There are no easy words to ease the impact of hearing you’re infertile, that you will never be able to have a baby.
So when Shari Locascio heard them, she didn’t hesitate before contacting a reproductive endocrinologist for help. After two years of failed treatments involving clomid and inseminations, time was getting tight. She was 33 years old, and she and her husband Adam knew they needed to act quickly before their odds of pregnancy got even worse. They sought out USF IVF for a second opinion, and for IVF treatment.
Count four years after starting their fertility journey, after daily injectable and oral medications, monitoring calendars for every time nuance of her cycles, several egg retrievals, dozens of lab tests, several “didn’t take” pregnancies, and the extreme ups and downs during one of the most highly emotional processes in health care when, finally, baby Dominick came into the world.
Adam and Shari Locascio with 2-year-old Dominick.
“It was an emotional roller coaster and tested our marriage, but we feel so very blessed with our Dominick and were lucky to have connected with USF for medical help and amazing support throughout the entire effort,” Shari Locascio said.
The Locascios experienced what thousands of infertile couples go through on any given day: using in vitro fertilization (IVF) to help them become fuller families.
In 2012, there were more than 165,000 IVF cycles in the United States.
“The science behind helping infertile couples have babies has improved drastically in the last half century, especially in the last two decades with rapid improvement in IVF success rates,” said Shayne Plosker, MD, associate professor and director of IVF and Reproductive Endocrinology in the Department of Obstetrics and Gynecology in the USF Health Morsani College of Medicine.
A women under age 35, with good ovarian function, can realistically expect to have a 75 percent chance of delivering a baby or of being pregnant within a year of starting IVF, if she is prepared to go through more than one IVF attempt if needed, Dr. Plosker said.
“We’re so much better at it now,” he said. “Yet many women don’t hear these improved odds because they hesitate to talk with their doctors about their options for having children through IVF. The reality is, about half of all women using IVF to help them have children have children.”
Dr. Shayne Plosker
But it is important to have realistic expectations, he added.
“Nationwide, even those couples with the best prognosis still have at best a 50-50 chance of delivering a baby after one IVF try,” Dr. Plosker said. “Couples may require a second try, either with frozen embryos or another fresh cycle, to succeed. And, unfortunately, not everyone falls into that ‘good prognosis’ category and, even in 2014, not everyone goes home with a baby from IVF.”
Investing time
Dr. Plosker and his team provided the IVF expertise that helped the Locascios have Dominick.
The four years the Locascios spent undergoing infertility treatment is not uncommon, and some patients have been in treatment for 7 years or longer, Dr. Plosker said.
“Before you know it, time can get away from you,” he said. “In a typical scenario, a young couple might spend a year or so trying to conceive then visit their gynecologist who may try some conservative treatments. These treatments may work for some, but not for most. Another year can easily slip by before being referred to a reproductive endocrinologist, where several more conservative treatments may be undertaken. While these may eventually succeed, probably at least two thirds of couples will require IVF. Added to that, the emotional fatigue and financial burden that come with infertility treatment lead many couples to take a break, or give up on treatment entirely. In a heartbeat, several years have gone by and a couple’s emotional and financial reserves may be running on empty, without ever having tried what is by far the most successful treatment for infertility, IVF.
“When Shari and Adam came to see us, they were very proactive and very definite about what they wanted, which is a credit to their stamina and dedication. I would encourage all couples to take charge of their treatment. Our goal as infertility providers should be to shorten the time spent in treatment. The time from the start of IVF treatment to the delivery of a baby, could take as little as 13 months, if everything went according to textbook timing. And, for those couples for whom the dream does not come through, avoiding treatment delays can help them move on to consider other alternatives such as donor egg IVF, adoption, or choosing to be childless.”
“The real key is to not spend too much time deciding to begin IVF because, depending on your age, the window of time can start to close even faster as you age,” he said. “A woman produces far fewer eggs, and far fewer healthy eggs, as she ages.”
Looking at success
It’s just a number, but you can bet every woman who is told she is infertile will dig into reproductive endocrinologist websites looking for the number that will tell her what her odds for having a baby would be under that doctor’s care. Called success rates, these numbers are the overall likelihood of pregnancy through in vitro fertilization. And they can tell you which IVF teams have been proficient in using science where nature fails.
The best measure of IVF success is the likelihood of going home with a baby, or live birth, and that is how IVF programs report their results to the Society for Assisted Reproductive Technology and to the Centers for Disease Control, Dr. Plosker said.
Pregnancy and live birth rates are typically within age brackets to help put into perspective the profound effect age has on IVF success rates. For example, whereas the IVF live birth rate in the United States in women under age 35 was 41 percent in 2012, it fell to 31 percent in women ages 35 to 37 and 22 percent in women ages 38 to 40. Success rates are based on live births so 2013 numbers are not yet available since there are still on-going pregnancies.
In 2012, 10 percent of all IVF cycles involved eggs from egg donors. Egg donors are most often used by women who are in their 40s, young enough to have families but too old to achieve pregnancies using their own eggs. Egg donors are women in their 20s to early 30s. They take fertility drugs to produce many eggs and when the eggs are mature they are retrieved and fertilized with the sperm of the intended father. The best one or two fertilized eggs are then transferred to the recipient/mother.
Carrying a pregnancy is not affected by a woman’s age nearly as much as the number of and viability of her eggs for getting pregnant. Regardless of age, donor egg IVF success rates are 50 percent or better.
One approach to improve the odds of success with IVF, as well as simplifying the IVF process for patients, is using frozen embryos. Women with good ovarian reserve can provide 10 to 20 eggs during an IVF cycle. The retrieved eggs are fertilized and one to two of the viable embryos are implanted in the patient for an attempt at pregnancy while the remaining embryos are frozen. If the fresh embryos do not result in pregnancy, some of the frozen ones are thawed and then implanted, Dr. Plosker said. This technology has been around since the 1980s, but with a new freezing technique called vitrification success rates with frozen embryo transfers have increased.
In every age group the live birth rate from frozen embryo transfers exceeded that from fresh IVF in 2012, Dr. Plosker said, and, unlike the complex treatment protocols of fresh IVF cycles, frozen transfers can be undertaken with no, or minimal, hormonal medications.
A challenge still facing IVF is the high numbers of multiple births.
“While we have done a very good job of nearly eliminating triplet conceptions with IVF, we still have a ways to go to reduce twin pregnancies,” Dr. Plosker said. “Often our patients tell us they would love to have twins, but what many people don’t realize is just how risky twin pregnancies are. Twins have a high rate of premature delivery, which means a higher risk of complications such as cerebral palsy, intracranial hemorrhage, respiratory complications, and other developmental challenges.”
One way to address this challenge, he said, is to transfer back fewer embryos.
“From 2011 to 2012, the percentage of single embryo transfers in our youngest patients increased from 4 percent to 20 percent,” Dr. Plosker said.
IVF is also helping families grow later, with fertility preservation.
Men and women facing cancer-fighting chemotherapy and radiation, which can put an end to healthy reproductive systems, can now preserve their eggs, sperm and embryos in hopes of having a family later. And younger women, knowing they want to wait until later to have children – when the odds of conceiving naturally are greatly diminished – can use IVF to freeze eggs and embryos while their ovaries are producing plenty of eggs and forego the emotional turmoil of trying to harvest eggs later, when ovaries might produce only a few eggs and when pregnancy rates fall drastically.
Finding the right team
The Locascios connected with Dr. Plosker and his team because of their reputation – Dr. Plosker and James Mayer, MD, associate professor in the USF Health Department of Obstetrics and Gynecology, were ranked in the top 10 percent of infertility subspecialists and gynecologists in the United States by the US News and World Report in both 2010 and 2011.
In addition for their passion for IVF, each member of the IVF program brings a unique skill to the division. Dr. Anthony Imudia recently joined the USF Faculty after completing his reproductive endocrinology fellowship training at Harvard, with expertise in IVF and minimally invasive surgery. Dr. Mayer was the first Reproductive Endocrine Fellow at USF back in the 1980s, and has championed international IVF cycles for couples from Europe coming to USF for treatment. Dr. Plosker has carried out research on IVF outcomes and on embryo transfer technique. USF IVF’s embryology director, Ying Ying, PhD, assistant professor of Ob/Gyn and embryologist, has performed thousands of complex embryology procedures such as embryo biopsy for preimplantation genetic diagnosis, and intracytoplasmic sperm injection. Christine Kilfoyl, RN, the USF IVF program director, has 15 years of infertility nursing experience, has studied nursing abroad in several countries, and has authored reports on international IVF and on building an IVF nursing team. She leads a dedicated, compassionate team of nurses who have the greatest interaction with USF IVF’s patients.
From left, Dr. Anthony Imudia, Dr. James Mayer, and Dr. Shayne Plosker.
With word of the USF IVF program’s success getting out, the team now sees patients in offices throughout the Tampa Bay area: in South Tampa, on the USF main campus, in Sarasota, in St. Petersburg, in Lakeland, and starting in March in Wesley Chapel.
Their work has even reached international families.
“Our all-inclusive approach, with full IVF services in one place, is very intriguing for women from countries with laws limiting access to comprehensive IVF care,” Dr. Plosker said. “In particular, some countries do not permit the use of gestational carries, which means women who may have been born without a uterus, or who have had hysterectomies, cannot legally have their own genetic children. We are able to help these couples achieve their families here at USF.”
In helping couples become families, three points cannot be overlooked, Dr. Plosker said: the quality of the team of experts, access to the newest technology and science available, and the team’s compassion for truly caring about patients.
“Much of the treatment is standardized so what really counts is the assembly of qualified, experienced and caring staff who make it all come together,” Dr. Plosker said. “There are so many steps and people involved in IVF it’s like landing a plane, so everyone had better be at the top of their game clinically. We have to deliver our care with compassion and empathy. Infertility is a difficult journey, and we must remember that for every success story there is another couple whose dream has not come true. As happy as we are for every couple who is successful, we feel the disappointment with every couple who is not.”
IVF is a specialty that attracts a certain type of person, said Christine Kilfoyl, RN, program manager and IVF nurse coordinator for USF Health’s IVF program.
“The highs are very high, but the lows are very low,” Kilfoyl said. “With this specialty, you’re dealing with patients at both the clinical and emotional level. Personally, we want to help each patient feel comfortable, safe, and that they can trust us. There are so many paths they can take along the way that my foremost job is to educate them on those choices so they can make the best decisions for themselves.”
The second key consideration for IVF programs is access to new IVF science. As part of an academic medical center, the USF Health IVF program has access to many of the newest breakthroughs in IVF medicine. Using frozen eggs, and identifying candidates for single embryo transfer to reduce multiple pregnancy rates, are prime examples, Dr. Plosker said.
From left, Dr. James Mayer, Dr. Ying Ying, Dr. Anthony Imudia, and Dr. Shayne Plosker.
“Egg freezing was still considered investigational until just a few months ago, and only recently has become accepted as mainstream treatment,” he said. “USF IVF has achieved pregnancies utilizing this technology. But there are still many questions to be answered before we will fully know where egg freezing and thawing will fit.”
One step at a time. Then repeat.
Shari and Adam Locascio went into marriage like most couples, with no reason to think they’d have problems having children. After waiting a couple of years before trying to have baby, their approach was “let’s just see what happens.” One year ticked by. Then two years. No baby.
“Something isn’t right,” Shari recalled them thinking. “Our doctor said there wasn’t a firm medical reason why I wasn’t getting pregnant so we decided to not waste any more time and just go with IVF. We told ourselves we’d give it a try and, if it didn’t work, we’d look into adoption.”
Their health insurance plan through Adam’s job covered IVF – most plans cover diagnosing infertility but only about 20 percent of plans cover IVF with a limited number of cycles and a cap of total costs – giving the Locascios the luxury of trying IVF with limited out-of-pocket expenses. For the other 80 percent of patients without IVF coverage, the cost for one cycle would run about $15,000, including fertility medications.
Shari and Adam began their IVF journey with another physician, but found his group didn’t provide the personal approach they wanted.
“We didn’t realize all of the emotions involved with this experience,” Shari said. “We didn’t feel we were getting the attention this kind of decision and process deserved and felt we were more of a number than in a relationship toward a very personal goal.”
The couple then met with Dr. Plosker and his team.
The USF Health IVF team. Front row from left: Christine Kilfoyl, RN, program manager; Joy Taylor, RN, IVF nurse coordinator; Farideh Aljallad, LPN; Shayne Plosker, MD, associate professor and Division director; Lucy Lam MS, lab associate; Marlene Bravo, RDMS, sonographer; Alison Rodriguez, RN, clinical IVF nurse; and Anthony Imudia, MD, assistant professor. Back row from left: James Mayer, MD, associate professor; Robyn Burke, MA; Ivette Irizarry, administrative assistant; and Ying Ying, PhD, embryologist, assistant professor. Not pictured is Dawn Smith, finance.
“He spent a lot of time with us and his team made all the difference,” Shari said. “They made me feel like I was their priority, like they all knew my story and personalized every visit, every phone call. It’s a very difficult situation. You have tons of questions, even silly questions, and they make you feel comfortable enough to ask anything.”
The Locascios’ first IVF try resulted in only one egg being retrieved and the pregnancy didn’t take. Dr. Plosker adjusted Shari’s medication, which resulted in 14 eggs being extracted in the next retrieval. Once fertilized, four viable embryos were formed: two were frozen and two were implanted into Shari’s uterus. But that pregnancy didn’t take either.
Faced with having to start over with a new cycle of medications for another attempt at egg retrieval and additional embryo transfers, Dr. Plosker suggested using their frozen embryos.
“Those pregnancy losses were very devastating for us,” Shari said. “We knew another full cycle might be beyond what we wanted to handle. We considered the frozen embryos as, perhaps, our last shot for a pregnancy to take.”
And take it did. Shari was pregnant with Dominick, she carried him to full term and in August 2011 he was born.
“We are so very blessed with Dominick and can’t thank the USF Health IVF team enough,” she said.
All smile for mom and son.
Taking the long view
Deciding to go with IVF might be the easiest part of IVF. It’s a road filled with emotion, hope, hard facts – and failure.
“The science is so advanced and we’re finding out more every day but, even in 2014, there is still a large percent of women for which IVF just never works,” Dr. Plosker said.
Having an honest conversation with experts helps bring all the emotions, numbers and hope into context, Kilfoyl said.
“We don’t sugarcoat anything, but we carefully tell women the facts so they can make good decisions,” Kilfoyl said. “We can’t give them false hope because, for some infertility cases, why spend money going down a road that only has a long shot when they could use that money for a more likely approach, like egg donation or adoption?
“That is part of the complexity of infertility as each woman’s history can be completely different. Some can have a great success and others will be at the ends of the bell curve. When you discuss this with patients, human nature kicks in because they will pull out what they want to hear. Our job it to make sure they hear the entire story – be hopeful for the positive outcome but be grounded and prepared for the negative outcome”
Shari’s biggest take-home message for others, she said, is that IVF takes time.
“We didn’t just walk in and have it work right away,” Shari said. “You have to be flexible with the overall plan, which can change mid-course as you try something else. Our journey took four years. But Dominick was clearly worth waiting for.”
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Story by Sarah Worth, photos by Eric Younghans, USF Health Office of Communications
