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Evidence-Based Medicine

Evidence-Based Medicine Helps Patients Succeed

Given the significant changes to treatment protocols and technological innovation at Shady Grove Fertility over the past 25 years that have led to pregnancy and live birth outcomes practically doubling, you might wonder how such changes over the past 25 years have come about. The fertility care provided at SGF is built upon a foundation of evidence-based medicine. Due to this foundation, changes to protocols aren't always fast because hard evidence in the form of studies and research as well as protecting the best interest of patients must support such a modification. Ultimately though, this evidence will help us meet our goal, which is to provide the safest treatment for our patients that will lead to the greatest success for you, our patient.

One thing that speeds up the rate of change is our in-house research department, as mentioned above. With this team, SGF is able to participate in and lead groundbreaking studies that revolutionize fertility care. But evidence-based change doesn't happen in a silo. Our team of physicians collaborate with reproductive endocrinologists and scientists across the nation to analyze, author, and present research papers all aimed at improving patient outcomes. Together, these initiatives help SGF stay on the cutting-edge of advancements in the fertility field.

Getting More Out of IVF Treatment

Frozen Embryo Transfers (FET)

Fertility treatment can be complicated and expensive—two facts that no one debates. But if you could turn a single fresh IVF cycle into two, three, or even four—extending both your chances of success and your dollar—would you?

Embryo freezing has long been an option for patients. A medical breakthrough at the time, cryopreservation used a freezing method that called for the embryos to be slowly frozen. The resulting success rates however were subpar compared with a fresh IVF, making the treatment an inferior option, with live birth rates hovering around 30.5 percent per embryo transferred in women under the age of 35 at the time of freeze. The main benefit of cryopreserving embryos is that once frozen, embryos are suspended in time and may be stored long term without the decrease in quality associated with aging.

In the last few years, research and studies emerged regarding a new flash freeze technology called vitrification. This new freezing technology increased the survival rates of thawed embryos significantly, thus leading to greater pregnancy and live birth rates. Success rates when using frozen embryos increased from around 30.5 percent in 2004 to 47.4 percent in 2012.

Shady Grove Fertility has been in the forefront using vitrification technology for several years. As a result, patients with remaining high-quality blastocyst embryos can now flash freeze them to be used in subsequent FET treatment cycles nearly matching the success rates of a fresh IVF cycle. This increased success means that patients with remaining embryos can have a second chance at pregnancy that is equal to the first or have a second chance to have another child without going through ovarian stimulation, an egg retrieval, or the expense of a fresh IVF cycle.

In addition to offering more options for patients trying to conceive through IVF, improved freezing technology has also drastically changed the landscape of elective egg freezing, fertility preservation for oncology patients, and accessing donated eggs. Freezing unfertilized eggs in the past resulted in very low post-thaw survival rates, taking the option off the table for many women. Now, women looking to freeze their eggs either electively or prior to chemotherapy have that option, while women using frozen donor eggs no longer need to coordinate their cycles and locations with donors as seen in cycles using fresh donated eggs. In addition, women are no longer limited to the available donated eggs in their area as frozen eggs are being shipped directly to their local fertility center, providing more options to those using donated eggs.

Safer Outcomes for Mother and Baby

Elective Single Embryo Transfer (eSET)

"As many kids as you want, but preferably one at a time" is a motto shared by all of the physicians at Shady Grove Fertility. Decades ago, when IVF treatment was just getting started, the chances of multiples and high-order multiples (3+) was incredibly high, around 40 percent. We know now that there are many risks to both mother and child(ren) when there are two or more babies in utero at a time, ranging from prolonged bed rest and gestational diabetes for the mother to premature birth and neuromotor abnormalities in the babies.

Emerging research has resulted in technological advancements and a greater understanding of embryo culture. Through these advances, women now have higher quality blastocyst-stage embryos to transfer, which has caused pregnancy and live birth rates to nearly double to around 50 percent for a woman under the age of 35. The evolution of treatment has given physicians the opportunity to be more selective in the number of embryos transferred, giving patients the ability to have a healthy singleton pregnancy without hindering their chances of success. Shady Grove Fertility has been a leader in the success and safety with eSET.

By electing to transfer a single blastocyst instead of two in patients with a good prognosis, our data demonstrates that twin pregnancy, with its greater risk to mother and infants, can be nearly eliminated.

Greater Understanding of Fertility Potential

Anti-Müllerian hormone (AMH)

A few years ago, studies emerged confirming a breakthrough in evaluating a woman's fertility potential in the form of a simple blood test. Anti-Müllerian hormone (AMH) is a hormone produced by the small immature follicles within the ovary. The AMH level is indicative of the size of the pool of follicles that remain. Therefore, in conditions where there are many immature follicles, the AMH level is high. As a woman grows older and the pool of eggs decreases, the AMH level declines. Therefore, by the time a woman reaches menopause, AMH is undetectable.

Evaluating a woman's AMH level has proven to be the most reliable indicator of a woman's remaining ovarian reserve. As a result, at SGF we have added AMH as a standard test to determine a woman’s current fertility status when evaluating her for infertility. Unlike follicle-stimulating hormone (FSH) and other indicators of ovarian reserve, we can test AMH at any point in the menstrual cycle and the results do not vary from test to test, as seen in FSH testing.

We can also use AMH to evaluate not only a potential low response to stimulation medication, which is seen in patients with a decreased ovarian reserve, but also for a possible over-response. AMH is a better predictor of an excessive response than a woman’s age, body mass index (BMI), or FSH level. Should you have high AMH level, your physician will tailor your stimulation protocol accordingly to allow for the safest and most successful outcome. This insight has transformed the ability to individualize medication dosing and treatment plans for patients at a level that wasn't possible before.

Increasing IVF Pregnancy Rates

Progesterone Levels

In 2012, a study was published suggesting a correlation between a woman's progesterone level at the time of ovulation "trigger" and a decrease in resulting implantation and pregnancy rates. It was found that higher progesterone levels at the time of the “trigger" shot resulted in a decrease in successful cycles.

As a result, women found to have prematurely rising progesterone levels have the option to freeze all of their embryos and allow the progesterone levels to return to more normal levels, providing the embryo with the best possible environment for implantation. This two-step process of freezing the embryos following the fresh IVF cycle and then transferring during a FET cycle, allows you the optimal chance for a successful pregnancy.

While this option impacts a small percentage of our IVF patients, discoveries like this have helped all of our patients to have the best possible treatment outcome.

Our evidence-based approach to medicine supported by studies and research has allowed us to treat our patients with the most current and effective forms of fertility treatment. As a result, patients have increasingly safer and more successful options to consider when selecting the most appropriate form of fertility treatment.

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