Hugo Verhoeven, MD: "My name is Hugo Verhoeven and I'm from the Center for Reproductive Medicine in Dusseldorf, Germany. I'm on the Editorial Board for OBGYN.net, and I'm reporting from the 30th meeting of the AAGL in San Francisco, California. It is always a very big honor to talk to my good friend Professor Mark Surrey. Mark, I think we've known each other for about twenty years."
Mark Surrey, MD: "Probably."
Hugo Verhoeven, MD: "So we chose a topic for today that's interesting to quite a lot of people - aging and getting pregnant. First of all, if you're talking about aging when is somebody too old for getting pregnant and with what technique?"
Mark Surrey, MD: "Hugo, that's a very poignant question. My name is Mark Surrey, I run the Center for Reproductive Medicine in Southern California, and we're located in Beverly Hills. The average age of the patient that sees us is probably about thirty-eight. As you know, fertility declines as we age as human beings and this seems to be most apparent with women, much more so than with men. When you pose the question how old is too old, it depends upon, firstly, your gender, so we're going to limit our conversation today to women. Everybody is obviously different but the concept that many people have is that one must be menopausal or fifty years old or older to have a problem with fertility or to be infertile is really not accurate. Fertility declines as we age as human beings and it decreases significantly for most women after thirty-five so our management of patients in our center, and I mentioned the average age of the patient is thirty-eight, is much different than if we see a woman that comes in who's twenty-eight. There's a time issue and, therefore, when we evaluate the patient and choose therapeutic courses, in other words, what the patient's options are differs from the patient who's thirty-eight from a patient who's twenty-eight. For example, we become much more aggressive with the older patient because time is more of an issue. So when we think about what is the most time efficient way to manage patients, we realize that at twenty-eight maybe you say to somebody - go on vacation and don't worry about it for six months. At thirty-eight we don't have the same attitude."
Hugo Verhoeven, MD: "So why is the mean age of your patients thirty-eight? Why don't the patients come to see you earlier?"
Mark Surrey, MD: "Firstly, there is a question of delays in infertility needs. Where we're located there are a lot of professional women, women who have chosen to delay their own fertility because they've been involved with their careers and they haven't thought about it until they're forty or thirty-eight, and this is frequently a problem. The second reason has to do with the fact that many of the general ob-gyns that they seek care with further delay their therapy by doing surgical procedures or by giving them medications for sometimes years at a time so they may start their fertility evaluation when they're thirty-four and end up seeing us when they're thirty-nine or forty. So our goal would be to not only educate patients as to the necessity for earlier intervention at an older age but also to educate their physicians in regard to trying to have a more efficient and a quicker way to not only evaluate but treat patients. I'll give you an example of what I'm speaking of, if we see a patient who's thirty-eight, she's never had a child, and we suspect that perhaps one of the reasons why is that maybe she has a problem called endometriosis. It's a very common problem that may be present in a third of all women in her situation so we have two options. We have an option to do a laparoscopy, and if we do a laparoscopy and find endometriosis then we have to treat that sometimes with medical therapy for four to six months afterwards. Then we give her fertility medications for another four to six months, and then if that fails maybe she does another laparoscopy or we can go right to a process called in vitro fertilization. Now if we compare these two options and the time involved and the results that are achieved for a lady of thirty-eight by not doing a surgical procedure and going right to the in vitro, it is probably a much more efficient approach and a quicker approach to her fertility. If this lady was twenty-eight then she could be managed entirely differently and maybe she should have a laparoscopy done."
Hugo Verhoeven, MD: "So are you saying that in the older patient, let's say thirty-eight years old, she's coming to see you and you're trying to find for her the method for conception that is maybe the cheapest but certainly the quickest?"
Mark Surrey, MD: "Absolutely."
Hugo Verhoeven, MD: "That is what I heard in many of the meetings in the United States. Go directly to IVF instead of losing too much time by doing sperm treatments, laparoscopies, medical treatment, wait and see, or having intercourse at the right moment. Those treatments altogether cost more money and more frustration as going directly to IVF which apparently has a much higher success rate."
Mark Surrey, MD: "That's correct, Hugo, and you know that in centers such as yours and ours and many such centers around the world you can anticipate pregnancy rates from in vitro fertilization even in some of your patients in this age group exceeding 50% per cycle. There is no other treatment that will accomplish that in patients like this so it becomes an elective procedure in that, as you know, twenty years ago in vitro fertilization was the last mode of therapy for a number of reasons. One is that it didn't work very well and the other is that other alternatives were more palatable socially to patients as well as economically. What's been interesting over this last twenty years as we've watched surgery evolve into more minimally diagnostic and endoscopic procedures and we've watched in vitro fertilization evolve, we've seen rapid advances in both areas but when it comes to fertility what we're interested in is results. We're not interested in what a nice surgery we can do. The patients aren't impressed by watching their surgical videos; they're impressed by having a baby. When we look at what is the quickest way for them to achieve that, now because of increased success rates and improved laboratory environments, it frequently is in fact in vitro fertilization. So now it's more of a first or second line of therapy and not the last line of therapy."
Hugo Verhoeven, MD: "So we decided now that the patient will have in vitro fertilization. Is there any difference in the technique that you use in the younger patient or in the older patient? I'm thinking, for instance, of giving back more embryos or doing blastocyst transfers. Is there a difference between the twenty-eight year old patient and the forty year old patient?"
Mark Surrey, MD: "There is in that the forty year old patient usually will have a lowered ovarian reserve and, therefore, will probably require more stimulation in terms of the dosages of the medications that she may take. The other difference relates to embryo development in that frequently you don't have as many embryos or as many well developed embryos in ladies who are older. When you do there is a frequent problem with the chromosomal content of the embryos that you do derive and, therefore, there is now a technique where we can take a cell from the embryo and analyze it for its normalcy before putting it back. That can be then offered to the older patients if they develop enough embryos to check them for what is called aneuploidy or an abnormal genetic content before putting them back. You're right in your last comment that we would probably put back more embryos in the older patient than we would in the younger patient because there's a lower rate of attachments or implantation."
Hugo Verhoeven, MD: "So as a conclusion - more hormones, a higher intensity of stimulation, and preimplantation diagnostic."
Mark Surrey, MD: "Yes."
Hugo Verhoeven, MD: "And a transfer of more embryos. What about assisted hatching?"
Mark Surrey, MD: "Assisted hatching is clearly something that is done in most patients now but particularly is effective in older patients. That is a technique where prior to replacing the embryo if it's done at a cleavage stage, the zona around the embryo is thinned, as you know, by one of several techniques. This seems to assist the embryo in hatching through this membrane and implanting into the endometrium. This is something that is offered to and usually utilized by all patients who are over thirty-four or thirty-five."
Hugo Verhoeven, MD: "So now the patient is indeed too old, that means her response to hormones is too low, she has bad eggs, and bad embryos. There are alternatives for the patients?"
Mark Surrey, MD: "There are, there's a very, very effective one called ovum donation where it's possible to achieve pregnancy at a very, very high rate commensurate with that of the age of the ovum donor. For example, if you have a lady who is fifty and is incapable of getting pregnant on her own and she chooses a donor who is twenty-two, she can by this technique of utilizing the donor egg and her husband's sperm and carrying the pregnancy achieve pregnancy at the same rate that she would if she was twenty-two. That's a technologic advance that is underutilized now mostly for social reasons in that people are a little slow to accept the ethical issues that are involved with this. I must tell you that once they do, and most patients who are over forty-four who have children do so by this technique, I've never seen a patient who's been sorry that she's followed this technique. This is something that's available to women that are incapable of carrying pregnancies themselves."
Hugo Verhoeven, MD: "What I think is quite interesting for our listeners is what about the selection of the donors - how do you select them?"
Mark Surrey, MD: "This is a process that's done by agencies where we are, we don't do that ourselves. We simply provide the patient with a list of agencies who specialize in doing that and these donors are selected but also screened through criteria in this country that are set forth by the American Association of Tissue Banks. This meaning that they treat these patients to the same regulations as a kidney donor, a retinal donor, or a sperm donor would be treated where they have to undergo testing beforehand - medical testing, genetic testing, family histories are taken, legal screening, and psychological screening is performed on these patients. The recipient (the patient) that comes to us is provided with a list and pictures and backgrounds of the donors."
Hugo Verhoeven, MD: "It's not anonymous?"
Mark Surrey, MD: "It can be but it doesn't have to be. It can be directed for the donor where the patient can actually meet the donor."
Hugo Verhoeven, MD: "For us in Europe that is quite interesting, in only a few of the European countries we can do ovum donation and then most of the time it's anonymous. So this is then my last question - this must have some legal implications, for instance, what if the donor after three or four years decides to say that's my child, I'll sue the recipients, I would like to have my baby back? Is there a chance for that patient or is the legal situation such that she has no chance at all?"
Mark Surrey, MD: "They have no chance. It's similar to that of sperm, retinal, or kidney donation - you can't donate a kidney to somebody and say three years later you want it back. The legal system in this country is pretty clear about informed consent in that regard, and there have been some tests in court of this system. The recipients have prevailed in so much as it's not possible for an ovum donor to change her mind and decide that she wants to have the baby back."
Hugo Verhoeven, MD: "Maybe one final remark - in Europe we have the problem that patients without a uterus no longer have a chance to have a baby so obviously in Europe it's not possible, and I know that a lot of our listeners are from Europe or from South America. What are the chances in the United States for a surrogate? Is it easy or is it difficult to find somebody who is willing to carry a baby from somebody else and to deliver and give the baby away to them?"
Mark Surrey, MD: "It's not difficult at all in that there are groups similar to the groups that I just mentioned to you that recruit ovum donors that also recruit gestational surrogates. That is usually something that's not done anonymously, meaning that the patient usually will meet the surrogate and frequently follow the pregnancy along and be very involved with the delivery. They don't have to but it's very common that it is done like this. A gestational surrogate is probably more difficult and more expensive certainly than ovum donation because it obviously involves a much longer process."
Hugo Verhoeven, MD: "And medical costs for delivery, intensive care, neonatal care, and everything."
Mark Surrey, MD: "Precisely, but none the less legally and technically it's something that works very well. It's something that there are lots of precedent for and it's something, again, that has been tested in the legal system in the United States whereby gestational surrogates do not have any rights to the child after they've been born for a lot of different reasons, not the least of which is it is not her genetic material - it is not her child. It is the child of the couple who have donated their eggs and their sperm."
Hugo Verhoeven, MD: "What are you not offering your patients in Beverly Hills? Is there anything that you don't do because of your own ethical decision or what the government doesn't allow you? What you would like to offer the patients?"
Mark Surrey, MD: "I can't think of anything right now that we would like to offer patients medically that we're not able to because of legal restrictions other than the issues involving stem cell research and cloning. That is something that, unfortunately as you know, I think the U.S. Government has gotten involved in both nationally and locally. There is, in fact, a bill that was signed by the ex-governor of California in 1994 forbidding any research on stem cells or human cloning in the state of California until two years from now. I don't know why he picked 2003 but that's what he chose and the bill still stands. It's presently being tested, and that's the only area that comes to mind that involves our specialty that I think we really have been handed problems by the government and a legal system."
Hugo Verhoeven, MD: "That's the difference with the country where I'm working in, in Germany. In California, practically nothing is forbidden but everything is allowed, while I work in a country where practically nothing is allowed at this moment. Mark, I think this was very informative, thank you very much."
Mark Surrey, MD: "Thank you for having me."
Hugo Verhoeven, MD: "It's a pleasure like always, thank you."