Highlights of the 16th Annual In Vitro Fertilization and Embryo Transfer-A
Comprehensive Update-2003 Meeting, Santa Barbara, California (Part I)
By David R. Meldrum, M. D. 

The 16th Annual In Vitro Fertilization and Embryo Transfer Comprehensive Update, July 2003, directed by Dr. Meldrum in conjunction with the Office of Continuing Medical Education, UCLA School of Medicine each year since 1987, attracted over 200 participants from the U.S. and around the world, most of whom have been actively involved in IVF.  Over the years Dr. Meldrum has gathered a renowned group of faculty who are excellent speakers, each of whom assume the responsibility for being right up to date on their assigned topics.  Most U.S. IVF programs make a point of having one of their team attend at least every couple of years.

STIMULATION PROTOCOLS

Dr. David Meldrum (Reproductive Partners Medical Group, Southern California) spoke on standard stimulation regimens.  The majority of programs use a combined oral contraceptive (OC)/ gonadotropin releasing hormone (GnRH0 agonist (usually Lupron) regimen that allows flexibility without the menopausal symptoms accompanying extended use of Lupron.  With this regimen, it is customary to use some LH activity as part of the stimulation either in the form of human menopausal gonadotropins (hMG) or a small dose of human chorionic gonadotropin (hCG).  Dr. Meldrum has suggested using 20 or 30 units per day based on a study he did with one of the UCLA fellows showing the ability of “mini-hCG” to replenish the levels of LH activity in women who are suppressed.  This very simple protocol avoids the use of hMG which requires intramuscular injection or causes significant reactions in some women when given subcutaneously.

Dr. William Schoolcraft (Colorado Center for Reproductive Medicine, Englewood, Colorado) spoke on the use of pure follicle stimulating hormone (FSH) versus hMG.  Reduced outcomes have been associated with very low luteinizing hormone (LH) levels.  Under certain circumstances such as full dose Lupron, O.C./Lupron and antagonist, use of a combination of FSH and hMG may improve overall results.

Dr. Francois Olivennes (Hospital A. Beclere, Clamart, France) spoke on GnRH antagonists which simplify ovarian stimulation.  Although overall experience has shown about a 20% lower pregnancy rate with antagonist, experienced centers appear to be getting results equivalent to GnRH agonists.  It is important to maintain or even increase the gonadotropin dose when the antagonist is begun, since endogenous gonadotropins fall.  Use of pretreatment with an oral contraceptive will allow flexibility.  Administering some LH activity will prevent a reduced outcome for women whose LH levels markedly fall.  Starting the antagonist at 14 mm will prevent prolonged administration and limit any possible adverse effects on the endometrium.

Dr. Richard Scott (Reproductive Medicine Associates of New Jersey, West Orange, New Jersey) spoke on reserve testing and stimulation of the poor responder.  He emphasized the value of the basal follicle count in predicting outcome in addition to day 3 FSH and the clomiphene challenge test.  When the resting follicle count is less than 4, all outcomes are markedly reduced.  The two most common regimens for poor responders are “mini-dose Lupron” and Antagon (GnRH agonist). In his experience, the GnRH antagonist appears to yield results equal to the mini-Lupron flare.

SELECTION OF PROCEDURE

Dr. Bill Yee (Reproductive Partners Medical Group, Southern California) spoke on the GIFT procedure (gamete intrafallopian transfer), emphasizing its role in particular circumstances.  GIFT has been particularly successful with donor sperm, probably because of a more consistent fertilization than with infertile husbands sperm.  When embryo transfer continues to be difficult in spite of cervical dilation and ultrasound-guided transfer and the male factor is fairly normal, GIFT may be an excellent choice.  Finally, the trend has been toward higher results with GIFT for women over age 42, although no well-controlled study has been done comparing IVF and GIFT in this age group.

Dr. Gabriel Garzo (Reproductive Partners Medical Group, La Jolla, California) spoke on gestational surrogacy and mainly emphasized the complexity of this process and that surrogate agencies vary considerably in quality.  Patients should be referred to physicians who do surrogacy and are familiar with agencies that do this well, rather than to choose the agency from the Internet or other promotional materials. It is one of the most complex ART procedures but can be very gratifying for patients, surrogates and medical staff.

Dr. Joseph Gambone (UCLA School of Medicine, Los Angeles, California) discussed uterine factors and ART. Generally polyps and submucous myomas should be removed before ART. Specifically, the data on fibroids and IVF clearly shows reduced outcome with submucosal fibroids distorting the cavity.  The data on intramural (in the wall) fibroids not distorting the uterine cavity are mixed. Clearly the chance of an intramural fibroid preventing pregnancy or causing miscarriage will be greater if the fibroid is large or very close to the cavity. The data on polyps is scant since they are generally removed.  The consensus is that all except very small polyps (e.g. less than 5 mm) should be removed before IVF.

LABORATORY TECHNIQUES

Dr. Kwang-Yul Cha (Pochon CHA University, Seoul, Korea) reviewed the subject of human oocyte (egg) and ovarian tissue freezing.  Egg freezing is now successful enough to offer to women before having chemotherapy or radiation.  In some cases a woman might choose to store her oocytes to maintain her fertility options.

Dr. David K. Gardner (Colorado Center for Reproductive Medicine, Englewood, Colorado) spoke on holistic approach to IVF, emphasizing the importance of ovarian stimulation, testing of all laboratory materials contacting the gametes and embryos, culture media, laboratory factors such as the ratio of the number of incubators to the number of cases and embryo transfer technique. 

Lucinda Veeck, MLT, DSc (hon)  (Cornell University Medical Center, New York, New York) discussed the aspects of embryo morphology which have consistently been associated with implantation.  The most important are early cleavage to the two-cell, even 8 cell embryos, lack of multinucleated blastomeres and absent or minimal fragmentation.

All in all, the meeting was a great success.  This conference is unique in the world in having such a large number of speakers who are leaders in the field each indicating the methods associated with optimal results at each step in this complex process.  The U.S. has become a clear leader in IVF success in the world.  There is little doubt that this conference and its excellent faculty have played a significant role in that regard.

Next issue of Reproductive Times will feature Part 2 of the Highlights of the 16th Annual In Vitro Fertilization and Embryo Transfer-A Comprehensive Update-2003 including sections on male factor and improving IVF success.

Reproductive Partners Now Offering Telephone Consultations

Because of the overwhelming response to our website, two years ago we introduced Reproductive Partners Worldwide (RPWW). The purpose of RPWW is to make the programs and facilities of Reproductive Partners available to couples throughout the United States and around the globe.

Now, in conjunction with RPWW, we are offering telephone consultations to couples that do not live in Southern California and need a formal second opinion or would like to explore the possibility of coming to a Reproductive Partners facility for treatment. 

Prospective patients need to understand that a telephone consultation has its limitations and is not as valuable as a face-to-face meeting in which we are able to perform a physical examination and ultrasound, if necessary. However a review of the previous medical records and a discussion of relevant issues will provide far more information and direction than visiting web sites or posting on a bulletin board.

To make an appointment with one of the RPMG doctors offering telephone consultations, call the appropriate office to make arrangements:
 

The key to success of this effort is good communication. By utilizing modern communication technology such as e-mail, faxes and the Internet, we will be able to share information with a couple’s physician close to home.  That will minimize the time required for the couple to be present in one of Reproductive Partners’ nationally recognized centers in Southern California.

Travel arrangements can be made through the patient’s travel agent or a special travel consultant to take advantage of specially priced accommodations. An IVF cycle would require the female partner to be near one of our facilities from seven to ten days, while the male partner would have to be present for one to two days at the time of egg retrieval.

Although telephone consultations are now available, we feel it would be best that the couple have an in-person consultation in order that we may meet face-to-face and perform the pre-cycle semen analysis, semen culture and trial transfer at the time of the initial consultation. The remainder of the pre-cycle testing can be done close to one’s home. We will work with the couple’s physician to perform these vital tests. If a couple chooses, we can offer a telephone consultation and arrange to have the semen analysis, culture and trial transfer done in the couple’s home city.

We will instruct the patient’s local physician in monitoring the initial portion of the preparation and stimulation phase and request the female partner arrive at a Reproductive Partners facility starting with the sixth day of stimulation. She should plan to stay until the completion of two days of bed rest following the transfer.

To make an appointment for a consultation, semen analysis, trial transfer and other precycle testing please call one of the offices for the doctor you wish.

To make travel arrangements, call your travel agent or contact our special travel consultant for special discount fares and accommodations:

 Sue Lorman
 Carlson Wagonlit Travel
 2509 Pacific Coast Highway
 Torrance, California 90505
 Phone: (310) 325-7162
 Fax: (310) 534-3686
 E-Mail: yourpartnerintravel@worldnet.att.net