Low Tech and High Tech Options -- Maria Bustillo, MD -- 09/25/02

WebMD Live Events Transcript

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

From low tech to high tech, the treatment options for infertility keep expanding. As part of National Infertility Awareness Week, WebMD teamed with RESOLVE: The National Infertility Association to bring you the Trying to Conceive (TTC) Cyber Conference. Maria Bustillo, MD, joined us to discuss the latest treatment options in the field of infertility.

Moderator: Welcome, Dr. Bustillo. Thanks for being our guest this hour.

Bustillo: It's a pleasure to be here.

Member: What high-tech innovations are you aware of that are in the works that we can look forward to in the next couple of years?

Bustillo: In terms of infertility, one of the most interesting high-tech innovations is the use of a technology to ascertain whether an embryo is normal or not. This is called FISH. And it's looking at certain chromosomes of an embryo to see if they are present and accounted for in the way they should be (two of each kind) and it's also used for sexing of embryos to tell if they are male or female. This innovation will be helpful for two subgroups of couples: ones with repeated failure with IVF, and those who are not necessarily infertile but who carry chromosomal translocations or certain genetic diseases (X-linked) affecting male fetuses. So in that case, one would choose to transfer the female embryos that are normal in terms of chromosome number.

Member: Currently, during IVF procedures, is any technology normally used to check for genetic defect or disease in the embryos before implantation?

Bustillo: This is the technology we were just discussing and it's called preimplantation genetic diagnosis. It involves biopsying an embryo, removing a cell, and performing this FISH procedure or amplifying the genetic material of the one cell so routine genetic testing for diseases where we know what the defects are can be done on that cell. This is not done routinely. Again, there are certain indications and reasons to do it, like with previous failures or for families with certain genetic problems. These techniques require a certain amount of expertise and therefore are only available in a handful of clinics in the U.S.

Member: Can you talk about the use of Viagra suppositories, in conjunction with superov and IUI, to help thicken the uterine lining?

Bustillo: Yes, I can discuss that. There is one study that looked at this issue and showed some improvement in the uterine lining in women with a poor uterine lining. The incidence of a problem with uterine lining in the absence of the use of Clomiphene is fairly low. And Viagra seems to help if vascular factors are the cause of the abnormal development of the endometrium. The resistance of the blood flow to the uterus can be tested with a technology called Doppler Ultrasound. And aspirin has also been used for this purpose. Again, this is fairly uncommon so large data sets for comparing results with different treatments are not available.

Member: Have you heard of a treatment for poor quality embryos called, co-culturing?

Bustillo: Yes. Co-culturing is the culturing of embryos on a layer of cells that theoretically may remove any toxic substances that the embryo may produce. There is some data suggesting this might be helpful in a small number of patients. Co-culture requires a great deal of laboratory effort, and it's reserved for a small subset of patients who have poor embryos in the absence of any sign of ovarian aging. Patients who are older are less likely to benefit from this. Co-culture does not change the genetic compliments of the embryo and only influences embryo metabolism. A very large percentage of poor quality embryos are that way because they are genetically abnormal.

Member: Where can we find this data?

Bustillo: The data on co-culture has been published in Fertility and Sterility and Human Reproduction (both are research journals). They are available on the Internet.

Member: My wife and I did one cycle of IVF/ICSI, and we chose to have preimplantation genetic diagnosis. Twenty-two eggs were retrieved, 12 were ICSI'd, and seven fertilized. Of those, by day three, only four could be biopsied, and of those four, only one was normal, which was implanted. The cycle failed. Would you recommend PGD again for a second cycle and are there downsides or risks associated with PGD?

Bustillo: I would be very interested in the age of your wife. And if only four were available for biopsy and she's over 35 or 37, I don't think that PGD will add significantly, and it would be just as easy to transfer all four embryos. The majority of the time, they would not all implant.

Member: What are the newest high-tech options to help maintain embryo implantation and reduce miscarriage?

Bustillo: This is a very controversial area, but obviously knowing the embryo is genetically normal would be one way to improve chances of implantation. In women who have a history of recurrent miscarriage, or repeated IVF failure, in the presence of good quality embryos, there are some researchers who are looking at immune factors that may affect both implantation and prevention of early pregnancy loss. These immunologic treatments have traditionally involved the administration of experimental medicines or blood products and are generally not FDA approved and should be given cautiously and with informed consent. This is an area that could benefit from a tremendous amount of research. However, as most couples that fail repeatedly are generally desperate, it's difficult without government funding to attempt to do good randomized placebo controlled clinical trials in this area.

Member: What has a better success rate -- GIFT or ZIFT?

Bustillo: In the U.S., we are basically not doing GIFT or ZIFT any more because in general they require a laparoscopic procedure to place eggs and sperm in the tube (in the case of GIFT), or a fertilized egg (zygote) into the fallopian tube (in the case of ZIFT). As laparoscopy requires general anesthesia and routine IVF success rates have significantly improved, there is no medical indication to do GIFT or ZIFT. There are couples that for religious reasons may find GIFT or ZIFT more palatable. But from a medical point of view, it is hardly ever done in the U.S.

Member: How soon until women well over 40 can use their own genetic material in the egg of younger women?

Bustillo: Good question. What we are talking about now is cloning. To take genetic material from a woman, it has full genetic compliment. It would be not to take her material and put it with her husband's genetic material. The egg is the only cell in the female body that has half the number of chromosomes, so when fertilization occurs with a sperm; a full chromosomal compliment is accomplished.

At the moment, reproductive cloning is technically not allowed in this country. In some states there are actually laws against it. And I personally see this as a nonviable solution for the older woman in terms of family building. Egg donation on the other hand, even though it uses a third-party egg (younger egg), allows for pregnancy utilizing the husband's sperm, and the older recipient woman has the privilege and fun (!) of being pregnant and delivering.

Member: Do you expect the success rate for fresh IVF cycles (non-donor) to improve over the next few years?

Bustillo: I actually believe that the success rates are as good as they are going to get. And actually I suspect as we really battle the problem of multiple pregnancy, we may expect a minor drop in success rates with accomplishing the goal of healthy babies, mostly one at a time. Theoretically, with the use of PGD -- FISH, the success per embryo transfer might improve. However, what will likely happen is that fewer women will actually get transfers. Therefore, the success rates per initiation of IVF will not change but may appear better if looked at per embryo transfer.

Member: What's in the future as far as frozen eggs are concerned? Will they perfect this technology soon?

Bustillo: Egg cryopreservation has been around for over a decade and has certainly improved but definitely needs further improvement. The hope that this will occur makes this technology extremely attractive, particularly to young women who we know are candidates for loss of ovarian function because of cancer treatment. Progress has been somewhat limited, but hopefully some breakthrough will speed it up in the near future.

Member: I heard there is a technology that can help you choose whether your baby has blue eyes and blonde hair or brown eyes and brown hair. What is this and what do you think of it in terms of having a baby?

Bustillo: I do not believe that technology exists, as those characteristics are likely multigenic (many genes) and those genes have not been fully identified. Infertility physicians in general like to help people build families and often are not interested in such requests.

Member: Are there any high-tech options in the pipeline to improve poor egg quality?

Bustillo: There is an experimental technique that has been used on a very limited basis to attempt to improve egg quality. It's called cytoplasmic transfer -- where some cytoplasm [the cellular contents] from young donor eggs is taken and placed into the cytoplasm of an older or supposedly "less good" egg. The theory behind this technique is that in the cytoplasm there are mitochondrial DNA and this is a source of potential energy for the egg that would help the older egg undergo the late stages of the reduction of chromosome number in a more normal fashion and be less likely to be abnormal; therefore leading to more normal embryos from a genetic point of view. There is controversy as to who benefits from this technology, as well as due to the fact that DNA from a third party is now introduced into the embryo, and we do not now know all the implications of such a procedure.

Member: Are there any new treatments or innovations for a man who has 100% sperm antibodies? We did miraculously conceive one little boy with IUI/sperm washing five years ago but it is not working now. IVF is out of our reach! I have PCOS and diabetes now (I did not have diabetes the first time around).

Bustillo: The area of immunology of reproduction again is understudied and if the antibodies are in the man and directed at the head of the sperm, IVF with ICSI is likely the only therapy to be successful. There are a number of financing programs available, as an increasing number of clinics in the U.S. offer this. Hopefully this would be within reach.

Member: Since endometriosis runs in families, is that a disease that would warrant sex preselection for males -- to avoid having a child with the disease?

Bustillo: In my opinion, no. I think there are a number of ways to potentially protect a young woman from endometriosis, including the use of oral contraceptives early on, as well as pregnancy as early as feasible. The genetic aspects of endometriosis are not completely genetically defined, and likely all female relatives would not be affected. So selection for males in this case would be rather radical.

Member: As there are women who become pregnant despite high FSH levels, do you champion any low-tech or alternative methods of women TTC with high FSH?

Bustillo: In women who are young with high FSH we tend to get better results or good results with some low-tech options, but we worry about time passing and whether the situation would get worse. So about as low tech as we get is, in the absence of any other causes such as tubal or male problems, we use ovulation induction for a limited number of cycles with Clomiphene and then move on to more aggressive technologies.

Moderator: Thanks to Maria Bustillo, MD, for being our guest. For more information on all fertility issues, be sure to explore all the TTC info here at WebMD, including our message boards and regular live chats with Amos Grunebaum, MD.

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