Frontiers of Fertility

Better IVF. Cutting-edge ways to size up embryos. For couples struggling to conceive, the options are expanding—and the outlook is improving

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A baby in utero. New techniques can improve the odds of conception.

At Rosenwaks’ clinic, doctors are addressing that challenge with a time-lapse-photography system that snaps pictures of growing embryos every 10 to 20 minutes for the first few days of incubation. Subtle differences in the way they divide can provide clues to which embryos are the strongest. Similar techniques were tried in the past, but the pictures were taken manually by lab technicians, which required opening the incubator several times a day, exposing the embryos to blasts of room-temperature air and contaminants. The new cameras peer through glass into the sealed incubator and fire off their pictures automatically. “We have increased pregnancy rates across the board while decreasing the likelihood of multiple [births],” says Rosenwaks. “Whether the woman is younger or older, in every category we have improved pregnancy rates by 15% to 20%.”

This process too faces some early challenges—principally ones of access. There are more than 400 fertility clinics in the U.S., but only a few dozen so far have a system like Rosenwaks’. Not only does that exclude an overwhelming share of patients; it also means the 15%-to-20% improvement rate could be a premature boast, depending on how other clinics fare if they adopt the new technology.

Further out on the developmental frontier are stem cells. For decades it was assumed that girls are born with all the eggs they will ever have and can produce no more during their lives. In 2012 that wisdom was overturned when Jonathan Tilly, director of reproductive biology at Massachusetts General Hospital, announced that the ovaries harbor stem cells that, with the right chemical coaxing, could be made to mature into eggs.

Tilly accomplished that egg-growing feat—after a fashion—by harvesting stem cells from ovaries removed during sex-reassignment surgery, growing them in a dish, repackaging them in a bit of the original ovarian tissue and transplanting the entire little bundle into a lab mouse so that it would receive a steady blood supply. (Implanting it in a woman would have raised ethical issues.) When Tilly extracted the cells, they had indeed matured into what at least appeared to be fully mature ova. Not even Tilly pretends that his method is safe or practical—at least not yet—but as a proof-of-concept study, it shows promise. The threshold requirement for parents conceiving via IVF, after all, is at least one healthy sperm meeting one healthy egg. If you don’t have that, all the improvements in the world in embryo monitoring and implantation do you no good.

Investigators at Newcastle University in England had similar success on the male side of the equation in 2009, using embryonic stem cells to create living, swimming, healthy-looking sperm—though the researchers have no idea if the sperm are viable, and British law prevents them from attempting fertilization and implantation to find out for sure. Since then, they have been working on ways to sidestep the use of embryonic stem cells and all the ethical issues they raise by creating stem cells from the skin cells of the infertile men, which could then develop into sperm.

Expanding the Choices?
The more the medical options expand, the more some doctors—and couples—wrestle with the implications. Fertility counselors, when framing patients’ choices, remind them that they can continue to try to conceive or they can choose to adopt or live child-free. That’s a word that’s carefully chosen with the intention of replacing the bleaker-sounding childless and capturing the notion of an upside for a loving couple living a free and relatively unencumbered life.

For those who decide to turn to science to boost their fertility, cost is no small issue. Assisted reproduction remains expensive and is typically not covered by insurance. Under the Affordable Care Act—a.k.a. Obamacare—basic gynecologic and obstetric care are covered, but infertility treatment isn’t. The law does increase the available deduction for those treatments from 7.5% of pretax income to 10%. (For people who adopt, there is a tax credit of $13,360.)

In a perfect world, money wouldn’t stand in the way of having a child, but in a perfect world, neither would fertility problems. Basic as the reproductive drive might be, a lot of things have to go just right for a healthy baby to be the result. For a growing number of parents-in-waiting, more is starting to go right than wrong.

with reporting by Alexandra Sifferlin / New York

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