Deep Dive FAQ: How many eggs should I fertilize?

Author: John David Gordon, MD

From time to time I will take one of the FAQs from our new website and use this blog to discuss the question in more depth…this is one of those times…so here we go…

Patients considering IVF often ask me how many eggs do I think that they will get and how many should they fertilize. Those are excellent questions and I believe that all patients need to carefully consider what to do before jumping onto the fertility treatment treadmill…

In the world of IVF we are facing an ever increasing crisis caused by our inability to address the huge number of frozen embryos being created by fertility clinics. In our efforts to help patients we are contributing to the moral and ethical dilemmas faced by the very patients that we are so desperate to help.

This issue was one of the reasons that ultimately led me to make the big move from Washington DC to Knoxville. There is no way that we are ever going to be able to get ahead of this problem if we don’t address the decision making process that has led to the fertilization of so many eggs in the first place. It is hard to get patients to consider the possibility that having extra embryos could ever be a bad thing and yet time and time again during my 23 years of treating infertility I have seen patients agonize over what to do with their extra embryos.

The difficulty in making a disposition decision is not limited to patients who are religious or Christian or conservative. Once patients have a child following IVF their perspective on how they regard these extra embryos that are stored in liquid nitrogen tanks at their fertility clinic often shifts dramatically. These embryos are no longer nondescript clumps of cells…They are something more. They are something special. They are something unique.

At Southeastern Fertility we carefully discuss with our patients how many eggs to fertilize before the IVF process even starts. We offer both Natural Cycle IVF and Mini-Stim IVF as options to avoid the temptation of fertilizing too many eggs. In our Stimulated IVF Program we limit the number of eggs fertilized but are happy to freeze the extra unfertilized eggs for future use. If clinics fail to counsel patients appropriately then the problem will only get worse. A recent segment on the Today Show (and another featuring yours truly on local TV) highlighted this very issue and suggested that if we do not take steps to address this issue, then it is only a matter of time before the government decides to address it for us.

FAQ 24.  How many eggs should I fertilize?

Our recommendation to all patients is that they consider fertilizing only as many eggs as embryos that they are willing to transfer either now or in a future FET cycle. Since we are very comfortable with freezing unfertilized eggs we recommend that patients carefully consider this decision so as to avoid the difficulties inherent in deciding what to do with frozen embryos once a couple no longer wishes to use them to have additional children. Although the National Embryo Donation Center (NEDC) has matched thousands of donated embryos with recipients, there are estimated to be over 1 million frozen embryos stored in IVF clinics across the United States. At Southeastern Fertility we are committed to helping resolve the problem inherent in storing these embryos indefinitely by avoiding the creation of too many surplus embryos.

Stepping out in Faith

Author: John David Gordon, MD

Anyone who has been in my office can readily guess that I am a dog person and not a cat person. If you are a cat person, then you have my sympathies…Dogs have families and cats have servants. Making the decision to move to Knoxville was clearly a case of stepping out in faith. I am someone who is loathe to change toothpaste brands and who, much to my wife’s chagrin, always orders the exact same menu items whenever and wherever we go out for Indian food. So the decision to move was not insignificant. But sometimes making a leap is the right call (like moving to Knoxville) and sometimes making a leap can end up with you getting a bit of a surprise…

A few summers ago we adopted a second four-legged friend from a high kill shelter in South Carolina. Lucky was heartworm positive and his life had taken a turn for the worse since he had been abandoned by his former owners. Fortunately, he responded very well to medical treatment and was declared healthy prior to making the journey up to join our family.

Although we think that he may be a Goldendoodle, we really have no idea about his doggie DNA. He has shown absolutely no interest in swimming and after getting a bath to get whatever that black deer musk is off of him he now refuses to go anywhere near a bathroom!

But one thing that he absolutely loves is riding in the car. He sometimes sits in the minivan while it is in the garage in hopes that one of us will decide to take him for a spin. Since a boat is kind of like a car with no roof he quickly decided that tooling around on our boat was pretty awesome.

One summer day we were out on the lake and pulled up to the dock at the market to grab a snack. Lucky was happy to get back on land for a few moments to use the doggie facilities (nearest tree). Suddenly he realized that just 20 yards away there were a bunch of Canadian Geese. However, they were not on land. They were happily gliding around the end of the docks seemingly oblivious to Lucky. As we walked back to the boat he decided to check out the geese from a different vantage point. I walked with him to the end of the dock and we stood for a few moments watching the geese mill around about 10-15 yards away from us.

Then Lucky launched himself into the air and off the end of the dock. I have no idea what he was thinking… He hit the cold water and immediately turned back toward the dock…all hope of catching a goose quickly forgotten. As I helped him clamber up on the dock he seemed a bit embarrassed by the whole affair. However, his happy personality soon returned and he dried out quickly in the heat of the day.  He now clearly regards swimming as a near-death experience.

So what does this shaggy dog tale have to do with infertility? Well, on some level pursuing fertility treatment is a leap of faith. Our patients are making the assumption that there is a good egg, a good sperm and a uterus capable of carrying a pregnancy. We really wish that we had definitive tests to figure out if these assumptions are correct, but we do not.

AMH, FSH/estradiol and antral follicle count will predict responsiveness to fertility medications for stimulated IUI or stimulated IVF cycles. However, these tests will not predict who will conceive either with or without treatment.

Recently I had this discussion with a patient who was over 40 years old but with poor ovarian reserve as evidenced by her AMH, antral follicle count, FSH levels and previous response to fertility medications. I explained that the further use of medications was unlikely to improve her odds of success and that NC IVF probably made the most sense in her situation unless she was interested in Embryo Adoption or traditional adoption. I explained that NC IVF pregnancy rates per embryo transfer depend upon her age (which I cannot change) and are NOT dependent upon ovarian reserve.

Making that leap of faith is difficult. Sometimes you come up short…just like Lucky in his attempt to secure a tasty lunch of Canadian Goose….BUT sometimes the leap is successful. The only way to find out is to take a deep breath and take the plunge.