How to Make a Family: The Blog

Making Babies with Zack Booth Simpson

It may not seem like it, but I really do take every opportunity to see outside my little repro med box. In fact, you should know that when my blogging grinds to a halt, it's because I'm doing just that -- peering over the edge, maybe even venturing a toe into the world out there where not everyone is fascinated with baby-making. Or at least, not obsessively (or consciously...)

(I know. Who ARE these people?)

So when my attention is directed away from my typical fare by someone outside of my usual day-counting, hormone-injecting, finger-crossing crowd, I am extra delighted when the subject is actually the same topic, different window.

Because after all, it is ALL about baby-making, isn't it?

Zack Booth Simpson may be a scientific artist genius-type, but he knows what's important. Baby-making. And in The birds and the bees he tells his little one how babies come to be.

Chalk him up to yet another reason to hang out in Austin.

Zack's explanation is so exquisitely male in my eyes. It's a viewpoint that will, I guess, be forever less represented. (And I don't know, but I'm thinking guys really have it going on with the whole scarcity-value relationship thing when it comes to heartfelt expressions about creating progeny...)

All whining aside, here's to Zack and dorky nerds like him who take time away from their discussions of molecular computers to grace us all with their tender side.

{Edit 7.8.09 9:50 PM ET: And just to demonstrate how good my taste is (and that of the friend who first directed me to Zack's blog) -- the link to 'Birds and Bees' is currently dysfunctional because Zack, himself, is awaiting word from an unnamed highbrow publisher who might just give it a go in bigger territory. Stay tuned to find out if I get the a-ok from Zack to reinstall a link to his blog, or (better yet) if I get to link to the even more glamorous publication.}

{Final Edit 7.29.09 9:55 PM ET: Zack's informed me that the 'other' publication failed to respond to his query in a timely manner, so he's taken matters into his own hands and re-published "Updated birds and bees"... a must-read.}

The Right Time to Have A Baby

When is the time right to pursue pregnancy and have a baby?

In her blog today, Pamela Madsen of SIRM talks more about CGH and egg freezing and how she views those two particular techniques as The Cutting Edge of repro med right now. She says "everyone is working on this technology - it will change the face of the practice of reproductive medicine."

True. Just like all the other, now-standard techniques did before them. Good thing about science: it just keeps rolling.

So here we are again at the junction of We Can and We Should.

Like some of my infertility blogger compadres, my perspective is now tempered by not just pregnancy or having a baby, but by a quite-eventful life filled with some of parenting's best and worst moments. I can't help it. If you haven't had your hoped-for child yet, trust us: there will come a time when you won't be able to help yourself either. The world just looks different when someone's life is in your hands.

The point I'm pondering now -- and as some of you know, a point around which I've wandered for a few years now -- was ruffled up again when I read in Pam's blog today this sentence: "It is not just about preventing pregnancy until we are ready - it is also about having a baby when we are ready." She says egg freezing will do that.

The increasingly available and more-proven technology of freezing egg cells will allow women to have babies when they are ready.

Without intending to go too high-brow on everyone -- when is that, exactly? What does "ready" mean?

It's my favorite part of this whole baby-making puzzle, the part that almost never gets brought into the picture by the repro med experts.

Is it really as simple as "My entire being is craving the experience of reproduction, therefore I must be 'ready'?"

Is being ready the same thing as financially stable? Maybe that, combined with having achieved the level of education and experience perceived to be necessary for being a "good" parent?

I can hear some of you parents getting twitchy, remembering all those pre-baby things you said you'd do or never do. Right. No fast food for MY kid, by golly. And only educational television, if any TV at all. My child would never hear his parents argue. He would witness and learn through the osmosis of our carefully prepared existence the fine balancing acts of life that pit need against want, pair art with science, reason with faith, and all in steadily practiced moderation.

Because I was an educated planner.
Chances are good that, like me, you started out believing (rationalizing?) you were "ready" and became steadily, even if in tiny increments, less sure along the way. Remember that feeling the first time you went into labor and realized the true meaning of "no turning back"?

Ready or not, life happens. Don't get me wrong -- I am a whole-hearted proponent of family planning. I cared for too many abused and neglected kids to feel otherwise. Even the reasons for egg-freezing by healthy young women, I get. It's the notion of this focus on "being ready to have a baby" -- combined with what seems like an absence of conversation about what that term means -- that's losing me.

I'm recalling a PSA from long ago -- I've tried to locate it online, to no avail -- that spouted out a few typical societal rationales for having a baby, and ended with the big smooshy DUH: "The only good reason to have a baby... is because you really want one." Helpful.

So we need a sort of barometer of both desire and readiness.

Or we could try the old standby of attempting some foresight... Let's imagine a world where freezing gametes is the standard for planning parenthood. I invite reader participation for this project. In my mind, there are myriad possible outcomes, not all bad or good. In fact, I'll not try to squeeze every related idea into this one blog post, but will try to revisit it from time to time when more thoughts from Prophecy Lane come wafting my mind's way.

Here's a kickstart -- based on my assumption that this New World of Lotsa Frozen Eggs will inherently mean even more middle-aged new mommas:

In their trendspotting blog "Intelligent Dialogue," the public relations agency Porter Novelli compiles admittedly not-so-new stats  to synthesize a picture for use by marketers and corporations of the changing concepts in "Cradle & Grave". While they plug aging first-time parents as having done "a lot of soul-searching," their white paper adds the oft-overlooked financial disadvantage: late-30-somethings and 40-somethings may be more financially stable at the start of Project Baby, but older parents will quite likely be trying to fund their precious kiddoes' expensive teen activities and college education while generational peers are starting to draw on pensions.

Get ready to work til you drop, Pops!

Sure is a good thing that "50 is the new 40" or is that the "new 30"?

What do you think the world will look like when the average high schooler is trying to decide on both which college to attend and which egg-freezing facility to use? In what conversations should we be engaging young people today about what "being ready to have a baby" means -- beyond the romantic cliches?

Moderation is Key: Case in Point

This rather sad personal tale by Julie Suratt in Boston Magazine illustrates the concept of "too much of a good thing" -- an unfortunately recurrent theme in the world of infertility treatment.

It's not all doom and gloom. Suratt manages to pull some humorous anecdotes and even a bit of poignancy from the trials and tribs of her own MOT (mother of twins) experience and those of her similarly-saddled compadres.

As a still-ecstatic mother of a 9 year old only, but mostly as someone who studied and worked directly with families and children for a couple of decades before having my own, it's impossible for me to read such essays without a taste of bitter in my mouth.

Suratt's angle isn't so much just to whine about her situation -- she adeptly connects it to the rather intriguing problem that's erupted in her state of residence, Massachusetts, due in large part to how well-insured they've been there for years. Everyone's wanted their state to follow Massachusetts' lead to infertility insurance mandates. People have moved there just to get the goods, in fact. So now the place finds itself literally crawling with multiple babies and all that results from such.

Oh, if I only had a nickel for every mom who uttered online that she'd LOVE to have twins, even triplets, if only she could get pregnant.

But the bitter old family services worker in me offers this up: Why did any one of these folks expect parenting to be peachy? It matters little how many you push forth into the world. Bad things happen. If they haven't happened in your cocoon yet, you can bet they will. It's that simple.

So whether your troubles stem from the fact that you took full advantage of your insurance and had a brood in one fell swoop, most likely too early in their gestation to go without a bushel-full of dollars spent on keeping them alive and fixing up a few health conditions, or from your simply getting pregnant the old-fashioned way and having a single baby -- you'll be having your share of troubles and more. We don't get to choose. Welcome to Parenthood.

Double Trouble - Boston Magazine.

Passin On The Good Stuff Again

Okay, off my high horse, back to more compassionate reality again... The organization I mentioned long ago, Fertile Dreams, is hosting another conference and they've asked me to mention it.

Fertility conferences come and go, all over the place -- but this one is not only free, the keynote speaker is none other than Ali Domar, herself.

Alice Domar, PhD, is the woman who's taken mind-body concepts (pioneered and shown the public light of day by her Harvard mentor, Herbert Benson) into the realm of women's health and fertility and never looked back. You may see "mind-body" stuff touted everywhere you go, but Dr Domar is the It Woman who started the concepts on the path to infertility clinics.

You can see her speak for no charge at the Fertile Dreams 4th Annual Pathways to Parenthood Conference. Registration in advance is required.

Nothing New, But Stay Tuned

A New York Times piece, Racing to Beat the Maternal Clock, was published on December 12, under the section head Frontline Report.

With my own daily existence being rather mired in the topic, I can no longer provide the perspective of a newcomer to the infertility world. But really -- a NYT article on how reproductive biology is still trumping science? This is still news?

Right. Lots of people are buying into the heavy-duty marketing by the industry that nearly claims the ability to get anyone pregnant at any time. At least, that's how desperate minds can translate what they read. The relationship between provider and receiver of family-building help is a two-way street.

The instinctual drive to have a baby can be for some a cause of near insanity. Otherwise reasonable people will literally hear and read what they long for the most -- that their dilemma can be resolved by the experts. Fertility experts are often happy to oblige.

My face is overtaken by a grin when I read (in Leslie Berger's NYT article) how Dr Bradley Van Voorhis of the University of Iowa School of Medicine referred to the older patients crowding fertility clinics' doors as "otherwise highly educated..."

One quote in the same article did catch my eye, with the same sort of zing that I recall when finding out about PGD back in the mid-90's. Sherman Silber, a doc in St Louis who's made history in the field a few times, announced his opinion that egg-freezing "will emancipate women as much as the birth control pill did in 1960." That's a keeper for posterity.

Not all fertility docs are as quotable as Zev Rosenwaks. Berger's interview of him, Turning Points on the Road to Conception, is more informative than the 'maternal clock' piece. Still, even he, the Director of The Center for Reproductive Medicine and Infertility at New York-Presbyterian Hospital, says "Today, we help most of our patients depending on their age. Depending on how far couples are willing to go, we can treat them pretty successfully 90 percent of the time." This near the end of the interview in which he started by saying that the sometimes-reported "higher" rates of infertility are really just a product, especially in the U.S., of people trying to conceive later in life.

While he 'hopes' that people will take what we know about the biological clock into consideration when they're planning families, Rosenwaks and others stand by, waiting to offer the best they can to those of us who pursue life as if our unborn children are angels in the wings who will enter on cue. 

Ambience is Everything

It's nice to see studies that confirm my own unfounded opinions, even if there's a slight 'duh' factor involved.

Turns out that little in vitro embies don't like nasty lighting. Neither do I. My colleagues and I at AIDS Foundation Houston, back in the day, were affectionately referred to as "the lamp people" -- we refused to use our office hovel's fluorescents overhead, favoring the soft warm glow of incandescent lamps on our desks. Life was tough enough doing social work with sick people at their homes; when we had to be desk-bound, we wanted as much soothing as could be mustered in that moldy building. But I digress...

So, me and the embies have it right. Fluorescent (and even sunlight for the little ones) is out. Warm-white is in.

Link: IVF News - Lights in fertility clinics may damage embryos.

Too Much of a Good Thing?

Coming up from the 'Better Late Than Never' Dept:

Recent articles sprouted from published research that implies there's a bit too much ICSI going 'round. So, I asked both the researcher and one of the pioneers of the technology to comment on the media hullabaloo that ensued.

ICSI, for the uninitiated, is the acronym for intracytoplasmic sperm injection, arguably one of the most diety-like assisted reproductive technologies available. Just like it's name says, ICSI is performed by an embryologist who uses tiny tools to pick up a single sperm cell and injects it into the cytoplasm of an egg cell. In "ordinary" IVF, a batch of egg and sperm cells are tossed together in a dish to see who the winner is -- with ICSI, only two specially chosen cells get the honor of trying to make a baby.

Dr. Tarun Jain in Chicago is the lead author of the study, published in the July 19 New England Journal of Medicine. The study concludes with a question mark as to why so much ICSI is being performed.

ICSI's primary benefit is the treatment of male-factor infertility, that is, problematic sperm. Combined with pretty darned invasive sperm gathering techniques for some men, even those whose semen analyses render no visible sperm cells have been able to become biological dads. In lay person's terms, guys who are shooting blanks can still get a woman pregnant. That's no small science.

The science and related micro-technology have been around for awhile. One of the first in the arena was embryologist Michael Tucker, PhD, who works in Atlanta and Baltimore and Chicago. Since ICSI's early days (way back in the late 80's, early 90's, a long time for this fast-moving field), technicians have become more adept at using the tiny tools, and labs have learned more about things like fluids that promote viability of cells. The result is quite a big change in the consistency of infertility treatment outcomes, for the better. In short, ICSI not only helps men with sperm cell problems, it takes a lot of guess-work and chance out of IVF for people with non-male-factor issues.

So Jain, who has gained a reputation as a reproductive doctor whose research studies advocate for the little guy (e.g. patients who cannot afford treatment or who are discriminated against), wondered on paper why there was so much ICSI being done when male-factor infertility rates seem to be static.

I've interviewed both Jain and Tucker over the years and assert that they're both good guys and not necessarily diametrically opposed. So I'll just quote them, from emailed responses to my query for their comments.

To Tarun Jain, from me: Could you comment on what spurred you and the co-researchers toward examining the use of ICSI?

From Jain:
Thanks for your interest.

ICSI is an important and useful technique that is used frequently as part of IVF treatment for male factor infertility.  We had anecdotally been seeing a greater use of ICSI for other indications.  There has also been a lot of recent debate in the literature about the indications for ICSI use.  We therefore set out to objectively look at the true utilization of ICSI in the US over a 10 year period.  Our study was the result of that impetus.

Best regards,
Tarun Jain

To Michael Tucker, from me: I would love to know both your quotable and off-the-record comments on the NEJM pub'd study by Tarun Jain et al from U of Illinois to Chicago.

From Tucker (only the quotables...):

I remember getting fired up about this back in the day (for example, Tucker et al. Lancet 2001 in a back-and-forth on when to use IXI), and I hav always been very aggressive with it's use simply because over the years I have seen (my own "evidenced based" assessments!), the ability of IXI to overcome complete failure of fertilization following conventional insemination, even when no male factor is involved.  And these cases are due simply (for example) to issues with the receptors on the oocytes, possibly due to the unphysiological nature of the ovarian hyperstimulation or inherent bad oocyte quality, and in some cases you can take these unfertilised eggs, fertilize them with "rescue IXI", make embryos (rescue IXI = FIXI...), and transfer them even though developmentally they are 12-18 hrs delayed, and generate healthy babies (see for example, Morton et al Fert Steril 1997).

Heck, this can go either way. Do I think IXI is sometimes needlessly utilised? Yes, maybe just occasionally, but on balance, it can be argued that it is the way to go for all cases. I have been offsite director in Chicago (www.fcionline.com) for about 3-4 yrs, and they do 100% ICSI - why? Because they have an all inclusive deal with the insurance companies that makes IXI dirt cheap; it allows optimal examination of oocyte quality and maturity on all patients the day they are retrieved; avoids the 5-10% unexpected failed or reduced fertililzation cases that compromise about 10-20% of all conventional insemination cases; and further it may improve on nature... This last statement is based on a newer emphasis in the last few years where we get much more particular about which sperm we actually inject.  We utilize higher magnification than we used to, to scrutinise the precise morphology of the sperm that we immobilise for IXI, and this appears to be linked significantly with improved clinical outcomes, making the not unreasonable leap that good morphology correlates with better overall DNA packaging - see for example,  Bartoov et al, J Androl 2002.

The enthusiastic and motivated Tucker continues, expressing frustration at "studies like this" because... they are so missing alot of the multifactorial stuff that goes into the making of decisions in our business - not to mention a 31 to 33% outcome comparison is no way significant in such a mess of patients. Steve Ory mentioned the "art" of what we do; and by and large we are one of the most "policed" areas of medicine (cue Michael Moore?), and while there may be a little "abuse"/overuse of IXI, I think it is utilised principally in a totally appropriate and well-intentioned way. If done properly in the lab, it kicks arse, and that's the only way we use it under my guidance (usually about 55-65% of cases in most labs other than Chicago), and the patients get a good deal, believe me. That there are extra chromosomal / genetic disorder issues with IXI is (IMHO) entirely due to the nature of the gametes that are achieving fertilization and oftimes pregnancy, that would not have a donkey's chance on the horse stud farm to achieve success (healthy pregnancy) otherwise.

It's good to know that professionals like both Jain and Tucker are on the job. To me, they represent two essential components to problem resolution -- inspired, enlightened momentum and compassionate, educated caution.

Evidence-based Science Versus The Desperate Wanna-be Mom

Back when it seemed like I was miscarrying pregnancies left and right (approximately every 6 months, to be accurate), scouring the Internet for answers developed from a hobby into an obsession and, finally, a career. If there was something out there that my MFM or RE hadn't suggested yet, by gosh, I was going to find it and lay it out for them.

That's how I wound up begging to use prednisone, a glucocorticoid aka steroid hormone.

Link: Steroid use fails to boost pregnancy rates in infertility treatments.

Using Stem Cells to Create Sperm

Far from being a done deal, there is at least the possibility of more hope on the horizon for men with cellular level infertility. Research published in the American Journal of Pathology reports that infertile mice recognized promising results when bone marrow stem cells were transplanted into the testis to see if they would replace nonfunctioning cells.

While no full sperm cells were created, the stem cells did indeed differentiate into either germ cells or supporting cells. Also, the different types of "new" cells were found among similar types, indicating influence on the stem cells by their immediate environment.

This is one of those very precursory studies in a long line of future explorations, but hopefully it's one that we'll all look back on one day and say "Remember when we'd just started to figure out how to use stem cells to create sperm?"

Link: Treating Male Infertility With Stem Cells.

Letting Fertility Docs Off the Hook

For years, the rates of multiple and other high-risk pregnancies have been on the rise. For the same amount of time, reproductive specialists have taken a beating for at least having the appearance of being the primary sources for the increase.

But in this AP article by Marilynn Marchione on the Monterey Herald website, comments by maternal-fetal medicine (MFM) experts call attention to the other players in the high-risk baby story.

Link: Monterey County Herald | 02/13/2007 | Risky pregnancies increase.