Infertile patients cannot afford to wait for treatment while their eggs get older.
Dr. Sherman Silber, Infertility Center of St. Louis, is offering free video consultations for patients who need to plan now for their treatment while stay-at-home orders are in place. He is talking to and evaluating patients in their home via to comply with social distancing measures.
Dr. Silber is discovering that patients actually prefer this method of telemedicine consultation over the conventional office visit. Patients have conveyed that “it is so much more convenient and less stressful” to have a free telemedicine personal consultation than to take a day off from work to travel to the doctor’s office and sit with other nervous patients in the waiting room.
The COVID-19 pandemic is thus changing much of the way we will do things in the future, and for the better. "Our patients are surprisingly much happier with this approach. Of course, at some point we need to perform hands on treatment. But with this new manner of seeing patients, we can come to the right diagnosis and treatment plan for most patients more efficiently, quickly, and painlessly, with no loss of personal one-on-one communication.” This is a very welcome new era of telemedicine that has been forced on us by the current difficult times.
Dr. Jenny Remington-Hobbs is a 31 year old doctor from London, a neurologist, who had come down with multiple sclerosis (MS), one of the most common devastating neurological diseases, which at best has been treated palliatively with anti-inflammatory drugs, but never really cured. MS gradually incapacitates young adults and they wind up in a wheelchair and eventually die of complications of neuro-degeneration.
She came to the United States last year to try a remarkable new curative treatment involving a stem cell transplant similar to what young cancer patients have undergone for many years.
For cancer patients, the idea is to give lethally high doses of radiation and chemotherapy that would obviously kill the patient by destroying all of her bone marrow and blood cell producing stem cells. But the object is to kill all of her cancer cells too. Then to save her life from the otherwise lethal effect of the treatment, blood cell producing stem cells or bone marrow cells are then injected to restore what would otherwise be a total absence of blood cells. This saves her life from the lethal effects of the radiation and chemotherapy that has killed all of her cancer cells. This aggressive treatment, called BMT or bone marrow transplant, or stem cell transplant, has saved countless lives of young patients with otherwise non-curable cancers like Hodgkin’s disease and leukemia. This treatment also renders these cured cancer patients infertile or sterile. So we routinely freeze the ovary of such patients before their bone marrow transplant, and then after they are cured, we transplant that frozen ovary back to them so that they can then regain their otherwise lost fertility.
However such a stem cell transplant can now be use (in a milder fashion) to cure auto-immune disease, and the number one target right now for that treatment is multiple sclerosis (MS). So Dr. Remington-Hobbs had her own blood stem cells harvested and frozen, and underwent otherwise lethal myeloablative chemotherapy to destroy all of her white blood cells, immune cells that are attacking her nerves’ myelin sheaths and causing her multiple sclerosis because they mistakenly “think” her myelin sheath cells are foreign, and need to be rejected. After all of her immune white cells are destroyed by the chemotherapy, then her previously frozen bone marrow or blood stem cells are injected back to her as “naive” pluripotent blood stem cells. These cells then go through her thymus gland, just like happens when we are a fetus and our immune system is first recognizing “self” from “non-self” when we are still in our mother’s uterus. so her “naive” re-injected stem cells undergo a fresh “education”, and her immune system is completely rebooted, so that it no longer misreads her myelin sheaths as foreign, and so her immune system no longer attacks her nervous system as foreign, and she is cured of her MS.
But of course she is now sterile and indeed menopausal at age 32. However, we froze one of her ovaries last year one week before she had her stem cell transplant and chemotherapy. Now in October, one year later, and remarkably cured of her MS, Dr. Remington-Hobbs is flying back to St. Louis from London, to have her frozen ovary thawed and re-planted, so that she will then no longer be menopausal, and will have her fertility restored, so that she can now have children.
This is a remarkable first for millions of people suffering from a previously uncurable disease, MS, and she is now going through the final phase of this treatment, having her ovary transplanted back so that she can now be fertile again.
Below is my letter to the editor of The New York Times in regard to this article they published July 16, 2012:
In response to The New York Times article on the overdosage of medication given to IVF patients, I could not agree more that it is time for milder stimulation in IVF. The so called “controversy” about whether we should be doing milder stimulation IVF is completely artificial. There should be no controversy. We do “mini-IVF” routinely. We have no hyperstimulation syndrome from it, and great pregnancy rates, at half the cost for the patients, plus a much more pleasant experience for the patients.
In addition, we get pregnancies in much older women that you can not get with conventional high dose stimulation. So there should be no controversy about this. The only reason for the appearance of a controversy is that doing “mini-IVF” well is harder for the doctor and the lab, although certainly easier, safer, and cheaper for the patient; and this is clearly what patients prefer.
New research has the potential to take the pregnancy revolution one step further. Doctors have discovered that ovarian transplants can maintain a woman’s fertility well into her fifties, effectively manipulating the biological clock to postpone menopause.
Dr. Sherman Silber is the surgeon who pioneered this research. He specializes in fertility at St. Luke’s Hospital in St. Louis, Missouri. Dr. Lori Gruen discusses the potential ethical concerns surrounding this new procedure. She is a professor of philosophy and feminist, gender, and sexuality studies at Wesleyan University, in Middletown, Connecticut.
Dr. Silber Explains That ICSI Offspring Are Normal, And Are No Different From Naturally Conceived Children
I am afraid the journal has made a terrible error in publishing this stupid, retrospective, and terribly flawed article. It is a plus for tabloid type, sensationalistic myth propagation, but a serious negative for truthful scientific publishing. I am so sorry the journal has made such a really egregious error, which so sadly hurts its credibility as a journal.
We have studied this issue very extensively, prospectively, and published on it in scientific journals over the last 20 years. You can study all these scientific papers published by Bonduelle et al, and Van Steirteghem and Devroey and myself, and read my book “How to Get Pregnant” (easily downloadable for Kindle or from Amazon) for detailed discussion of all the studies. All the scare papers have been shown to be totally flawed, uncontrolled, and retrospective, like the current flawed study you may have read about May 6, 2012. Careful prospective studies over the last 20 years, have consistently shown no difference at all between ICSI and IVF in the risk of congenital abnormalities, and no difference from a population of natural conceptions.
Furthermore, the ridiculous idea promoted in this study alleging that twin pregnancies would have less congenital defects than singletons just serves to prove how invalid the whole retrospective methodology is of this “new” study. NEJM should be ashamed of themselves for stooping so low just to get publicity for a paper which is so obviously flawed, and totally misleading, and in fact which has been disproven by better quality previous studies.
Over 5 million babies have been born by IVF and ICSI, and they have been clearly shown to be no different than normal populations of naturally conceived babies. We have followed these ICSI and IVF babies into adulthood, and found no difference in any parameters of health or mental development between IVF and ICSI babies, or between them and a naturally conceived population.
Our IVF and our ICSI children have all been followed into adulthood for over 20 years, and we find nothing but happiness and joy. The risk of congenital anomalies in IVF, ICSI, and in natural conceptions, is identical.
Dr. Silber was invited by Chinese medical experts to export his technology for ovary freezing and transplantation, and preservation of fertility for cancer patients to China, as well as to preserve the biological clock to protect women from becoming infertile just by aging. These are photographs from his historical mission to China in Guangzhou in February 2012, where he performed the first ovary transplant and ovary freezing in China, and taught Chinese doctors from all over the country. News coverage in China was enormous with every newspaper from every province represented, as well as every TV news station.
From the magazine of the Lance Armstrong Foundation Consumer Advocacy Group for Cancer Patients. “Cancer takes away so much from too many. Fertility medicine has stepped in with newfound successes, long-awaited births, and mind-boggling solutions that together say to cancer: That’s enough.”
Several days ago, the first patient in the United States delivered a healthy baby from a transplanted ovary which had been frozen thirteen years ago, before she underwent otherwise sterilizing cancer treatment as a 19 year old girl. Dr. Silber’s paper published in Fertility and Sterility, provides otherwise rare information for guiding fertility preservation practices, and counseling patients about the likelihood of success of ovary transplantation. This is the largest series of ovarian transplants to date, with the largest number of pregnancies and live births, and the longest number of follow-up years to evaluate the efficacy of ovary transplantation, fresh or frozen, and the expected duration of function of the transplanted ovary.
There is no more confused medical care in our field than what is delivered by many urologists to the couple that suffers from “male infertility.” In fact, many couples are told to delay the IVF treatment they should have had sooner (because of the wife’s advancing age) in order just to wait for some dubious treatment of the male partner to increase his sperm count. Numerous control studies have demonstrated that administering clomid or nutritional supplements to the male does nothing to improve his sperm count, and the often suggested testosterone supplements just lowers rather than raises his sperm count, and may even render him totally sterile.
Unfortunately, there are many patients who receive poor microsurgical care by physicians who do not have the proper expertise and who commercialize vasectomy reversal for easy profit. So there are many traps to watch out for when choosing a doctor to perform your reversal.
For example, some doctors will offer a “money back guarantee,” but patients rarely get their money back after a failed procedure despite promises to the contrary. We have operated on many patients whose previous vasectomy reversal attempts at “money back guarantee centers” had failed, and none of these patients have ever gotten their money back. There was always some fine print wording that allowed the clinic to keep their money despite the “money back guarantee.”
In most so-called “centers,” the only procedure performed to reverse the vasectomy is “vasovasostomy” to try to reconnect the severed vas. However, in most cases there is also “epididymal” blockage (closer to the testicles) created by the pressure build-up after vasectomy. Thus, there is no chance for most cases of “vasovasostomy” to be a success, because there is also blockage in the more delicate duct closer to the testis, and this would have to be bypassed also with a very tricky-to-perform“vasoepididymostomy” [technical video] in order to have a successful result.
After more than 20 years and nearly $200,000 worth of failed infertility treatments, Monique and Neil Ward of Stafford, England, have finally became the proud parents of twin boys, Britain’s Press Association reports.
The Wards’ 25-year struggle to become pregnant — even though ultimately it was through the use of donor sperm and donor eggs — raises a question many infertility specialists and aspiring parents face: Does there come a point when a couple should give up on trying to conceive?
After 15 failed attempts with various types of assisted reproductive technology since 1986, some might say the Wards were operating on blind optimism when they signed up for another $20,000 round of in vitro fertilization (IVF) with donor eggs and sperm last spring. An earlier round with this technique had failed five months before.
But against all odds, Monique Ward finally became pregnant. On Dec. 29, at the age of 46, she gave birth to two healthy twin boys, Walker and Benjamin.
Vasectomy reversal is often incorrectly thought of as simply a reconnection of the severed vas deferens. In fact, the term many doctors mistakenly use for the reversal of vasectomy is “vasovasostomy”. But vasovasostomy just means reconnecting the vas. Simply “reconnecting the vas” is not enough to restore fertility to most vasectomized men. The reason for so many failures of vasectomy reversal, even with “microsurgery”, is that in over 80 per cent of cases the pressure buildup inside the vas (caused by the original vasectomy) results in microscopic “blowouts” and “concretions” in the more delicate ductwork closer to the testicle (called the “epididymis”) which is where the sperm leave the testis on their way to the vas. If this complex, truly more delicate pathway, the epididymis, is not microscopically bypassed, the vasovasostomy will not work, because the sperm still cannot get to the site of the vas reconnection. They are blocked from even reaching the vasovasostomy site because the more delicate ductwork closer to the testicle remains blocked. So the routinely performed vasovasostomy was destined never to work no matter how accurate the reconnection.
The reason for this most commonly practiced error is that repair of the epididymis is very difficult, and requires years of very specialized practice and experience. Most urologists would be lost in the epididymis. So they might very earnestly apply what they think are “microsurgical skills” to perform a vasovasostomy, just hoping that there are no proximal blowouts in the epididymis. They might even tell the patient that they saw “sperm” in the vas fluid at the time of the vasovasostomy, increasing their hope that vasovasostomy is enough in their case. They will do anything to avoid trying to repair the usually obstructed epididymis because it is so difficult for the less experienced.
The problem is that there will always be creamy thick fluid in the vas deference on the proximal side of the vasectomy site, which has been stored in that obstructed site for years, and there might even be decayed old dead sperm or sperm parts in that fluid, and so it might be mistaken for epididymal continuity. But if the vas does not have translucent fluid with normal intact motile sperm, then you can be sure that no fresh new sperm have reached this area for many years, because of epididymal blockage more proximally. So you might leave the clinic with “wait and see” advice from the doctor even though there is no chance of the “vasovasostomy” working. It may not be until a year later with consistently negative semen analysis results, that you realize you had the wrong operation.
This problem of epididymal blowouts is much more common now than 20 or 30 years ago, and occurs much earlier after vasectomy, as early as 6 months even. The reason is that urologists are performing the original vasectomy much more tightly, allowing no leaks whatsoever of sperm. Therefore, it is important for the microsurgeon to perform this more delicate vasoepididymostomy procedure [technical video] in over 80 per cent of cases, when there is secondary epididymal blockage.
Click here to read an excellent article by The London Daily Telegraph Sunday Magazine that reviews a lot of my groundbreaking research and really goes into great detail about how I work with my patients to help resolve their fertility issues.
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
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.
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. 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?
TV/Radio/Print News Coverage
Listen to Dr. Silber and Joan Hamburg discuss the recent birth of octuplets as a result of IVF on WOR Radio in New York.
Listen to Dr. Silber discusses the recent birth of octuplets as a result of IVF on KMOX Radio in St. Louis.
“How to Prevent Another Octomom” St. Louis Post-Dispatch; February 28, 2009
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.
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.