responsibility of the embryologist to prepare the sperm from the husband in a way that can be put with the egg. We hope that 24 hours later it will be possible to identify fertilization of that particular egg. The fertilized egg is then transferred to the female partner, sometimes at 72 hours, sometimes later, by a rather simple procedure that can generally be done through the vagina. It is not too different from an ordinary pelvic exam done at the doctor's office.

Ultrasound allows you to visualize the follicle in the ovary. It also is arranged so that it allows you to see the needle, and you can follow the needle into the follicle. When the needle tip is in the follicle, suction is applied to the needle, and the fluid in the follicle containing the egg is withdrawn.

Question from Metaphysician: Though dressed up in medical terms, we are still talking about human sexuality. Are you ever confronted by your own human fear, shame or uncertainty, as most of us often are regarding sex?

Dr. Jones I have never experienced any of the sensations you have described.

Question from E : Are there any psychological problems or side effects that occur?

Dr. Jones: I think we need to give a little background before answering that question. There are often what we call side effects from reproduction regardless of how it is done.

The physician should regularly inquire of and counsel a patient about these matters prior to undertaking an infertility investigation, regardless of the therapy involved. He/she then needs to go an additional step and inquire about the use of IVF and its acceptability to the pair.

There is an occasional patient and her partner who will undertake an infertility investigation and accept treatment involving medication or surgery, but who for whatever reason is unprepared to use IVF. As physicians, we must recognize this, and respect the patient's view.

On the other hand, if their goal is to achieve pregnancy, I think the physician, sometimes the psychological counselor, has a responsibility to be sure that the reasons of the patient are in fact reasonable.

Question from curious: Is it possible through in-vitro to harvest eggs and sperm and create a fetus and then harvest desired organs?

Dr. Jones: If you are talking about if this is technologically possible, it is, but I think socially it is inappropriate.

I need to qualify that a little bit. You need to understand that to get to the organ level, the fetus would have to develop far beyond the stage that can be done in vitro. It would have to be done in the uterus of the mother. This would mean having the fetus go to birth, and organs supplied in this way. This is from a sociological point of view, we think, undesirable and unacceptable.

Question from Stephanie: How many embryos die in the process of IVF?

Dr. Jones: There are not so many embryos that die in IVF, if the implication is that it is IVF that causes them to die. You must realize that human reproduction is inefficient.

It has been determined that about one in four or one in five unions of the egg and sperm are viable and have the potential to produce a child. In IVF, we see this process up close and personal, as they say on TV. There is no reason to think that IVF itself is responsible for this inefficiency. Rather, we are viewing the process of natural selection, Darwinism if you will, in a more intimate way than has ever been possible to observe.

Question from Milkman_Dan:> So why would multiple birth gestation be a bad thing? What is multiple birth gestation?

Dr. Jones: Multiple birth gestation means that instead of having a single fetus, there are twins, triplets or more. That phenomenon is the subject of a conference to be sponsored by the Bertarelli Foundation and the NIH (National Institutes of Health) tomorrow and Sunday. There will be a webcast on Sunday from this conference.

The point is that as multiple births occur, there is an increase in obstetrical complications and an increase in problems with the children. From a medical point of view, and indeed from a sociological point of view, it is generally thought that there should be a goal of having a minimal number of multiple gestations.

Question from Citron: Do your patients get counseling on selective reduction if multiple embryos survive the process?

Dr. Jones: That is an option, yes.

Question from Citron: What about the stresses multiple birth places on the mother-child relationship? Is it fair to the children being born?

Dr. Jones: I believe that we mentioned undesirable sociological consequences of multiple births, and the answer deals with that issue.

Question from Is: Is IVF the best option for a woman who previously had her tubes tied?

Dr. Jones: That depends on the age of the woman, how the tubes were tied, and whether other factors were involved, such as male infertility. There is no yes-or-no answer.

Question from Justine: I have had two transfers, both called "good transfers" by the embryologist. Both failed. Any suggestions as to why?

Dr. Jones: This is inherent in the process of IVF. It really goes back to the point that was made earlier about the inefficiency of human reproduction, with the realization that not all egg/sperm matings result in an embryo that has viability -- that is, an embryo that has the ability to produce a child.

Therefore, two transfers that did not result in a pregnancy may simply be dealing with the roulette wheel of life. On the other hand, there may be patients that have specific difficulties, and the physician takes these into consideration. In baseball, you may be out with three strikes, but you are not out with two in IVF.

Question from Is: What do you mean by how tubes were tied?

Dr. Jones: It requires a minimal remaining length of tube for the tube to function. That length is 4cm of the distal part of the tube, or the part away from the uterus. If, in tying the tubes, some of the distal part of the tube is destroyed, then surgery is not applicable.

Question from Allen: Are there any defects observed from children as a result of the IVF (developmental, health, neurological)?

Dr. Jones: There have been several studies with follow-up of children produced by IVF. The incidents of birth abnormalities are essentially the same as the incidents with natural reproduction. There have been studies of the IQs of children of IVF. The IQs are generally higher than the normal population.

My own view is that it is difficult to tell whether this high IQ is the result of the child, or if we are dealing with parents anxious to have a child and were eager to go the last mile, caring and providing for the child in a special way.

IVF does not introduce any factor which increases the congenital anomaly rate, or introduce any factor which should give us concern about the development of the child.

Now, there is a caveat. What I have said applies to single children and perhaps to twins but may not apply to multiple births beyond that, which brings us to the importance of the NIH/Bertarelli conference, which will be held over the next two days, which addresses these multiple birth issues.

Question from hi: How economical is this test for a common man in this world?

Mr. Bertarelli: It very much depends where the couple is located in the world. Many countries reimburse the treatment of IVF, and therefore, the cost for the couple is not very high, obviously.

Other countries do not reimburse for the treatment, for example, the United States. The patient has to find ways to finance the procedure, either with their own funds or through insurance.

One of the activities of the Bertarelli Foundation is to identify where lack of funding exists and advocate for coverage of the procedures so that patients can have children with dignity.

Question from Kris: If you were to pay out of pocket for in-vitro process, how much would it be? And have costs come down over the years?

Mr. Bertarelli: It very much depends on the procedure itself. I will say between $5,000 and $15,000. The cost for a basic procedure may have come down, but the number of options offered today is much greater, and obviously the more complicated the procedure, the higher the cost. In 25 years, we have probably gone from being able to treat 20 percent of the patients to being able to treat almost every patient today.

Question from Jo: I have PCO, and my doctor told me that my husband and I should do IVF to conceive. What are the complications, if any, from this procedure?

Dr. Jones: PCO is polycystic ovarian disease, which used to be called the Stein-Levanthal syndrome. It is really very difficult to prescribe the exact treatment without knowing many more details. Let me say that this is a well-recognized and common disorder. The exact treatment for a particular couple varies a great deal, depending on the details, which are not available to me in this circumstance.

Question from J : How many eggs should be implanted on the first cycle of IVF?

Dr. Jones: Again, this depends on unknowns: the age of the mother, the quality of the fertilized eggs, the character of the sperm involved, shape of the uterus. A single number is probably not really meaningful without the details.

Question from Jo: Is it OK to be working full time when I do IVF?

Dr. Jones: I would not recommend going to work on the day the harvest is done. In general it only takes a day or two to accomplish the procedure.

Question from RobB: Other than selection reduction, are there ways to limit multiple births and still have a decent success rate with IVF?

Dr. Jones: Yes. It would be entirely possible to limit the number of fertilized eggs that are transferred to two, to cryo-preserve the remainder, and then to serially thaw and transfer the cryo-preserved eggs using no more than two on any given occasion.

Question from Justine: We have had two failed attempts, one fresh and one frozen. Can you give any indication of if the chances of success increase with subsequent attempts?

Dr. Jones: The answer is that this has been studied many times. Generally, the chance on subsequent cycles is the same as the first. Chance has no memory. It is the same situation.

Question from chadoo: Do you think there are some evolutionary-biological ramifications with helping people conceive, helping the individual couple but not helping humanity?

Dr. Jones: I am not sure I understand that question exactly. It is quite clear that the evolutionary process is difficult to measure in a single lifetime or indeed in a single century. But I think if we are talking in terms of a million years, the answer would be yes. I don't think from an evolutionary process that we can foretell if something is good or bad. It has to do with whether the survivors survive.

There are many, many factors that contribute to overpopulation as compared with the contributions IVF can make. I think we need to view the population problem from two points: mainly the macrocosm of the universe, in which we are apt to come to the conclusion that we need to be concerned with the number of people on the earth. On the other hand, we can view it from the microcosm of the family, where it is devastating to not have children.

We must then realize that if we are able to accommodate all the infertile people by solving their problem, this would not make a measurable difference in the total population of the world.

Question from Jo: My grandmother told me about a pill that has come into the market that can help a woman ovulate. Do you know anything about this?

Dr. Jones: I don't know your grandmother. No, I don't.

Question from Metaphysician: Instead of looking at the ethics of artificial reproduction, what about the morality? For example, does IVF, cloning, etc., suggest a more ideal human development than that to which we might otherwise be limited physiologically?

Dr. Jones: I think it is important to separate IVF and cloning. IVF has no judgment about whether the result of the efforts is better or worse than the generation before.

Therefore, IVF is doing nothing more than enabling the infertile couple to have a child, and it will not be any better or worse than if that child were the product of normal intercourse.

On the other hand, cloning, which is not applicable to humans at the time and is unlikely to be in the foreseeable future, is used in the animal kingdom to stabilize the results of breeding, which has been going on for a long time, to produce cattle that will give more milk, sheep that will give more wool.

If cloning can do that, it will reduce the cost of these things, and express contentment with the level reached. We must not confuse cloning with IVF.

Mr. Bertarelli: In our opinion, human cloning is unacceptable. It is very important to separate IVF and cloning. IVF is only a treatment for people who are disabled, like any treatment for a disease where people end up being disabled. The objective in IVF is to provide an opportunity to have the joy of having children with dignity.

Question from Metaphysician: When artificial reproductive strategies become as commonplace as biological sex, do you expect to see couples performing mating rituals surrounding your procedure?

Dr. Jones: You will have to ask the couple.

Question from Brenda:My husband and I are "newbies" to all of this fertility stuff. I am 43; he is 39; we want to get pregnant (first for both of us). Where do we start?

Dr. Jones: I assume that it has been determined that natural intercourse cannot produce a pregnancy. If it has been demonstrated that there is infertility, I believe you start with seeking medical help.

It is quite clear that with age, fecundity, that, is the ability to get pregnant and produce a child in a period of time, is reduced. Therefore, seeking timely medical advice becomes more important as you reach the end of the fertility cycle.

Question from Stephanie: What is the focus of this weekend's conference?

Mr. Bertarelli: This weekend conference, sponsored by the Bertarelli Foundation and the NIH, is to come to consensus on the problems associated particularly with multiple births.

We have a panel of speakers from around the world that will share their experiences, knowledge and practice to educate, facilitate and probably advocate for some sort of practice that will reduce the number of multiple births that result from IVF and other assisted reproductive technology. On Sunday, through the Bertarelli Internet site, we will share the results of this conference at noon.

Chat Moderator: Do either of you have any final thoughts for the chatters?

Mr. Bertarelli: From where I stand, as chairman of the foundation, I strongly believe it is important to educate the public in general so that infertility is recognized as a disease, so that it gets treated. I also think it is important that a debate continues with the many stakeholders so that a consensus can be reached on the many dimensions of reproductive health, and that the debate can share the benefits and risks of this technology.

Most important, we must advocate the right for parents to have children with dignity when they are affected by infertility.

Dr. Jones: As a clinician, I can easily remember the time when it was necessary to sit across the desk from an infertile couple and say that there was nothing more that could be done. In the past 20 years the percent of patients who have had to receive that news has been greatly decreased. The field is so dynamic that I have no doubt that in the next decade that percentage will be less and less.

Chat Moderator:Thank you for joining us, Dr. Jones and Mr. Bertarelli!

Dr. Jones: Thank you.

Mr. Bertarelli: Thank you.