The Ramblings of a Middle Aged Fertility Physician whose life revolves around Eggs, Sperms & Embryos....
Saturday, March 5, 2011
Embryo swap mother of all mix-ups
Carolyn and Sean Savage were on their fourth round of IVF when they discovered she was pregnant - with another couple's child. Emma Brockes talks to them about what happened next.
In some US states, Carolyn Savage would be called the ''natural mother''. In others she is known as the ''birth mother''. The fertility industry generally refers to her as a ''gestational carrier'', a term she finds abhorrent. It's a complicated situation. In February 2009, while undergoing IVF, Savage was mistakenly implanted with the fertilised egg of another couple. She carried the baby to term and, after giving birth, handed him over to his ''genetic parents''. If she doesn't know exactly what she is to 18-month-old Logan, she does know this: ''I took him from 12 cells to a living, breathing human being.'' The 41-year-old pauses. ''That's a big deal.''
Since news of their situation got out, Sean and Carolyn Savage have been caught in a publicity whirlwind. They come from Sylvania, Ohio, where Sean works for a financial services firm and Carolyn was headteacher of a primary school. At the time of starting what they thought would be their last try at IVF, she had already undergone 20 ovarian stimulation cycles, three rounds of IVF, and had four miscarriages. So the first shock, on reading the book they have co-written, comes on page two, when the couple asserts that if treatment didn't work this time, ''We would thank God for our three beautiful, healthy children and move forward.''
The Savages were, by most standards, a complete family: they had two teenage boys, naturally conceived, and a one-year-old daughter conceived by IVF. Even to want four children in this age of dwindling birth rates is considered eccentric, and to pursue that aim across years of cost and turmoil has incurred rapid judgment, and the suggestion that, despite the uniquely dreadful circumstances in which they found themselves, they are less deserving of sympathy than they seem.
Today, in a Manhattan hotel room, they are braced for the onslaught. As a couple, Carolyn says, ''Sean's a type A and I'm like a B+. So we're swell together'' - though she is by far the more assertive in conversation.
Sean, a young-looking 40, was at work when he received a call from the couple's fertility doctor. That morning, Carolyn had gone into the clinic for a pregnancy test. Now, the doctor said: ''I have bad news, but not the type of bad news you'd expect. Carolyn is pregnant with another couple's genetic child.'' Sean drove home immediately to break the news to his wife. ''You are joking,'' she said. What else could she say? They both collapsed into tears.
So began nine months of unimaginable heartache, including, as they saw it, the thoughtlessness of the baby's genetic parents, the inadequacy of the clinic's response and the condemnation of the Catholic church, to which they belonged, for their use of IVF. Meanwhile, Carolyn struggled to figure out what it meant to carry another woman's child.
It would take a long investigation to discover exactly how the error occurred; the other woman, Shannon Morell, had registered for IVF under her maiden name, Savage. The two women's files were next to each other in the clinic and were mixed up, so when it came to locating Carolyn's fertilised eggs in cryopreservation, the wrong information was used. The mistake came to light only because of a small, unrelated error - Carolyn's birth year was wrong on her hospital wristband - which sent a technician back to the paperwork, where the bigger anomaly was discovered. By then it was too late; the eggs had already been transferred.
Technically, when the mistake was revealed, there was a decision to make, but the Savages say they had already made it. They had chosen their fertility doctor in part because he didn't believe in abortion. To their amazement, he urged them to consider a termination. They couldn't. They would have the child, they said, and after the birth, return it to its rightful parents. This decision was all the more extraordinary given Carolyn's pregnancy history: she had nearly died giving birth to their second son, Ryan, after suffering a rare form of pre-eclampsia, and Mary Kate had been born prematurely and spent a month in a neonatal unit.
The second question was: who were the other couple and how much interaction should they have with them? Sean urged caution. They might sell the story to the tabloids, he thought, or lobby for termination. A letter was sent through the Savages' lawyer, confirming that they would proceed with the pregnancy and keep the Morells informed but that, at this stage, they didn't wish to be in direct contact. The lawyer concluded: ''My clients do request that your clients understand how devastated they are by this situation.''
There is nothing like other people's child-bearing decisions to bring out any free-floating prejudices. Sean, the second youngest of nine children, and Carolyn, one of three, always wanted a large family. ''Yeah!'' says Carolyn, brightly. ''Well, I'm a teacher. I love kids. Sean was from a huge family. The idea just appealed to us. So we pursued that.''
''It's a personal choice,'' Sean says. ''We've seen some things out there [about us] - you know, why try to have four? It's tough to pass judgment on people. It's like looking at someone without a child and saying, why? But that's a personal choice.''
After the mistake was discovered, the first thing Sean did was start a giant filing system to deal with the paperwork. They had to find lawyers, a therapist - above all, a new physician. Their fertility doctor, utterly horrified by what had happened, made what they considered a bizarre suggestion: that they ''reverse surrogacy'', ie, transfer their embryos into the other woman and swap babies when they were born. As they write in the book, ''The idea sounded like it belonged in the circus.''
The next task was to tell friends and family. After reassuring everyone that no one had died and they weren't getting divorced, they called a meeting at the church hall - and warned those present that they detested the religious platitude that put their misfortune down to God's will. ''Ugh,'' Carolyn says. ''It got said a lot of times - 'It's God's plan' - and I thought, really? You think God did this to me? I don't believe in God's plan. I believe in God, but I think sometimes bad stuff happens.''
Early on, she had to decide how to consider the child she was carrying. Was it in any way hers? Could she possibly detach from it as it grew, so that come the handover, she was any less devastated?
No, she says. Even if she'd wanted to, her body wouldn't let her. ''I tried. I tried. In the first couple of days, I heard the term 'gestational carrier' thrown at me. And I just kept thinking, I'm not, I'm a mother. I tried to detach, but I couldn't.'' And it was, in some ways, her child. ''Obviously we kept our promise to return him to his genetic parents, but we made a decision to bring him into this world and I'll always feel responsibility towards him. It's just we don't get to raise him.''
Into the equation came the Morells, who'd been together for seven years and had twins conceived by IVF. Given the Savages' religious principles, would their decision not to fight for custody have been different if the Other Family had turned out, say, to be a divorced woman, having a child alone?
Carolyn says: ''We knew whoever was coming through that door was going to get this child. We knew that. So it didn't matter who they were. It was nice it was a family and a married couple. But we had already prepared ourselves for anything.''
What they didn't know was just how difficult interaction with the Morells would be. The most compelling part of the book is the terrible dance that takes place between the two families. When an introductory email from Shannon Morell arrived, the Savages' lawyer forwarded it with the warning: ''Think carefully before reading this, Carolyn.''
The letter had an incendiary effect. In it, Shannon complained about how she'd lose her privacy, how hard it would be to explain things to her co-workers and, in the line that inflamed Carolyn most, said, ''God for some reason decided another woman would carry this baby for me.''
Carolyn said to Sean: ''It's heartless.''
It was the beginning of a series of exchanges with the Morells, culminating in a very difficult meeting, which the Savages felt was characterised by the other family's insensitivity to their feelings; their failure to recognise the scale of what was being done for them. In that meeting, in the presence of lawyers, Carolyn was so distressed she couldn't look Shannon in the face, fixing instead on her necklace.
Shannon's husband Paul was, Sean thought, ''unbelievably uncomfortable''. Shannon is portrayed as flippant, pointing out the overlap between her maiden name and Sean's surname, and joking, ''Do you think you and I are related?'' She did express gratitude to the Savages for continuing with the pregnancy, but in a later phone call complained to Carolyn that her doctor had questioned her ultimate right to keep the child.
Carolyn says: ''It had never even occurred to her she might not be entitled to this child. I remember hearing that and thinking, OK, I feel a little bit vindicated because someone actually understands I am making a contribution. I didn't want to be looked at as an oven, or an incubator for this child.''
The Savages say they are on friendly enough terms with the Morells now, not least because they want to stay involved in Logan's life - something the Morells say they would also like. They have yet to see the book. Carolyn says: ''I offered to sit down with Shannon and go through some of the tougher moments, and she declined. That's their prerogative. We're not sugar-coating it; we experienced feelings we're not proud of and that aren't flattering to us. We all have those moments, right? We have weak moments and lose our patience; there's bitterness, resentment, anger, frustration. On the flip side, we're trying to show people if you keep focused, you can push that to the side and get to where you need to be. That's why we included those moments. We don't anticipate any...'' She hesitates. ''I hope they understand. Time will tell.''
All the Savages had left, after the birth, was the moral high ground, and you can hardly blame them if an air of condescension creeps into their references to the Morells. Their youngest son, Ryan, when told about the baby, asked of the Other Family: ''Do they smoke? What do they do for a living? Where do they live?''
The pregnancy continued and Sean and Carolyn talked about what they would do after it. Astonishingly, they decided to pursue having another child. Given Carolyn's age, they felt more IVF might not be ideal. So, as the birth approached, they found a surrogate. She was implanted with their remaining fertilised eggs and became pregnant.
There is a sense, in the book at least, that Carolyn is the driving force behind this relentless push to have more children. Earlier on in their marriage, Sean had said, ''Drew and Ryan are beautiful and healthy. Why can't this be our family?''
Carolyn replied, ''Sean, you don't understand. Our family is supposed to be bigger than this.''
To which her husband said, ''I am not opposed to more children. But at what cost?''
The cost was, of course, huge. There comes a point in the story when each scene seems more cruel than the last. Having invited Shannon along to an ultrasound, Carolyn is desperately upset when the technician directs all her comments to Shannon, handing her the scans at the end. And when, finally, she goes into labour, she is grief-stricken. ''I wasn't ready for this child to be born. I wasn't ready to say goodbye.'' She had suggested having the Morells in the delivery room, but Sean put his foot down. ''It will be like a birth and a death in the same room at the same time,'' he said.
They negotiated with the other family to have some private time with the baby after he was born. They introduced him to their other children, then, as a couple, spent a few moments with the baby they could not be sure they would ever see again. Sean took him from Carolyn to where the Morells were waiting and handed him over, in tears. The other couple shrieked and clapped. Sean said, ''Congratulations, you have a healthy baby boy. Five pounds, three ounces.'' They said they were calling him Logan, which means ''lucky'', and that his middle name would be Savage.
The hospital asked the Savages if they'd like a ''bereavement box'', given to families who lose a child at or after birth, containing, among other things, a photo and a footprint in clay. Carolyn said she would. A week after the birth, the surrogate mother pregnant with their own baby miscarried.
The couple have said their ability to withstand these experiences has come down in part to their faith. Yet the Catholic church called their use of IVF ''morally unacceptable''. It's hard to imagine how they dealt with such an unforgiving attitude.
Sean says, ''Our view is our church is a man-made institution, founded on the principles of an incredible God. But man-made institutions are flawed and they're going to make mistakes.''
They continue to seek fertility treatment of one kind or another, in the hopes of having a fourth child. (On the issue of adoption, Sean says, ''We have significant respect for people who adopt. We considered it. It's a very personal choice as well.'')
Isn't there a danger it has become an obsession?
''Oh, sure,'' says Carolyn. ''I can see that. I don't think it has, for us. We're in a pretty peaceful place right now. That said, we're not willing to slam the door on anything.''
If it hadn't been for the slip-up with her birth date in hospital, the mistake would never have been discovered. Do they ever wish that was the case?
''Oh, yes,'' says Carolyn. She laughs. ''Of course. Yeah. Sean and I are stronger and better people for what we've been through, OK? But I don't know how you wouldn't consider that... Logan - we would've never known. We just wouldn't have.''
Sean looks alarmed. ''In no way are we saying we wish the mistake wasn't discovered,'' he says. His wife turns to him as if he's taken leave of his senses. He continues, ''I don't think that's a fair -''
''Well, whatever,'' snaps Carolyn. ''OK. I would say it's fair to say there are moments when we wonder, hmmm. So.''
After the birth, the Morells sent out a card announcing Logan's arrival, with a photo of the family in which he was wearing an outfit given to them by the Savages. When he was three months old, the Morells brought him for a visit. Shannon let Carolyn change his nappy; while she was doing so, she murmured to him, ''Mamma loves you.''
''I said that to him all the time in utero - to all my babies. That's not saying I'm his mum. I'm saying when he was with me, he had my love, like he was my child; now - we had a great afternoon [with Shannon] - I've seen his mother loves him.''
It had a double meaning? ''It did.''
Sean says, ''I think you have to celebrate that. We have unconditional love for him. I don't know if there's a greater love.'' That they decided to ''embrace the gift'' by loving the baby is, says Sean, ''probably the way we survived it''.
They came to a settlement with the hospital, the size of which can't be disclosed. Some of it, along with proceeds from the book, will be tithed to a charitable foundation set up in their name.
They hope when Logan grows up and reads the story of his birth, he'll want to be part of their lives. But they know they will always be in a strange no man's land where he is concerned. ''We have three children. Or do we have four?'' they ask. During the pregnancy, Carolyn had an amniocentesis, to make absolutely sure the baby wasn't hers. A small part of her still hoped that, despite all evidence to the contrary, the error was in itself an error. The results came back: there was a zero per cent chance the baby was her genetic child. ''I thought, surely, a little bit of my soul had crept into him. But I guess the DNA test couldn't measure my contribution.''
Inconceivable by Carolyn and Sean Savage is published by HarperOne.
Friday, March 4, 2011
IVF odds of success are decent - study
IVF treatment continues to be a popular choice for making babies.
The treatment, known formally as in vitro fertilisation, is successful in producing a live birth in 41.4 per cent of treatment cycles for women under age 35, according to information released Monday by the Society for Assisted Reproductive Technology.
Data for 2009, the most recent year analysed, showed the rate of live births per cycle with fresh embryos did not change much from 2008, when it was 41.3 per cent for women under 35. However, that's an improvement from 2003, when the rate was 37.5 per cent.
Success rates fall off quickly for older women, however. In 2009, the percentage of cycles with fresh embryos resulting in live births was 31.7 per cent for women aged 35 to 37, 22.3 per cent for women aged 38-40 and 12.6 per cent for those aged 41-42.
The more embryos transferred, the higher the risk of multiple births. Several years ago, the Society for Assisted Reproductive Technology called on doctors and patients to limit embryo transfers to one in healthy, younger women who have a good chance of pregnancy.
But it appears as if SART's goal of reducing the number of embryos transferred isn't enthusiastically embraced. Only 7.2 per cent of women under age 35 opted for a single-embryo transfer in 2009, up from 5.2 per cent in 2008. In 2003, the rate was 0.7 per cent.
Overall, the average number of fresh embryos transferred was 2.0 for all age groups in 2009 compared with 2.6 in 2003.
The rate of live births with twins for women under age 35 was 32.9 per cent, a trend that hasn't changed much since 2003. The rate of triplet births in that age group, however, was 1.6 per cent in 2009 compared with 6.4 per cent in 2003.
The leading, single cause of infertility continues to be the male factor, which accounts for 17 per cent of cases in which people seek IVF treatment. A diminished number of eggs, which occurs most often in women age 35 and older, accounted for 15 per cent of cases, and in 12 per cent of cases the cause of infertility cannot be explained.
The rate of patients who elect to have preimplantation genetic diagnosis, in which a cell from the embryo is screened for evidence of genetic disorders, was 4 per cent in 2009.
The reports on specific clinics' success rates can be found on the SART website at www.sart.org. The society announced plans to enhance its website for consumers later this year to make it easier to find data.
Thursday, March 3, 2011
Google Earth Images Actually Make for Great Surrealist Art
Who knew Google was hiding an artistic touch in Google Earth? Clement Valla, an artist, fiddled with Google Earth and found some amazingly surrealist images. Turns out, when you zoom in at just the right angle, bridges droop dramatically, 2D roads look pasted on in a 3D world and the entire world looks like it's melting.
Here's what Valla says about the pictures:
"The images are screenshots from Google Earth with basic color adjustments and cropping. I am collecting these new typologies as a means of conservation - as Google Earth improves its 3D models, its terrain, and its satellite imagery, these strange, surrealist depictions of our built environment and its relation to the natural landscape will disappear in favor of better illusionistic imagery.
Valla wants to preserve these images so that we remember how awkward technology and reality once co-existed. I just love 'em cause they're funny lookin'.
I love how the bridge disappears and then pops back up again.
Bridges really get twisted in Valla's collection.
Gnarly drive.
This would make for a great roller coaster, actually.
Wednesday, March 2, 2011
IVF parents travel overseas to pick baby's sex
A leading IVF clinic is helping clients choose the sex of their baby by sending them to an overseas clinic it co-owns, avoiding Australian rules which allow the practice only for medical reasons.
Sydney IVF, which has several clinics in NSW as well as in Canberra, Perth and Tasmania, is part-owner of Superior ART, a Thai clinic that will provide IVF for ''family balancing'' - when families with children of one gender are seeking another child of the opposite sex.
It costs $11,000 including flights and accommodation, a spokesman for Sydney IVF said.
Australian fertility clinics are prohibited from offering sex selection for non-medical reasons by national ethical guidelines by which they must abide to be accredited.
But Sydney IVF maintains it is not doing anything wrong, arguing the rules banning the procedure are hurting Australian families.
The National Health and Medical Research Council's health ethics committee developed the guidelines. Its chairwoman, Sandra Hacker, said Australians generally believed parents should not be allowed to choose their child's gender to "balance" out their family.
"The right to life should not be determined by gender," she said. "There is a view that you should be happy with whatever gender you bring into the world, as long as they are well and happy".
However, it would breach people's rights to ban them from travelling overseas to have the procedure. If they did, she could understand Sydney IVF wanting to ensure they used a reputable provider. "But that doesn't make it any more ethical, it just makes it safer," she said.
The chief executive of Sydney IVF, Kylie de Boer, said that when the company had stopped offering sex selection in early 2005 families were left "devastated".
"These were people who loved children," she said. "They had a lot of children already and they wanted to have more."
She said the clinic still received about 15 phone calls a week from parents seeking the procedure, despite openly explaining on its website it was banned and the only option was to travel overseas.
Dr de Boer said when Sydney IVF had done the procedure clients were often mothers wanting a daughter.
"The desire for a mother-daughter relationship was very strong," she said.
She believed the decision was a highly personal one which should be made between doctors and patients.
"I think the guidelines are due for review and I think the guidelines are wrong,'' she said.
The medical director at Sydney IVF, Mark Bowman, said the sense of ''loss and grief'' felt by couples who could not conceive a child of the gender they desired was as strong as that felt by infertile couples.
The president of the Fertility Society of Australia, Peter Illingworth, did not have a problem with Sydney IVF providing sex selection overseas, so long as it complied with the rules of the country it operated in.
Public debate on whether the national guidelines were right and enforceable was needed.
"What is important is the community view about these matters, not necessarily the views of IVF specialists," he said.
The National Health and Medical Research Council said the guidelines would be reconsidered after a legislative review into the use of human embryos. That review, chaired by the former Federal Court judge Peter Heerey, is open for submissions.
Tuesday, March 1, 2011
Michiana woman creates Invitro App for Apple
Facebook, Twitter and Angry Birds are all popular apps. There are apps for almost anything these days, including an app to help you get pregnant.
Yup, there's an app for that and it was designed for Apple by a mom from Michiana.
The sound of a lullaby is music all people wanting to be parents hope to hear. And it's the ring tone alert you will hear when using Apple's Invitro App called "IVF-Baby in the Making."
Granger mom and designer Kim Konopa was motivated to design an invitro app because she knew the pain of trying to become pregnant, saying, "It was actually a personal experience with invitro fertilization and I just thought the need was there."
So Konopa, who works in sales decided to put her organization skills to work. She did her homework and found a software developer to work with her and her 22-year-old son, JR, who is one of her partners.
She explains how it works.
"The main component is the calendar and, because you're taking so many medications and making so many appointments, we've pre-loaded those into the iPhone app so it's very simple to use. So, let's say you have a doctor's visit. You can put the location in. Let's say you're going to add a medication, you do the same thing. You choose from a pre-populated list of all the medications they could give you."
And because women often feel so alone going through invitro, Konopa has that covered too.
"We built in a blog so that people can kind of get together and share their experiences. We also built in a resources section, things like how to inject, which I was naïve about too at the time."
And since invitro isn't cheap and not always covered by insurance, the application is also practical.
"It has a budget tracker, which allows you to easily enter your invoices so when you enter them it keeps track of the remaining budget and then it just keeps a running balance."
You can also personalize your app.
"It has a photo and journal section so when they hand you your embryo picture, or when you have an ultrasound --a lot of people are excited-- and want to share that. So you can journal about it and share it on facebook or email if you want too."
And in the three months Apple has offered the Invitro App, Konopa says the response has been steady in the U.S., U.K., Australia and Japan.
Konopa says becoming a mother is the best thing that happened to her and she's hoping her app may give other women the same experience.
"I love it. It allows me somewhere to put my energy that's extremely positive and hopefully it helps other become successful in their journey to become pregnant."
Hoping her Baby in the Making app will give more moms-and-dads-to-be their own bundle of joy, with a little help from technology.
Konopa consulted with her own reproductive endocrinologist while working on the invitro app.
Monday, February 28, 2011
Granulocyte-colony stimulating factor (G-CSF) significantly improves inadequate endometrium
During in vitro fertilization (IVF) cycles, treatment with a medication called granulocyte-colony stimulating factor (G-CSF) significantly improves inadequate endometrium (lining of the uterus), according to a report published electronically on February 15 in Fertility and Sterility - the official journal of the American Society for Reproductive Medicine (ASRM). The reported case series also suggests that G-CSF treatment may, in general, improve IVF pregnancy chances.
G-CSF is a cytokine (protein molecules that facilitate communication between cells) that has already been FDA approved for other clinical indications.
Researchers from New York City-based Center for Human Reproduction (CHR) and a second NY fertility center reported on four women with highly inadequate endometrium, unresponsive to conventional treatments and facing IVF cycle cancellation. In all four cases, endometrial perfusion of G-CSF expanded the endometrium to a minimal thickness of 7mm within approximately 48 hours, allowing for embryo transfer. Surprisingly, all four patients also conceived.
In approximately 1% of all IVF cycles, the endometrium stays too thin for embryos to successfully implant, even with treatment. In such IVF cycles, patients and physicians face two poor options: they either accept lower pregnancy chances and transfer embryos despite inadequate endometrium, or they can cancel the embryo transfer and freeze all embryos in hope of better future cycles. Unfortunately, women with inadequate endometrium often show inadequate endometrium again in future cycles. This situation was demonstrated by two patients in this reported case series with histories of repeat IVF failures due to thin endometrium.
"Conventional treatments for inadequate endometrium have had spotty success at best. Without G-CSF perfusion, these patients, likely, would not have reached embryo transfer," explains David Barad, MD, Director of Clinical ART at CHR and one of the senior authors of the report. "That all of them also conceived was a big surprise, and is, of course, quite remarkable."
"The efficacy of G-CSF in improving endometrium, and possibly pregnancy rates in general, still needs to be confirmed in randomized controlled trials," adds Norbert Gleicher, MD, lead author of the report and Medical Director of CHR. "Indeed, we already started two such trials to test both hypotheses; but until first results become available later in 2011, we caution against over-interpreting results of this small pilot study."
G-CSF is a cytokine (protein molecules that facilitate communication between cells) that has already been FDA approved for other clinical indications.
Researchers from New York City-based Center for Human Reproduction (CHR) and a second NY fertility center reported on four women with highly inadequate endometrium, unresponsive to conventional treatments and facing IVF cycle cancellation. In all four cases, endometrial perfusion of G-CSF expanded the endometrium to a minimal thickness of 7mm within approximately 48 hours, allowing for embryo transfer. Surprisingly, all four patients also conceived.
In approximately 1% of all IVF cycles, the endometrium stays too thin for embryos to successfully implant, even with treatment. In such IVF cycles, patients and physicians face two poor options: they either accept lower pregnancy chances and transfer embryos despite inadequate endometrium, or they can cancel the embryo transfer and freeze all embryos in hope of better future cycles. Unfortunately, women with inadequate endometrium often show inadequate endometrium again in future cycles. This situation was demonstrated by two patients in this reported case series with histories of repeat IVF failures due to thin endometrium.
"Conventional treatments for inadequate endometrium have had spotty success at best. Without G-CSF perfusion, these patients, likely, would not have reached embryo transfer," explains David Barad, MD, Director of Clinical ART at CHR and one of the senior authors of the report. "That all of them also conceived was a big surprise, and is, of course, quite remarkable."
"The efficacy of G-CSF in improving endometrium, and possibly pregnancy rates in general, still needs to be confirmed in randomized controlled trials," adds Norbert Gleicher, MD, lead author of the report and Medical Director of CHR. "Indeed, we already started two such trials to test both hypotheses; but until first results become available later in 2011, we caution against over-interpreting results of this small pilot study."
Sunday, February 27, 2011
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