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Sunday, November 25, 2007

Go Directly to IVF - Do Not Pass Go?

A new study seems to suggest that couples suffering from infertility should not waste their time or money on less invasive fertility treatments, but instead should con sider going straight to in-vitro fertilization:
So it makes sense that some researchers are pushing to skip the middle step and go straight to IVF when the first-round effort fails. In a study presented last month at the annual meeting of the American Society of Reproductive Medicine, doctors from Dartmouth Medical School and Boston IVF concluded that women who were fast-tracked to IVF got pregnant three months faster on average, and spent $10,000 less than those who went through the usual preliminaries.
Considering how many couples I know who tried most or all of the less invasive treatments before finally being successful with IVF, this study would seem to be recommending the exact opposite approach. What's particularly interesting is that I had a conversation with a close friend regarding the halachic parameters of fertility treatments, and her halachic authority was definitely recommending that she and her husband try other treatments before approaching IVF, and seemed to treat IVF as pretty much a last resort (short of treatments such as surrogacy and sperm/egg donors, which can raise more complicated halachic questions). One of the reasons seemed to be a psychological - that the couple should not pull out all the stops treatment-wise, and then be dejected if the holy grail of fertility treatments doesn't show immediate results. While I can understand the motivations behind that, this study would seem to show that such waiting, considering the lower rate of success from the less involved treatments, might be more of a cruel and unusual psychological punishment in and of itself, as the article notes:
Shorter waits bring welcome psychological relief. One study claimed that women going through infertility treatment were as distressed as women diagnosed with cancer, heart disease, or HIV. Fast-tracking can mean fewer episodes of dashed hopes. That could lead to less depression, anxiety, and stress, which hurts marriages and, some claim, may lower one's chances of conceiving.
Another reason seemed to be because her Rav was concerned about the supposed higher rates of multiple births with IVF, and the fact that such multiple pregnancies entail a higher risk for both mother and children - however, that IVF does have a higher propensity for multiple births seems to be disproved from the study noted above.
The first is the potential to prevent higher-order multiple births—triplets, quadruplets, and beyond, which carry a greater risk to the mother's and babies' health. Women who get pregnant from injections with insemination face a 10 percent to 15 percent chance of carrying litters because the drugs can make them release six or more eggs. There's no way to control how many get fertilized. With IVF, by contrast, doctors create embryos in a lab and choose how many to transfer back to the womb, bringing the risk of triplets and beyond down to 2 percent to 4 percent. (The odds of conceiving triplets naturally are between 1 in 6,000 and 1 in 8,100.) That IVF figure is likely to decline further as doctors increasingly transfer fewer embryos.
So the question is, will the halachic recommendations change as a result of these findings, as the medical recommendation is hopefully going to - if they haven't already? Feel free to chime in with your experience as to whether halachic guidance given to infertile couples jibes with this medical recommendation to fast-track IVF. Though I know a few people who received halachic guidance to wait on IVF until other treatments have been tried, I know of at least one friend, living in Israel, who received a psak to go straight to IVF - but that obviously might have been complicated by her specific situation. So I'd love to hear some weighing in - anecdotal though it might be - on what seems to be the halachic consensus at this moment.

More on halacha and infertility here, from the indefatigable Chana's excellent notes from a medical ethics conference she attended at YU.

59 Comments:

Blogger Alexis said...

I think it's a popular misconception that IVF results in more multiple births. Once upon a time it did, as REs would use multiple embryos in the hopes that one would implant. Now they generally only use 2. In fact IVF offers the best chance for avoiding multiples as there's greater control. Other methods (such as IUI) can have a greater chance of multiple births because you don't have that control. I personally know of one case of triplets--RE thought there were only 2 mature follicles, but one of the borderline ones was actually mature.

3:22 PM  
Blogger DAG said...

Just a note, that this seems to be referring to FEMALE Factor infertility ONLY. 50% of unexplained infertility turns out to be male factor. One of the problems in standard Halachik IF treatment, is that women are often forced to undergo invasive, and dangerous procedures BEFORE the husband is given a Heter to have a sample tested.

8:15 PM  
Anonymous IVF survivor said...

As an infertility survivor I would like to share what I know

1. Halacha prefers that conception take place in the bedroom.
2. Second place is in the woman's body.
3. Halacha does permit IVF, however there are minority opinions that forbid it. There are other minority opinions that allow IVF but posit that the child is not the halachic child of the parents or that the parents have not fulfilled the mitzvah of pru u'rvu.
4. For the above reasons, IVF is seen as a last resort. I am not aware of the psychological issues playing a big part. If anything most ppl are petrified of IVF. Another consideration is cost, since in NY many infertility procedures are covered by insurance, where IVF is usually not.
5. Many halachic authorities are not experts in infertility and related halachos and cause a couple much anguish (an example would be what DAG explained above by not allowing a semen analysis to be done prior to treatments). Please refer ppl to ATIME (www.atime.org) or Machon Puah to find a competent halachic authority.
6. In the realm of infertility treatmens there are various risks of multiples. IVF promotes the most control over these risks. Single embryo transfers are now the norm in many European countries (where medical care is socialized and they don't want to pay for the expense of a multiple pregnancy and possible preterm birth) with no measurable reduction in pregnancy rates. Even in the US it is more and more common to transfer 2, with the result being at most twins (one is more common). With injectibles (with or without IUI) the risks are much higher. Clomid however does not carry a very high risk of multiples (though it does raise the chances of twins by a few percentage points).

I would advice a couple trying to conceive unsuccessfully (12 months if under 35, 6 months if 35+) to see a reproductive endocrinologist and skip the OB-GYN. Find a good Rav. Do not start treatment without a full workup of both partners (have the doctor talk to the Rav if necessary, I know too many people who thought it was a female problem only to find out they also had a male factor problem and medicated themselves and subjected themselves to pointless procedures). Reach out to others (through ATIME, or Resolve etc) - more ppl are in this boat that you dream. And have faith that you will eventually be successful.

HTH

9:04 PM  
Anonymous Anonymous said...

HTH-
After 2 months on Clomid, I got pregnant with quintuplets, yes you read right- 5 embryos, 5 heartbeats. Under the guidance of Machon Puah, the pregnancy was reduced to twins. I cannot begin to describe the stress of having to go before the "abortion committee" at an Israeli hospital (b/c this was considered abortion and all abortions in Israel have to approved by a committee), and the raw fear that the reduction would result in miscarrying all the babies. B'H I ended up with healthy twins, but going straight to IVF would have saved me a lot of heartache.

9:26 PM  
Blogger yael said...

You have to consider the finances of that particular couple to see if it is worth it financially. It is assuming that they have no insurance coverage for IF.

The other question is if the stats are the same across the board age-wise. Frum couples are typically much younger than average. They may have more success on the treatments before ivf.

For an older frum couple, ivf sooner makes more sense so they don't waste time on the treatments that don't work.

For the younger couples you also have to ask if they are emotionally ready for ivf. You are sometimes talking about 21-22 year olds (with frum couples who got married very young).

1:37 AM  
Anonymous Anonymous said...

this note is for bloggers who conceived their frist child, and now cannot conceive again.
I tried EVERYTHING short of IVF, you name it we did,
medictions; surgery; every day; once a month; cough syrup; legs up; over your head:) anything and everything, except....changing the time of day. Who wants the child knocking at the door, or opening the door!!ugh!!
Anyway, I realized we conceived on vacation during the morning, so we tried morning, we were able to get time only two mornings, two weeks apart.. and we conceived!!
We tried for years my children are about 6 years apart. A
few weeks after we conceived a study came out, that men and woman are more rested in morning, men sperm count at the highest, women are relaxed. So try the morning, and then repeat after me, we are not morning people, UGH, and I am gratful for my blessings.

9:08 AM  
Blogger -suitepotato- said...

For me and my wife it is as simple as this: before we invite a rabbi into our bedroom, we should ask the one authority who is there no matter what: G-d.

G-d says do what you have to without causing harm to anyone to achieve it. Follow the golden rule, and then be fruitful and multiply. Be good parents. Go for it.

You know, it occurs that old men (and I am no spring chicken) who are not likely burning up the sheets with their rebbetzin so much anymore might want to think back to their youth with a bit more humility and consider the cost to couples who try the old fashioned way until they grow sick of each others' touch and wish for a divorce or death if a baby isn't forthcoming.

That's hardly spreading love, kindness, and decency nevermind increasing the Jewish birth rate. Couples should try the old fashioned way, but it doesn't exist just for reproduction in a marriage, passion and intimacy are serious needs, and hammering those latter ones out of existence for the sake of the former is a harsh way to a pointless let down.

BTW, every doc we've seen so far has said to go right to IVF and we agree.

6:38 PM  
Blogger Barbara said...

After 12 years of trying every procedure, having 3 surgeries, I was finally able to afford IVF. I conceived quads on the 2nd round and it self-reduced to twins in 3 weeks.

I understand Halacha but I must say there are very serious psychological issues. I have PCOS and I will agree with HTH that RESOLVE and INCIID where of tremendous help for me. Even finding me counseling.

I am a convert but I was Catholic before and my Priest didn't like the idea of IVF. I tried a few times to explain that I was being shunned by people who had kids now, and I felt like 'less of a woman' because of all this (still do) but he made me feel terribly guilty.

I am glad I went ahead with it though. Even though, if you read my response to another of OM's posts here about beauty sleep & new moms, my having children brought on a divorce and a lot of physical and emotional pain for me - I adore my children. I spend a lot of time with them and they are the biggest part of my life & what kept me going.

Again, I agree that IVF should be a first choice for a number of people. It should have been for me. But religion and affordability were large hurdles when I started trying in 1985.

10:34 PM  
Anonymous Kmelion said...

Well then it first needs to be taken up with all the various insurance companies.

In Israel (and in the US when you're lucky enough to have insurance that covered IF stuff), they require a certain protocol (especially when male-factor IF has been ruled out). X number of cycles done one way before moving on to X number of IUI before reaching IVF.

Having said that, IF is an individual, case by case situation and there isn't one across the board solution. I went through 3 IUI cycles to conceive my son. Personally, that was invasive enough for me. I'm glad my doctor and I took the time to do that step before jumping to IVF although if the third cycle had also failed, IVF was just a few months away.

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12:40 AM  
Anonymous ivf survivor said...

I agree with the previous commnenter: it is a shame that rabbonim do not allow the testing of the male before invasive procedures are done on the female. Sine 50% of infertility is male factor, this process forces 50% of women with trouble conceiving to undergo medical procedures which are totally unnecessary. Yes, those are the couples who should be going straight to IVF. In my opinion those are also probably the couples who should be transferring one embryo. In a 21 year old woman with no health issues of her own, transferring 2 embryos will result in twins about 65%-85% of the time at top clinics.

2:18 PM  
Anonymous ORTHO WHAT said...

As if there isn't enough people in the world. People waste resources. We don't need more inventions to play god. Its bad enough we understand genetic code. Please die right now.

4:31 PM  
Blogger Karen said...

A commenter in my blog pointed me to this post, which I found very interesting. I begged and begged my doctors to move on to IVF after 3 failed IUIs. I was told to do one more IUI and I got pregnant, but miscarried after 12+ weeks. When it was time to resume treatment, I again begged and begged multiple doctors to move on to IVF, but the answer I got was "why would you do the invasive, costly procedure when you know that IUI can and does get you pregnant?" Well, there were a few reasons: 1. I was terrified of ending up with triplets (or more!), 2. IUI and all the testing had already cost a lot of money and there was a cap on the amount of insurance coverage I had, but no requirement from my insurance to do any number of less invasive procedures, 3. I was taking so long to stim with IUI protocol (because I'm a super-responder and they were worried about me growing too many follicles), that my cycles went on forever and all the frustration of each cycle was getting to be too much with too little chance of payoff, 4. Did I mention I was terrified I would end up pregnant with triplets?

My doctor finally "compromised" and suggested two more IUIs before moving on to IVF. The first failed. The second cycle was ridiculous...everything went wrong and we (including the doctors) were so sure it had failed that we had already ordered everything we needed for the IVF cycle when I learned I was pregnant. With triplets.

B"H, my triplets are here now, safe and sound. But I had a very difficult pregnancy and some very scary moments. Though I adore these babies, and can't imagine life without them, I still wholeheartedly agree with the approach of moving straight to IVF. We spent at least as much money on our six IUIs and all the associated testing as we would have if we'd just jumped straight to IVF, and odds are good that I would have had one baby at a time with IVF.

I'm insane enough to want more kids and another chance at my normal singleton pregnancy, and you can be darned sure that I won't agree to try IUI again. We spent far too much money and wasted so much time. I won't do that again, and especially not with the risk of another set of triplets. (I should add that my Rav fully supported us moving on to IVF after our first three failed IUIs... I'm not sure he would have been so quick to agree to skipping the IUIs all together, but I have told him that when I do this again I plan to skip the IUI step because of the risk of high order multiples and he agrees that would be prudent, particularly in light of how difficult my pregnancy was)

8:03 PM  
Anonymous Anonymous said...

Hi! I went straight to IVF (very complicated medical history) and had triplets. THey transferred 3 embryos and said hopefully one will take- and they all took! We can cheshbon but Hashem runs the world. I am very lucky!

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