In response to a question about how this reflects on the fertility industry Dr. Wisot replied, "Most people understand that these are the actions of somebody who is way, way out of bounds and doesn't represent the mainstream of fertility treatment," said Dr. Arthur Wisot, fertility specialist with Reproductive Partners in Redondo Beach . "He has been shunned by the medical community as much as you can possibly shun somebody….He's totally out there, flying solo."
 

Reproductive Partners was cited in an article in the November 2009 issue of ELLE magazine, “Girl Crazy: Women Who Suffer from Gender Disappointment.” The article profiles women whose lives are disrupted because they have not been able to have the girl child that they are craving. According to the author, they resort to a variety of techniques to try to achieve their elusive dream from folk remedies to IVF with preimplantation genetic screening (PGS), also know as preimplantation genetic diagnosis (PDG) for chromosomes. The focus of the article was the degree of emotional impairment from which these women suffer rather than the procedure itself. The article profiles a physician whose practice is devoted to IVF/PGS for gender selection, although the technique is widely available, including at Reproductive Partners.

The article states, “Physicians at other clinics, including California’s topranked Reproductive Partners Medical Group, use PGD as a screening tool to identify embryos with defects, and—if pressed— will reveal the sex of embryos in conjunction with other findings. ‘We would transfer embryos of one sex or another if that is the patient’s preference,’ says Arthur Wisot, its executive director and a clinical professor of reproductive medicine at UCLA. ‘We would do it if they seem like reasonable people and no one is hurt by it. But we certainly don’t advertise it and promote it the way Steinberg does. The people he services are more on the fringe, and he’s just playing to their neuroses.’”

 Actually Reproductive Partners offers IVF/PGS for family balancing and we do not need to be “pressed” to reveal the sex of embryos. It is just not the only focus of our practice. We mostly employ this technology to detect embryos with chromosomal abnormalities, when appropriate, and diseases caused by known gene abnormalities carried by one or both parents. In fact, the most recent recommendation from the American Society for Reproductive Medicine has reduced the number of reasons for doing PGS for chromosomes because of evidence that it does not improve live birth rates in patients with advanced maternal age, previous implantation failure, recurrent pregnancy loss and even those who have recurrent pregnancy loss from chromosomal abnormalities.

    There is no doubt that the goal to reduce the incidence of IVF-induced twins is a noble effort given the increased incidence of prematurity and its cost both in healthcare dollars and morbidity and potential long-term disability for the babies.

    The most effective answer is to increase the number of elective single embryo transfers (SET) in patients with a good chance of success based on their age and embryo quality. But, how do we accomplish this. Some bloggers advocate legislation to mandate the numbers of embryos that may be transferred. Many countries have such restrictions. In many of those countries, the Golden Rule applies: “the one with the gold rules.” In other words, IVF is covered by national health insurance and government control is an accepted concept.

    Not so in the U.S. where we live in an era of reproductive freedom which means we are all free to reproduce or not reproduce without government interference. In fact legislators are unlikely to become involved and let us hope that they continue to stay out of all reproductive issues.  Our medical specialty societies are formulating new, more conservative guidelines, but if many IVF centers are already not abiding by the current recommendations, they certainly will not embrace newer, more restrictive limitations.

    So it’s up to us- the reproductive specialists to work harder to educate couples that transferring a single embryo when there is a good chance for success is in the patient’s and the baby’s own best interests. It sounds simple. But there are market forces which makes this unlikely to become a wide-spread trend. First, the IVF centers live and die by their reported success rates and are unlikely to embrace any policy which may lower their overall success rates. Secondly, most patients are paying for the procedure and think that a multiple embryo transfer will reduce the chance that they will have to pay for an additional expensive procedure to achieve success. In making this decision they are not mindful of the possibility of creating a more risky pregnancy which can result in the costs of prematurity and the life-long responsibility for a potentially disabled child.

    At Reproductive Partners we have advocated transferring fewer embryos for a long time and now try to educate appropriate patients to consider elective single embryo transfers. But often that is not enough because the many patients still have the incentive and desire to exceed our recommendations. We are currently seeking to develop a program of economic incentives to encourage couples with a good prognosis to consider SET more seriously. What would also help is if the CDC/SART reporting system emphasized singleton pregnancies as a success and did not consider twins or more, or cases requiring selective reduction as a success. Another option would be to have a separate category for the success rate of elective SET. This change might help remove the incentive to IVF centers to transfer more embryos than absolutely necessary.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Redondo Beach, California

 Also attending was Councilman Diels’ wife, Elizabeth, and their eight-month-old son, Luke. In his remarks, Mayor Gin cited the fact that Reproductive Partners has been helping South Bay couples, like the Diels, achieve the dream of completing their family for over 24 years in their Redondo Beach location. The group has expanded to now include offices in Beverly Hills, Westminster and La Jolla. The physicians at Reproductive Partners are responsible for over ten thousand births resulting from assisted reproductive technology. They offer comprehensive evaluation and practical treatment of all aspects of infertility care. Reproductive Partners is nationally recognized for their pioneering work in helping infertile couples.

Ultrasound Guided Transfer and Embryo Glue By David R. Meldrum, M. D. My experience as the guest of a pioneering group in Melbourne, Australia to learn IVF over 20 years ago gave me the very strong feeling that embryo transfer was the least understood and a very important part of IVF. Over the intervening years there have been many excellent studies thoroughly documenting that easy, atraumatic transfers are more likely to be successful, with also a lower risk of tubal pregnancy. Clearly a rehearsal of the transfer (trial transfer) helps to define the ideal conditions for the actual transfer. Today, ultrasound-guided transfer usually uses abdominal ultrasound to visualize the transfer catheter to verify its position in the uterus. A full bladder allows the uterus to be seen with an abdominal probe and provides the additional advantage of rotating the uterus into alignment with the cervical and vaginal canals, making transfers easier. Some studies have shown an increased pregnancy rate using ultrasound guidance. “Embryo glue” is a name for a recent refinement of the culture medium used for transfer to increase the viscosity (thickness) to the same as uterine fluid. This allows the culture medium to mix with uterine fluid rather than to be displaced. A recent study using a mechanical model to simulate the uterus documented that such a medium stays more localized. A study yet to be published has shown a significant increase of implantation using “embryo glue.” Refinements of transfer technique have resulted in higher success rates at Reproductive Partners for many years

RPMG Committed to Goal of Reducing High Order Multiple Pregnancy (HOMP) Reproductive Partners is committed to the goal of minimizing triplets and higher order multiples resulting from IVF and ovulation induction. At RPMG, the very large majority of women under age 35, and even under 38, are now being advised to have only two good quality embryos transferred. Women over 38 can also have only two embryos transferred by growing the embryos to the blastocyst (5-day) stage, with or without preimplantation genetic diagnosis, which allows selection of the highest quality embryos. Limiting transfer to two embryos has reduced the risk of having more than two embryos implant. In high-quality programs such as Reproductive Partners which utilize an excellent laboratory and refined transfer technique, this policy has resulted in little or no change in the chance of successful pregnancy. Avoidance of HOMP is a very important national goal, since such pregnancies are fraught with high costs and potential complications for both mother and offspring. Unfortunately not all programs are participating in this endeavor, fearing that their success rates may suffer. Ovulation induction also contributes to HOMP, partly because there is no absolute follicle diameter below which ovulation will not occur. By using conservative stimulation protocols, the incidence of HOMP can be minimized.