This post continues our series of IVF case studies. Here in our 10th case, we discuss a couple with infertility due to endometriosis plus an immunologic implantation dysfunction (IID) who conceived twins through IVF. This couple had two leftover cryobanked embryos that they did not want destroyed. Instead they chose to donate them to adoptive parents. Our discussion focuses on the effect of endometriosis on IVF outcome and tackles some of the procedural and ethical considerations associated with embryo adoption.

Background
Jennifer and her husband, Jim, two very religious Evangelicals, presented to me in 2009 after six (6) years of infertility, wanting to have a baby. She was a 35 year-old normally ovulating woman, with patent Fallopian tubes, no pelvic adhesions, but with mildendometriosis (diagnosed through laparoscopy). Jim was a perfectly fertile male with normal sperm parameters. The couple had previously tried unsuccessfully, to conceive on their own for 4 years. After visiting an infertility specialist, she underwent three (3) cycles of clomiphene citrate and had four (4) attempts at gonadotropin-induced controlled ovarian stimulation (COS) with intrauterine insemination induction, without achieving a pregnancy.

Based upon the above history, it was clear that IVF treatment was required. The couple began the process of pre-IVF evaluation during which I found that Jennifer had an immunologic implantation dysfunction (IID) associated with antiphospholipid antibodies (APA) and Natural Killer Cell activation-NKa (as measured by the K-562 target cell test). I performed one (1) cycle of IVF using an agonist antagonist conversion protocol (A/ACP) to achieve optimal COS. We treated her APA with Lovenox, and her NKa with dexamethasone and intravenous Intralipid (IL).

Egg retrieval (ER) yielded twelve (12) eggs, eight (8) of which were mature (MII’s). ICSI was performed resulting is the development of four (4) good quality day-5 blastocysts. I transferred two (2) fresh blastocysts to her uterus and the IVF laboratory vitrified (cryobanked) the remaining two (2) blastocysts. Jennifer immediately conceived and at thirty seven (37) weeks gave birth (vaginally) to a set of healthy twin boys.

Addressing the Issue of Leftover Frozen Embryos
Last year, the couple presented at my office to discuss what to do with their cryobanked blastocysts. They did not want the embryos destroyed, but instead preferred to have them “adopted” out. Accordingly, they wanted to know what policies and procedures SIRM had in place to facilitate this process.

I informed Jennifer and Jim that for reason of protecting the future parents’ (as well any offspring’s) right to privacy, and in an attempt to avoid any future conflict of interest between the biological and adoptive parents, our policy is not to divulge the identity of the prospective embryo recipient couple to the biological parents. They were willing to accept this, but insisted on having a say in selecting the prospective recipient couple. They wanted any babies resulting from their conceived embryos to have a healthy support system and wanted them to be raised in a devout Christian religious setting such as their own.

I agreed to having them take part in the selection process, provided that the recipient couple could retain their anonymity. Since they were willing to donate their embryos free of charge, I agreed to provide my services in processing and transferring these blastocysts to the recipient couple, free of charge.

Jennifer and Jim helped select a recipient couple from a long waiting list of candidates. I screened, evaluated and prepared the female partner using estrogen/progesterone hormone therapy and transferred the two (2) thawed (warmed) blastocysts to her uterus. She conceived and is currently about 5 months pregnant with a healthy singleton boy.

About Endometriosis and IVF
The natural conception rate for healthy ovulating women in their early 30’s (who are free of endometriosis) is about 17% per month of trying and 80% per year of actively attempting to conceive. Conversely, the conception rate for women of a comparable age who have mild or moderate pelvic endometriosis (absent or limited anatomical disease) is about 3% per month and 40% after 3 years of trying. The reduced conception rate in women with endometriosis can, in large part, be attributed to one or more of the following:

1. Toxins in the Peritoneal Fluid: Women with endometriosis (regardless of severity) are believed to have “toxic factors” in their pelvic peritoneal fluid. These “toxins” reduce the fertilization potential of eggs discharged during ovulation. IVF, which involves extracting eggsbefore they are released, bypasses this effect. This, at least in part, explains why normally ovulating women who have mild to moderately severe pelvic endometriosis are about 5 times less likely to conceive per month of trying than women with infertility due to other types of organic disease. It also serves to explain why the use of fertility drugs, IUI, or corrective surgery in ovulating women with mild to moderate endometriosis hardly improves the chance of achieving a successful pregnancy.
2. Immunologic Implantation Failure: We have previously reported that about 30% of women with endometriosis show evidence of increased Natural Killer Cell activity (NKa). In such cases, selective immunotherapy with steroids and Intralipid can counter associated IID and lead to successful IVF many times. To be effective, Intralipid therapy must commence well in advance of embryo transfer.
3. Endometriomas: These are cystic lesions (often called “chocolate cysts”) within the ovary that result from the accumulation of altered “menstrual blood” produced by the endometrial lining. Endometriomas can activate the surrounding ovarian connective tissue (stroma), which can compromise egg development and quality. Thus, any ovarian endometrioma that is more than 1cm in size should, in my opinion, be removed surgically or through a simple office procedure called “sclerotherapy” at least 6 weeks prior to the IVF cycle.
4. Pelvic Scarring and Adhesions: Endometriosis and/or its surgical treatment can result in local scarring, which can compromise tubal function and egg pick-up by the Fallopian tubes.

About Embryo Adoption
Embryo adoption refers to the situation in which a woman receives embryos to which she and her partner have not contributed biologically. When one or both partners are infertile, donor sperm and/or donor eggs must be used if the woman is to become pregnant. Previously, adoption of a child would have been such a couple’s only option if donor eggs/sperm were not feasible. Now, however, prenatal embryo adoption can be an alternative to adoption of a baby or child. I perform these procedures because I believe that apart from the fact that embryo adoption occurs far earlier than baby adoption, there is otherwise little difference between the two processes.

Embryo adoption is a very sensitive issue. There is an enormous inherent burden of responsibility placed on the treating medical team to screen all candidate couples through thorough and meticulous clinical, psychological, and laboratory testing.

Most couples undergoing IVF who have a baby will choose to hold on to the remaining embryos in case they want to have another child later on. Many of those that know that they do not want another baby usually will prefer to have their left-over embryos destroyed rather than donate them to a recipient couple. Some would rather donate such embryos for scientific research or for the propagation of embryonic stem cells for medical treatments. Few are willing to donate their embryos for adoption by a recipient couples. That is why there are currently so few embryos available for adoption and why the waiting list of hopeful recipient couples is so very long.

It is also an undeniable fact that less than 1-in-10 couples seeking to adopt embryos will ultimately gain access to them. And because the best embryos are usually transferred fresh (leaving the poorer quality ones available for adoption), less than 20% of those who receive adoptive embryos ultimately end up with a baby.

Conclusion: In my opinion, Embryo Adoption provides a highly commendable solution to dealing with leftover cryobanked embryos. And to me, it is far less fraught with ethical dilemmas than is destruction of such embryos or even using them for scientific research. Unfortunately, so few adoptive embryos are available that the waiting list of recipients keeps growing.

Addendum: It is important to understand that IVF is an ART-Science blend and not all practitioners agree on the same strategies. Thus, in the final analysis, it is important, after discussion with your personal doctor, to follow his/her advice to the letter.