Laura Martorello’s first IVF — in vitro fertilization — pregnancy was easy. So she thought her second would be too, despite her age of 48.
Instead, she says, her doctors at Baystate Regional Medical Center, were afraid she would miscarry. They asked her to come in weekly. “Every week, we had a doom and gloom conversation. One said, ‘I don’t think you’re gonna be here next week.’”
Martorello, who lives in Suffield, Connecticut, told them, “No — I’m having a miracle.”
She had faith it would work. “I prayed the rosary every day for a year before I did this.”
At 11 weeks, the doctors said she’d made it through the danger. But IVF, even decades after the first so-called “test tube baby” was born in 1978, is still unpredictable — as any pregnancy can be. One night not long after, she had a big scare. “I remember it was 5 in the evening. I was making dinner. And I had a big gush of blood.”
Naturally, she thought she’d lost the baby. But remarkably, it turned out everything was fine.
Martorello now is mother to two daughters, Antonia, 5, and Daniella, 5 months.
Martorello’s experience is in some ways typical in its ever-evolving state of uncertainty. IVF is, at best, a complicated process, for patients or doctors. It’s often the last stop on a wrenching roller coaster ride of treatments for couples who have trouble conceiving. On the other hand, it’s getting better, says Dr. Kelly Lynch, a reproductive enfdocrinologist at Baystate, based in Springfield, which boasts the only IVF center in western Massachusetts.
Still, the complex procedure requires several well-timed steps and precise manipulation on the part of doctors and lab technicians. The state of IVF practice is an ever-evolving combination of technology, experience and skill, and most of the advances of recent years have arrived not via new technology, but by way of experience and increasing skill.
These days, Lynch says, the numbers for Baystate’s IVF program are good. In 2013, its live birth rate for non-frozen embryo implantation was 36.4 percent for women under 35 and 15.2 percent for women ages 41 and 42, according to the Society for Assisted Reproductive Technology, which compiles data from clinics nationwide.
The 2013 national averages were live birth rates of 40.1 for women under 35 and 11.2 percent for women ages 41 and 42, though SART cautions that differences in patient selection, treatment approach and reporting make comparisons difficult.
Baystate’s emphasis, Lynch said, is on “giving couples a good chance of pregnancy and reducing rates of multiple births, a big problem in reproductive medicine.”
The rate of multiple births is higher with IVF because of its basic premise — the process culminates in the implantation of one or more embryos in a woman’s uterus, and when more than one of those embryos becomes a fetus, the result is twins.
It’s a long road just to get to the point of implantation, however. IVF patients begin the process with lots of drugs that stimulate egg production. Those eggs are taken directly from the ovaries, and combined with sperm in the lab. The resulting embryos develop in the lab for a few days, and those deemed most viable are implanted in the patient’s uterus. IVF is often used in cases of fallopian tube blockage, severe endometriosis, male infertility and age-related infertility.
When it comes to the last, the challenges of conceiving are hard to overcome, says Lynch. “Our success rates really drop off after the 43rd birthday.”
Such patients often use donor eggs, because the quality and viability of eggs drop steeply with age. Yet the uterus is not subject to the same decline, Lynch says.
Martorello came to Baystate Medical Center’s IVF program for reasons a little different than those of most people who seek help conceiving. She wasn’t after donor eggs, and hadn’t been diagnosed with any problems.
“I didn’t do it because of infertility,” said Martorello. “I’m single. I just didn’t have a man.”
Martorello’s age was still a significant factor — even perfectly healthy women in their 40s have much lower odds of conception, and their babies have higher rates of abnormalities. So after three unsuccessful insemination procedures, she underwent IVF.
She didn’t want the complications of using sperm from someone she knew, so she chose to use donor sperm. There was one major quality she wanted in a donor: “I chose an Italian, because I’m 100 percent Italian. I figured this is an opportunity to keep that 100 percent going.”
Unlike most people, she says, she wasn’t worried about intelligence, because she’s confident that’s covered — she holds a doctorate, and is a physical therapist in Hartford and former professor at American International College in Springfield.
Martorello was fortunate — both times she did IVF, the first attempt was successful. It’s hard to know whether such stories are due to luck, or if it’s evidence of IVF slowly improving. Improvements arrive via two routes, Lynch says. Over time, the skills of physicians and lab techs improve, and “what happens in the lab is the key to success in an IVF program.”
That’s because the lab staff controls the conditions in which embryos grow, aiming to reduce temperature variation as well as, Lynch says, “ambient gases and toxins in the air that might affect embryos.” The staff also helps doctors identify the embryos with the best chance of thriving.
They’ve learned that the way to determine the best embryos is relatively straightforward: “It’s morphological – just the way it looks,” Lynch said. “We sometimes call it the ‘beauty contest.’ ”
The beauty contest takes place at the blastocyst stage – when the embryo is a ball of 100 to 200 cells. At that point, she says, cells start transforming into different types, what will later become fetus and placenta. If that kind of transformation has begun, the chances of successful implantation are higher.
Because of improvements in choosing embryos, a major IVF trend is changing. Until recently, it was common to implant two embryos to increase the chances of success and avoid putting patients through another rigorous — and expensive — cycle. Now it’s common to transfer just one embryo into the uterus. “That single embryo transfer is moving into older groups now as well,” Lynch said.
The use of fewer of the embryos that come out of the process can lead to another issue for patients, one that isn’t as widely discussed as the main event.
Martorello’s second child is the product of fertilized eggs she saved the first time around; clinics freeze those which aren’t implanted. For Martorello and others, these frozen embryos raises ethical questions in the same realm as those of the abortion debate, about when life begins.
What do you do with “leftover” embryos if you believe life begins at conception?
Organizations exist, most of them affiliated with religious organizations, to help infertile couples obtain frozen embryos donated by others. Some couples choose to discard them, and others donate them for research. Some implant them when they’re unlikely to be successful. Martorello wasn’t satisfied with any of those options. “It’s an issue nobody really discussed with me,” she said. “I had three left. I’m very Catholic — I was not too happy about it. I prayed and prayed, and I spoke to my pastor.”
She chose to try for a second pregnancy. When the three frozen embryos were thawed, only one survived. That one became her second daughter, Daniella.
Though single-embryo implantation can increase the number of unused fertilized eggs, there’s a clear benefit: fewer multiple births result.
At first glance, multiple births may seem like a potentially good thing. “Many couples come to infertility treatments with frustration and desperation,” Lynch said, “and oftentimes they will see multiples as a desired outcome — they’ll think, ‘It’s a cure for infertility, and our family is complete.’”
But multiple births come with big challenges during as well as after pregnancy, she adds. “We’ve tried to educate patients that twins aren’t always a desired outcome. The goal should be a healthy singleton.”
Across the infertility treatment world, there are efforts to reduce multiple births. For insurers and the medical industry, there’s a clear benefit to singletons, she says — they don’t generally need as many resources or require the same level of medical intervention and monitoring along the way. For patients, there’s another benefit — singletons don’t endanger the health of the mother or child as often as multiple births do.
She adds that some insurers now require the implantation of one embryo at a time. Insurers are taking other steps that lower their costs, but also increase couples’ chances of conception. “Now some insurers require evidence that a couple has quit smoking before they can be eligible for treatment, and weight loss is required by some plans if there’s obesity playing a role.”
Massachusetts is one of only 14 states requiring insurers to cover IVF, but, according to the American Society for Reproductive Medicine, the particulars of those laws vary greatly among the 14. Those particulars matter a lot when it comes to cost — the national average, according the ASRM, is $12,400 per cycle. And for some patients, IVF involves additional steps that drive the cost far higher.
“IVF is the best, most effective treatment for infertility, but also the most expensive,” Lynch said. “Because of that, we usually try to offer couples less-expensive options first.”
In the absence of conditions requiring IVF, that usually means artificial insemination and fertility drugs.
As Martorello illustrates, not all IVF procedures are meant to address infertility. “More couples are delaying pregnancy because of careers or educational goals. So a lot that we see is age-related,” Lynch said.
Where and how we live may be contributing to infertility, too, she adds. “One of the other areas that we’re investigating along with (researchers at) UMass is environmental influences on infertility. There’s a lot of concern about environmental toxins.”
That includes things like phlalates, chemicals that come from plastic, which may cause changes to DNA.
It’s important to keep in mind how IVF success rates compare to rates of 100 percent natural conception, too. “Studies have looked at couple trying to conceive,” said Lynch, “and the rate of conception is anywhere between 25 and 30 percent in a natural cycle. We as humans are not in fact terribly fertile.”
For Martorello, IVF offered an alternative to other routes. “I always thought I was going to do adoption.”
Fertility treatment didn’t come cheap — “I calculated about $24,000 for Antonia, and for Daniella, $13,000” — but Martorello is clearly happy with the way things worked out. She recalls that it was her mother, Antonia, who died several years ago, who encouraged her to consider it. “She told me, ‘Laura, just try with your own body.’ ”
Martorello gave thanks to her mother for that advice when her first daughter was born. “I named Antonia after her.”
James Heflin can be reached at jheflin@gazettenet.com.