Starting a family is undeniably life-changing. We take into account everyday factors such as our age, our living arrangement, our careers and maybe even our friends. On a broader level, we look at evolving concepts such as birth and death rates, maternal and paternal age, and the balance of population and resources. In the backdrop of all these considerations are the advancements of the medical community in aiding infertility and infant survival. Deciding to begin a family and then facing difficulty conceiving can be unexpected and agonizing. It can also be expensive and ethically complicated. While the creation of new life is a complex concept, it is simply a miracle.
We sat down with Dr. Jennifer Eaton, Medical Director of Assisted Reproductive Technology and Director of the Oocyte Donation Program at Duke Fertility Center in Durham, NC. She has spent her many years of training at some of the most prestigious and progressive medical institutions in the world, all the while bringing empathy and personalized care to patients trying to navigate the road to family planning. Dr. Eaton is a valued member of our Summus physician network, and we spent some time with her to learn about overcoming fertility challenges and how medicine is advancing to help create families in a changing social landscape.
Jennifer Kherani: What is the most common cause of infertility and, once a fertility barrier has been identified, about how long does it take to successfully become pregnant?
Jennifer Eaton: The most common cause is probably anovulation, when the ovaries do not release an oocyte, an egg, during menstruation. For these couples, they can likely become pregnant within a few months. Anovulation can usually be solved with medication alone and has a good prognosis. For those facing other fertility challenges and disorders, the rate of success and length of time to get there varies. Testing for in vitro fertilization (IVF) usually takes about a month. Success rates are closely tied to age. For women under the age of 35, the success rate is around 50%. This then steadily decreases from that point forward and drastically diminishes after the age of 42.
JK: What is the average cost to have a baby for those requiring IVF?
JE: Nationally the cost of each cycle is approximately $12,000. Costs begin to add up rapidly. I trained in states with mandated insurance coverage for these costs (MA). Now, I’m in NC and most patients have to pay out of pocket. This is the case in most states. Many reproductive endocrinologists, including myself, are pushing for mandated insurance coverage. I recently published a paper on this. Infertility is a disease and should be covered as such. Individuals’ lack of access and/or cost concerns drive up the rate of multiple gestation. Women choose to have multiple eggs implanted to increase the likelihood of success and this, in turn, is what leads to multiple births. Multiple gestations have higher complication rates, the cost of which is likely greater than if we just covered patients with insurance to begin with.
JK: How do you choose which embryo gets implanted, and do patients have a say in the matter?
JE: Historically it has been based upon embryo grading. The scoring systems might vary slightly by lab but, in general, on the 3rd day embryos are viewed and are graded on things such as their symmetry and fragmentation. On day 5, they have become a blastocyst, this is the inner cell mass which will ultimately become the embryo. We can look at the cellular quality and predict the probability of successful implantation. Now we can also use genetic testing, a DNA biopsy, to look for more intact DNA.
JK: Do you think that genetic selection will become a utilized strategy at some point? Is that ethical?
JE: We will certainly have the capability to do this at some point and we will have to ethically decide on these capabilities in the not too distant future. Conversations have already started. Right now we already detect the sex of the baby prior to implantation. Ethically the community is mixed as to whether or not we should be allowed to do so. As it stands now, patients do see this information. Some families use the information to guide their implantation for gender balance in their home and others use it solely out of gender preference. We share the sex data with patients when choosing embryos. However, if there is a ‘higher quality’ choice of the opposite sex, we always counsel patients to use it. They, however, make the final decision. Some clinics are currently offering IVF solely to control the baby’s gender for patients. The ethical considerations are tremendous. Not only for reasons of nature and population but also, as transgender communities become more vocal, we’re learning about parental ‘expectations’. What if, for example, parents choose a female embryo for gender bias and then their daughter is a ‘tomboy’? Their disappointment in her can potentially be amplified by the energy and cost they invested to have a female baby.
JK: Is there a risk to using frozen eggs? Does the success rate differ from “fresh” eggs?
JE: People freeze their eggs for various reasons. Patients undergoing cancer treatment will do so for health concerns and single women will do so to advance their career and have peace of mind should they choose to have a family later. There is a lot of data to suggest similar success rates. However, it’s important to note that these studies have been done in women who were likely to have high success rates in the first place. We haven’t looked at populations such as women of advanced age. One study of women from ages 30-36 illustrated that to have one live birth, they would need ten frozen eggs. The next age bracket would’ve perhaps required 30 eggs, we just don’t know. For the freezing process, we do one round of stimulation and collect all available eggs. In patients under the age of 35 with normal ovarian reserve, we would expect to retrieve egg numbers in the teens. If older, we’ll likely retrieve less than ten.
JK: What is the most promising technology or advancement coming up?
JE: Advances in pre-implantation genetic screening (PGS) of embryos as well as endometrial testing which allows us to identify genetic changes that may impact the ability of a normal embryo to implant. This will likely allow us to further understand failed implantation and endometrial abnormalities which are currently great barriers to success. Why would a “normal” embryo not implant? This is not likely due to age. Age more commonly affects the embryo so what are we missing in our screening process now? Many steps can go wrong along the implantation process. PGS and endometrial testing will help us to understand and answer this to improve success rates.