Chance to Have a Child

LaTasha Craig, M.D., and Karl Hansen, M.D., Ph.D., are revitalizing OU’s program in reproductive endocrinology and infertility.

The OU College of Medicine is on a fast track to reestablish the state’s premiere program in reproductive endocrinology and infertility. In a few short years, OU physicians have gone from performing no fresh in-vitro fertilization (IVF) cycles to more than 100 per year, while now seeing 400 to 500 patients a month.

The program’s successful growth and performance are dramatic and gratifying to Karl Hansen, M.D., Ph.D., assistant professor of obstetrics and gynecology, who returned to his alma mater in 2004 to revitalize the reproductive endocrinology and infertility section.

OU Medicine’s infertility clinic is experiencing a rebirth of its own as its successful in-vitro fertilization program offers a growing number of prospective mothers the opportunity to have a baby.

In 2006, LaTasha Craig, M.D., assistant professor of obstetrics and gynecology, joined Hansen to build the program. Craig and Hansen worked together during fellowship training at the University of Washington in Seattle. The same year, the OU Medicine specialists were able to build a new IVF laboratory, run by Michael T. Zavy, Ph.D.

“The bottom line is that an IVF program’s pregnancy rates are only as good as the laboratory – and we are fortunate to have a very good lab,” Hansen said, noting that the OU program has about a 66 percent IVF success rate of live births per embryo transfer in women under age 35.

However, it’s not all in the lab.

Hansen and Craig have built a reliable, competent practice known for showing compassion and sensitivity to patients who desperately want to have a baby. It’s estimated that as many as 15 percent of couples experience infertility at some point in their lives.

Karl Hansen, M.D., Ph.D., right, discusses a case with Michael Zavy, Ph.D., director of OU Medicine’s in vitro fertilization lab.

“It’s a higher percentage than most people think because people don’t talk about it,” Hansen said.

“Unfortunately, about only half pursue treatment, but we think that number is improving because there’s a greater awareness that effective treatments are available. Additionally, the diagnostic evaluation of infertility is covered by many types of insurance today.”

Hansen and Craig have the job not only of meeting the patients’ physical challenges, but also of communicating to prospective mothers and fathers exactly where they are in a continuum of medical options. Topics frequently discussed include costs and the odds of success.

“For many patients, the biggest barrier to achieving pregnancy is that they drop out of treatment,” Hansen said.

“Certainly some patients get emotionally exhausted. Some get financially depleted because insurance doesn’t cover some types of treatments. And some patients are not willing to move to the next step.”

Some will not consider using an egg donor – at least initially. Others will not consider IVF because they’re not comfortable with the technology, Hansen said.

“We find that if the patients have realistic expectations, and we meet frequently to keep them involved in the decision-making process, that helps keep patients satisfied.”

The OU program offers a number of tests and procedures including:

• Fresh IVF, where a woman uses her own eggs to achieve a pregnancy
• Recipient/oocyte donation cycles, for women whose ovaries have been removed or damaged, or more commonly, for women with few eggs remaining
• Frozen (cryopreserved) embryo transfer
• Ovulation induction
• Intrauterine and donor insemination
• Preimplantation genetic diagnosis and transfer of unaffected embryos
• Surrogacy / gestational carrier

Most patients don’t require this array of procedures because their problems involve ovulation. Tests show they aren’t ovulating regularly or, in some cases, not at all. Ovulatory problems affect as many as 20 to 30 percent of couples struggling with infertility. For most women, medication can put them on the path to pregnancy.

At the other end of the spectrum, however, are those patients who will require multiple procedures and face uncertain odds.

LaTasha Craig, M.D.,  reads a hysterosalpingogram she took of a patient’s uterus and fallopian tubes.

“I’ve had patients who had a number of strikes against them in terms of achieving a pregnancy,” Hansen said.

“Some have had tubal damage, which in itself is relatively easy to overcome with IVF. But in addition, some of these patients had few eggs remaining in their ovaries. Some have even had surgeries on the inside of the uterus to decrease heavy bleeding, a procedure called endometrial ablation. As a result, the inside of the uterus was not normal.”

With one such patient, Hansen performed two surgeries to repair the uterus. “Even when I was done, the inside was still not completely normal, but it was the best we could do.”

Fortunately for this patient, some of her remaining eggs were recovered and fertilized, an embryo transfer was completed, and the patient’s dream of a successful pregnancy came true.

Because of the success of OU Medicine’s in-vitro fertilization program, it is now one of a select group to offer the national IntegraMed® Attain® Refund Program. Patients prepay at a discounted rate for up to three fresh IVF cycles and three frozen embryo transfers. They are then entitled to at least a 70 percent refund if they decide to discontinue treatment or they do not have a successful pregnancy.

“We’re pleased to be affiliated with IntegraMed® because it validates our success rates and it provides our patients with the option of undergoing IVF treatment knowing that if it isn’t successful, most of their money will be refunded,” Hansen said.

OU Physicians Reproductive Medicine is the only IVF program in Oklahoma to offer the Attain® Refund Program.

“It’s great that we’re able to offer it, but it doesn’t influence our care. Whether they choose it or not, we are going to do our best to help them achieve a pregnancy every time they try,” he said.

The number of patients who opt for advanced treatments can be a barometer of a clinic’s success, Hansen said. However, some clinics are more aggressive than others in encouraging IVF cycles.

“I’d say we’re probably in the middle,” Hansen said. “Patients are here because they want to achieve a pregnancy, and with IVF being so effective today, you can make a strong argument in favor of IVF from a cost-effectiveness standpoint.”

At one time, it was fairly common to use injections of fertility medications called gonadotropins to stimulate the ovaries to release multiple eggs, combined with artificial insemination.

The effectiveness of this procedure is no more than 10 to 15 percent per attempt at a cost of $1,500 to $2,500 each – and with a high risk of multiple pregnancies.

“You can spend months going through those treatments and spend every bit as much as you would undergoing an IVF cycle and still not achieve the pregnancy rate you would with just one fresh IVF cycle,” Hansen said.

A less aggressive treatment option for patients with unexplained or mild male factor infertility involves use of Clomid combined with artificial insemination, a plan that costs about $500 to $700, with a pregnancy rate of about 8 to 10 percent per attempt. Although that rate may seem low, it is considerably higher than the 2 to 3 percent pregnancy rate per month if couples continue to try on their own, and it is about half of the normal 20 percent pregnancy rate per month for couples with no problems.

“We usually do three of those treatment cycles before we move on to something else,” Hansen said. In most studies of this treatment plan, cumulative pregnancy rates are 24 to 30 percent over three cycles, meaning a good number of patients will achieve a pregnancy with this less expensive option. There is, however, an 8 percent risk of multiple births, with the vast majority being twins.

Hansen believes a fresh IVF cycle – even at the average cost of $15,000 per procedure – is the next best option.

Advantages include the ability to freeze embryos during the fresh IVF cycle to use for a second pregnancy attempt. Frozen cycles cost only about $4,500 an attempt as opposed to another more costly fresh IVF cycle.

In either the fresh or frozen process, women decide how many embryos are implanted, usually choosing only one or two.

“We want to avoid as many multiple pregnancies as possible. There’s just a whole level of control with IVF that you don’t have with the other types of cycles that I’m describing,” Hansen said.

Hansen enjoys explaining and performing the various procedures and tests that help his patients achieve their ultimate goals. However, he’s equally fascinated by why his patients have the problems they do, and it was the ability to continue his research that lured him back to the OU Health Sciences Center and an academic practice.

One of his main research interests is to better understand and predict the process of ovarian aging.

“We know that women are born with all the eggs they are ever going to have, and that at some point, those eggs are all gone, and a woman goes through menopause. On average, this occurs at age 51, but there is great variability from one woman to another,” he said. “As many as 10 percent of women go through menopause before age 45.”

Regardless of the age at which menopause occurs, research shows that about 10 years before menopause, a significant decrease in fertility occurs, not only because of low egg numbers, but also because of poor egg quality. Current tests can indicate this decline has occurred – for example, by measuring serum levels of follicle-stimulating hormone (FSH) and the hormone estradiol on the third day of the menstrual cycle.

However, these tests identify individuals with decreased egg number only after a significant loss has already occurred.

There are currently no tests that indicate how fast an individual’s biological clock is ticking.

In 2006, Hansen presented to the American Society for Reproductive Medicine (ASRM) his prize-winning paper that re-examined the decline in the number of eggs from birth to menopause. He started this study in Seattle as a fellow and completed it at OU with funding from the Oklahoma Center for the Advancement of Science and Technology.

He has since completed research concluding that the ovarian antral follicle count (a measurement obtained during a transvaginal ultrasound examination) is a marker for a woman’s remaining egg number. His study used ovarian ultrasound with women who were planning surgery to remove one or both of their ovaries. Before each surgery, a blood test and ultrasound were used to evaluate the patient’s ovaries and measure the different markers of ovarian reserve.

After surgery, the removed ovaries were examined in the laboratory using computer-assisted technology to count the remaining eggs. His findings were presented in late 2008 to the ASRM.

While Hansen and his associates recognize the negative effects of age on fertility, the public has a somewhat skewed view, he said.

“They read about women who have a baby at 50 or celebrities at age 45 having twins, and they think that those are naturally occurring pregnancies, and they’re not,” he said.

“The vast majority of those women are undergoing donor egg cycles, and they don’t publicize that. Why would they?”

With the advances in fertility medicine, do patients expect even more, such as procedures to allow them to select the sex of their baby or the color of eyes?

“It comes up occasionally, but not often,” Hansen said.

“The ASRM has a position statement on choosing a sex. They’re not necessarily opposed to that for family balance – someone with three girls wanting a boy, for example. But I don’t feel that it’s an important part of what we do.”

And, Hansen said, he would not use procedures like preimplantation genetic diagnosis for such purposes.

“I have so many patients with real problems, couples who would be happy to have a baby of any sex or eye color. It doesn’t usually come up, and I’m glad it doesn’t.”

For him, the technology that first attracted him to the field of reproductive medicine has given way to the satisfaction of helping people achieve their dream of being parents.

“I have two boys. I think about the joy they bring, and it’s exciting to be able to help couples achieve their goals of having a family,” he said.

* A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic. See our IVF Statistics page for detailed success rates for OU Physicians Reproductive Medicine.