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St. Louis Beacon: Fertility expert Dr. Sherman Silber gives hope to infertile men and women
Posted November 16, 2009
Click here to read a very well written article by the St. Louis Beacon that reviews some of my latest accomplishments and explores some of my personal background.
–Dr. Sherman Silber
Front page of the Sunday New York Times agrees with Dr. Silber on octuplets issue
Posted October 14, 2009
The following excerpt is from the front page of the October 11, 2009 Sunday New York Times. The common procedure of IUI is much less effective than IVF, in that it gives a much lower pregnancy rate (one-fifth the pregnancy rate of IVF), and is more dangerous (the major reason for high order multiple pregnancies) as well. If IVF is performed judiciously, with completely reliable embryo freezing, you can avoid triplets and other dangerous pregnancies, and nonetheless have a much higher pregnancy rate. See the New York Times article below:
It was the last piece of advice Thomas and Amanda Stansel wanted to hear. But their fertility doctor was delivering it, without sugarcoating.
Reduce, or you will lose them all, he told them.
For more than a year the Stansels had been relying on Dr. George Grunert, one of the busiest fertility doctors in Houston, to produce his industry’s coveted product — a healthy baby. He was using a common procedure called intrauterine insemination, which involved injecting sperm into Mrs. Stansel’s uterus after hormone shots.
But something had gone wrong. In April, an ultrasound revealed that Mrs. Stansel was carrying not one but six babies, and Dr. Grunert was recommending a procedure known as selective reduction, in which some of the fetuses would be eliminated.
The Stansels rejected Dr. Grunert’s advice and, since then, their vision of a family has collapsed into excruciating loss: the deaths of four children after their premature births on Aug. 4, including one who died late Sunday night. The two other infants remain in neonatal intensive care, their futures uncertain.
“I feel like we bonded with all of them, the short time they were here,” Mr. Stansel said. “We were able to hold them before they passed away.”
The birth of octuplets in California in January placed the onus for large multiple births on in vitro fertilization, a treatment in which eggs are joined with sperm in a petri dish and returned to the womb for gestation.
But the procedure the Stansels used is actually the major cause of quadruplets, quintuplets and sextuplets — the most dangerous pregnancies for both mother and children. While less effective than IVF, intrauterine insemination is used at least twice as frequently because it is less invasive, cheaper and more likely to be covered by insurance, interviews and data show.
Multiples can occur when the high-potency hormones frequently used with the procedure overstimulate the ovaries and produce large numbers of eggs. Parents are then left with the kind of tough choices the Stansels faced: whether to eliminate some of the fetuses or keep the babies and face extraordinary risks.
“I think, and so many of my colleagues think, it’s a primitive approach,” said Dr. Sherman Silber, a fertility doctor in St. Louis. “The pregnancy rate is lower than IVF, and you don’t have control over multiples.”
This is why we do not perform this type of procedure at the Infertility Center of St. Louis and prefer IVF. As I was quoted in the article, intrauterine insemination is a primitive procedure with poor results and a greater loss of control over multiples. This article also touches on the role insurance companies play in infertility treatments. I've discussed my thoughts on insurance companies in my previous blog post.
–Dr. Sherman Silber
My comments on the octuplets story
Posted March 5, 2009
TV/Radio/Print News Coverage
I have been inundated with questions about the octuplets story. This story just won't stop erupting in the news. The public is filled with curiosity, frank anger, fear, and this story just won’t go away. People seem to be angry with both the patient and her doctor, and they fear that reproductive technology [see video] and IVF have gotten ahead of ethics and the law. There is an undercurrent of fear in the public mind that infertility treatment is dangerous, and that IVF is not properly regulated. Many are afraid that because of this technology there will be too many kids being born, and in circumstances that are not ideal. Furthermore the lack of forthright answers, and the frank issue evasion on the part of our professional societies like ASRM as well as the many regulatory agencies that oversee us (and there are many), has exacerbated this anger and fear among the public, as well as in the media coverage of the story. It has become a nightmare for infertility patients and doctors alike.
I want to assure readers that in a properly supervised infertility clinic this sort of dangerous result should never occur, and that it was frank malpractice to have replaced so many embryos into this woman. But to clarify how this happened, and how to make sure this does not happen to others, we need to first separate the emotional complaints about this woman (whom none of us know really) having too many children that she may not be able to care for, from the medical risks the doctor and the patient took, and why patients and doctors sometimes do such foolish things. Furthermore, since there are 5 regulatory agencies that are supposed to be overseeing our field, in addition to guidelines set by our professional societies, how could this have happened? How do we prevent this medical disaster from occurring again in the future?
Confusion generated by press and media
Firstly, over the years, the press and media have treated such medical disasters as great achievements. Frankly, it is a tribute to modern neonatal care that such dangerous multiple pregnancies, resulting in such very low birth weight premature children, can result in any of them surviving at all, and without the majority of survivors being severely handicapped mentally and physically. So the press over the years with quintuplets and sextuplets and septuplets, has glorified the story and given the eager public some sensationalist but completely misleading impressions about the safety of multiple pregnancies. Even now with this octuplet story the press is only goading the public into criticizing the ethics of this woman having too many children when she is on welfare and cannot apparently afford to take care of them. The press has completely avoided the dangerous impairments that all of these children face, and the fact that this devastating complication could have been so easily avoided.
Multiple pregnancies carry much greater danger to mother and to the offspring than a singleton pregnancy. Every doctor knows that. Even twin pregnancies, which most infertile women seem to desire, which are acceptable under our professional guidelines, and which are a relatively safe pregnancy under competent OB care, do carry much more potential hazard than a singleton pregnancy. As soon as you get greater than twins, into triplets and quadruplets and higher, the pregnancy is very very dangerous and very costly to the health care provider. To safely care for even a triplet pregnancy the cost can increase to up to half a million dollars, and an octuplet pregnancy to many millions of dollars.
In Europe and Japan this just does NOT happen. In fact the Europeans and the Japanese are horrified by our high rates of dangerous multiple pregnancies in the U. S. So why are we, perhaps the wealthiest and most advanced nation of the world, so guilty of producing these dangerous pregnancies, and why is it that this does not occur even in the U. S. in some infertility programs, while it is a major problem in others?
Reasons for these dangerous multiple pregnancies in the U.S.
Firstly the regulatory law passed in the early 90’s known as the Wyden bill, has fostered this irresponsible transfer of too many embryos that some clinics do to increase their reportable pregnancy rate. This government mandated public reporting is used as a marketing tool by many IVF programs that artificially inflate their pregnancy rates so that they look to the unaware consumer as though they are performing for their patients better than they really are. They will cancel any IVF cycle in women with a low number of eggs and just do insemination for them, even though their best chance of pregnancy would have been with IVF. Furthermore they will transfer more embryos than they safely should transfer just to increase the reportable pregnancy rate for marketing purposes that are mandated by the Wyden bill. This gives incentive for physicians to transfer too many embryos, and to withhold IVF treatment from otherwise deserving patients who are in a lower success rate category.
In fact, IVF should be safer than any of the other fertility treatments in that the physician has complete control over the number of possible embryos transferred, which he does not have control over with the usual fertility drugs and insemination. With properly performed IVF, we can transfer back to the patient just one or two embryos, freeze safely the extras, and save them for a later time. However, for this approach to be useful, you must have an impeccable embryo freezing program that does not lower the chance of that embryo becoming a healthy baby.
Embryo freezing that does not lower pregnancy rate
We employ a special method for embryo freezing that was perfected in Japan just for this purpose. With this technology, we can freeze the extra embryos with no fear that we are compromising pregnancy chances. Embryos frozen with this method, which we call “vitrification”, are just as good as embryos that have never been frozen at all. I explain embryo and egg freezing, and vitrification, in other sections of this web site. Suffice it to say that embryo freezing with conventional machine cooled “slow freeze” methods work by reducing the water content of the cell, to try to prevent damage from the inevitable intracellular ice crystal formation. With vitrification, we completely avoid any ice crystal formation at all, and so the embryo is not harmed at all. This allows us to be very conservative in how many embryos we transfer without hurting the couple’s overall chance for pregnancy from any given stimulation cycle.
The problem with current regulation, and the solution
The IVF field is regulated already by five different agencies, the FDA, CLIA, CAP, SART, and CDC. We have lots of government oversight and auditing. The problem is that it is poor regulation, in line with the stupid Wyden legislation passed in the early 1990’s that encourages reckless practices.
Furthermore, the obstinate refusal of insurance companies to cover IVF treatment gives them no leverage in restricting the number of embryos transferred. Therefore insurance companies wind up paying a fortune for the delivery of these dangerous multiple pregnancies, costs they could have avoided if they had just covered IVF, and put a restriction on the number of embryos transferred. Many patients “demand” their physician put back too many embryos just because insurance does not cover their IVF, and they have just managed to save up and scrape together enough money for one cycle. Insurance companies could completely solve this problem, and save themselves a great deal of money, if they would just cover IVF.
In our clinic, The Infertility Center of St Louis, we do NOT have this problem. We are judicious in the number of embryos we transfer. However this is not true in all clinics, and this problem could be solved if IVF coverage by health insurance companies were mandated by state laws. Then the insurance companies would be able to restrict the number of embryos transferred, and patients would not be putting pressure on doctors to irresponsibly transfer too many. Health insurance coverage of IVF would thus save the insurance companies money they have to dole out otherwise for dangerous multiple pregnancies, and at the same time make infertility treatment safer and available to all patients in need of it.
–Dr. Sherman Silber
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