6. The Nevada Center for Reproductive Medicine, Reno
- Number of ART cycles and transfers in 2002: 281
- Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 52% (under age 35), 49% (ages 35-37), 38% (ages 38-40); there were too few cycles in women ages 41-42 to report the results as a percentage
- Is testing a new form of progesterone -- a hormone that helps sustain a pregnancy -- to see if it's better than the types currently available
- Has a successful donor-egg program; the 2004 pregnancy rate approached 70% for fresh embryos in women of all ages
- Arranges travel and sightseeing for out-of-town patients
Doctors can often tell by the quality of the blastocysts -- embryos that have been grown for about five days -- how likely a patient is to get pregnant. "But in some older patients who have repeated failed cycles, the blastocysts look beautiful," says Russell Foulk, M.D., director of the Nevada Center for Reproductive Medicine.
Dr. Foulk and other researchers working with the National Institute of Child Health & Human Development may have figured out what's causing the problem for at least some of these patients. They found that at the time of implantation, the blastocyst expresses much larger amounts of a protein called L-selectin than it does beforehand. If a woman's uterus doesn't have receptors for this protein, Dr. Foulk theorizes, the blastocyst won't attach. "I've started doing uterine biopsies recently and discovered that two of my patients lacked these receptors," he says. "One of them had nine unsuccessful transfers -- all with good-looking embryos."
Future studies may confirm that checking for the receptors should be part of fertility screening. If that happens, Dr. Foulk says, some couples may avoid repeated failed cycles. Rather, they could consider surrogacy or adoption from the start.
7. Presbyterian Hospital ARTS Program, Dallas and Plano, TX
- Number of ART cycles and transfers in 2002: 1,180
- Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 49% (under age 35), 38% (ages 35-37), 23% (ages 38-40), 12% (ages 41-42)
- Is studying whether antibodies in a woman's blood affect her ability to get pregnant
- Offers an incentive program for the transfer of a single embryo to patients (age 37 or under if using their own eggs) who have two or more blastocysts; 200-plus couples have signed up, and more than six in 10 have conceived on the first try
- Has a policy that embryologists, in conjunction with nurses or administrative staff, give couples trying IVF a daily status report on how well their embryos are growing
Since about 90% of genetic abnormalities are caused by the egg alone, doctors in the Presbyterian Hospital ARTS Program are studying the feasibility of routine analysis of polar bodies, which are formed outside the egg after fertilization. "These are waste products -- they degenerate within one to two days -- but they provide mirror images of what's inside the egg," says scientific director Marius Meintjes, Ph.D. "With them, we can look for genetic problems, passed on by the mother, that would make the resulting embryo less likely to implant or more likely to cause a miscarriage."
Why might it be more beneficial to do that than screen the embryo for genetic problems, especially when you can't detect abnormalities passed on by the father? The test has no chance of damaging the embryo, unlike pre-implantation genetic diagnosis, which requires the removal of a small piece of the embryo.
8. Florida Institute for Reproductive Medicine, Jacksonville
- Number of ART cycles and transfers in 2002: 832
- Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 44% (under age 35), 40% (ages 35-37), 33% (ages 38-40), 17% (ages 41-42)
- Cancels a low percentage of cycles, which suggests a good response to treatments
- Is one of a handful of centers that publish comprehensive results on their Web sites
- Has persuaded drug companies to donate medications for the institute's cancer patients who are freezing their eggs, saving each person about $3,000
When a woman doesn't conceive on her first IVF cycle using fresh embryos, she may be able to try again at about one-fifth the cost if she has embryos to freeze. The Florida Institute for Reproductive Medicine is a leader in freezing techniques, called cryopreservation. "Most of our patients get enough high-quality embryos to have one fresh and one or two frozen cycles, adding a great deal to their cumulative chance of conceiving at a reasonable cost," says Kevin Winslow, M.D., the center's director.
What the center has learned from embryos over the years has also helped them freeze unfertilized eggs for more than 200 patients, and they are continuing to study the technique to pinpoint the optimum environment for frozen eggs. "We have 33 babies born and nine ongoing pregnancies with this technique to date -- the most of any center in the country," says Dr. Winslow.
Egg freezing is an option for cancer patients who want to preserve their fertility or those who fear they will be too old to conceive before they're ready to start a family. "But we only do it for women 38 and under," says Dr. Winslow. "After that, the eggs aren't of high-enough quality to freeze."
9. Southern California Reproductive Center, Beverly Hills
- Number of ART cycles and transfers in 2002: 217
- Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 68% (under age 35), 56% (ages 35-37), 26% (ages 38-40), 21% (ages 41-42) (These numbers refer only to the practice of Hal Danzer, M.D.; occasionally, fertility centers provide the government with statistics based on the practice of individual physicians rather than the overall center.)
- Reported no pregnancies with triplets or greater in 2002 for women under 35 despite the fact that the live-birth rate for these patients was nearly twice the national average
- In 2002, performed 98 of its IVF cycles on patients who had at least two previous failed attempts
- Constructed a state-of-the-art lab with triple-gas incubators and a sophisticated air-filtration system to promote the best environment for growing embryos
Once a couple's embryos are ready, doctors put them in a woman's uterus, where the hope is that they'll implant -- a process called embryo transfer. "Most transfers are easy. But in about 10% of patients, pinpointing the placement of embryos is difficult because of the shape or position of the uterus," says Hal Danzer, M.D., a reproductive endocrinologist at the Southern California Reproductive Center (SCRC). The center is one of the few nationwide that use four-dimensional ultrasound for every transfer; it provides 3-D images in real time. A new SCRC study on more than 100 patients suggests the new technology does slightly increase pregnancy rates.
Another way the center makes transfers smoother: "Before every transfer, women are given the option of having an acupuncture treatment to help them relax," says Dr. Danzer. "Some research suggests that acupuncture helps improve pregnancy rates in women undergoing IVF."
10. Center for Reproductive Medicine of New Mexico, Albuquerque
- Number of ART cycles and transfers in 2002: 183
- Percentage of ART cycles from non-donor fresh embryos resulting in live births in 2002: 57% (under age 35), 55% (ages 35-37), 29% (ages 38-40); there were too few cycles in women ages 41-42 to report the results as a percentage
- Opened in 1986, making it one of the oldest fertility centers; at that time, there were approximately 40 centers in the U.S., compared to the more than 400 today
- Is one of five U.S. facilities collaborating on the development of quality-control measures in the analysis of sperm samples
- Boasts a 2002 live-birth rate of 72% for fresh embryo transfers from donor eggs, above the national average of 50%
Running the Center for Reproductive Medicine of New Mexico in a poor state that doesn't require insurers to cover infertility, Jim Thompson, M.D., focuses on giving patients value for their money. "My exam rooms and waiting areas have no frills," says Dr. Thompson, the center's director. "Instead, we try to keep our costs low and our success rates high."
He seems to be doing a good job at both: In 2002, the center's live-birth rate for women ages 35 to 37 using their own eggs was about 70% above the national average -- 55% compared to 30% -- though its price for a standard IVF cycle (not including medications) is $8,500, less than the typical charge. He also has stellar success rates for women under age 35 and those who are 38 to 40 years old.