Kamrava Hysteroscopic Embryo Implantation - Your Comments

July 19, 2011

Comments from Specialists I heard from a reliable newspaper or television station that he implanted 6 and two of the embryos split into twins. Allen Worrall, RDMS Intra - endometrial implantation is evolving to be a superior method and Dr Kamrava deserves recognition for this contribution but......if hysteroscopic embryo implantation is supposed to be 70% more effective than the "blind technique", why then would Dr Kamrava aim to obtain 8 pregnancies??????George Haber, MD Regardless of the media hype and not knowing the inside story of why so many embryos were implanted, we have apparently a high success rate technique with zero ectopics, this is worth considering. Let's separate science from entertainment.Mario E. Domenzain, M.D., F.A.C.O.G. What we so far know about implantation is that it is a very complex process, where a sequence of events happens with a very delicate synchronization (selection of the site of implantation by Selectin molecules which help the blastocyst "roll" to the right spot, MUC-1 repelling it from the "bad" ones, chemokines and cytokines -LIF, IL-1. Integrins- attracting it, adhesion molecules attaching it to pinopodes, to cite a few). I doubt that forcibly "implanting" an embryo into a self-selected spot in the endometrium could really improve pregnancy rates; it is bypassing the natural selection process (for example: embryos do not "take" on endometrium without pinopodes either because of poor timing or because of endometrium defect).  Hysteroscopic embryo implantation might reduce the rate for ectopic pregnancies. But unless the hysteroscopic process in itself stimulates the release of these molecules on the spot (like the repeated Pipelle might be doing???), it should not improve the overall pregnancy rate. I of course -and all my IVF team in Jerusalem, where we do see several very religious women "pushing" for many children!!!, cannot agree with replacing 8 embryos by ANY type of woman (especially if she is young and proven fertile !!!!) Dr Hava-Yael Schreiber, M.DOB/GYN and Fertility specialist Zir Chemed Medical Center and Bikur Holim Hospital, Jerusalem Roberta and friends, There has been such a media frenzy about this, and for good reason. While any licensed practitioner is theoretically entitled to their own opinion about procedures, standard of care dictates the concept of evidence-based medicine, i.e. do no harm and do what is reasonable based on the best interpretation of peer-reviewed medical literature. When Dr. Kavarna gave this interview awhile ago, perhaps he had a hypothesis that hysteroscopic assistance of embryo transfers would aid the success of implantation. To my knowledge, he hasn't proven the value of this technique, nor has anyone else. And in fact, the standard of care has become ultrasound-assisted embryo transfer, which is hardly a blind technique. In fact, many centers (such as ours) utilize echo-tip catheters which allow for excellent visualization of transfer catheter placement via abdominal ultrasound, especially when the patient has a moderately full bladder. Now as far as results, prospective patients who are looking into IVF, along with their physicians, should be strongly urged to evaluate data published annually online by the Society for Assisted Reproductive Technology (SART) at www.sart.org Although there is a lag in SART's ability to compile and post data, both patients and physicians can get an idea of who is doing what, practice-by-practice, and both nationally and regionally. Currently, the latest data listed on the SART website is from 2006, but I believe 2007 will be available soon. Most SART clinics have already compiled preliminary 2008 data but have not yet submitted, mainly because final results are not in yet for live births generated from 2008 cycles. Now, you asked about our data. And here is what I can share, which is available already publicly (2006) and will soon be available publicly (2007): For women under 35 using fresh non-donor eggs, the live birth rate per transfer in 2006 was 51.4 percent, and we transferred an average of 1.8 embryos for those patients. For that group, 22.2 percent had elective single embryo transfer. The overall implantation rate was 43.1% (see https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=2442 for the full summary) In 2007 for the same group, the live birth rate per transfer was 55.1%, and we transferred an average of 1.4 embryos. Approximately 60% of our patients < 35 had a single embryo transfer. SART calculates the implantation rate after the data is submitted, but I would estimate it to be around 45-50%. This trend towards "fewer is better" is again seen in our preliminary 2008 results. We had an abstract at ASRM in 2007 which also concluded this, based on the results we had at that time. There is so much focus these days on clinics that are doing a substandard job, I think it's time for the media to infuse some hope into those who could benefit from great fertility care, and by letting people know there are some centers that are exceeding national averages and have the data to prove it. There are many important factors that go into generating high success rates, and I'm happy to discuss this further with anyone in the media who might be interested. Regards to all,Ronald F. Feinberg MD, PhDIVF Medical Director Reproductive Associates of Delaware Suite 3217, Medical Arts Pavilion 2 4735 Ogletown-Stanton Road Newark, DE 19713 302-623-4242 FAX 302-623-4241www.ivf-de.org "The ethical, personal care that helps families grow." Dear Editor of Ob-Gyn Net: I was appalled and saddened when I heard that a physician had intentionally transferred multiple embryos into a woman who had already had a multiples birth. This showed very poor judgment, in my opinion. It is also contrary to the guidelines of SART for infertility clinics. Because of all of the potential problems for these ultra-light babies, now and in the future, it is against the ethical principle of justice or “community good”. I am sure the California Board of Medical Examiners will be looking into this and well they should. The public is rightly infuriated over this situation and should demand an investigation by the Board if it is not forthcoming. Even the old caution that doctors have tried to follow for centuries, “primum non-nocere”, first, do no harm, has been breached. This whole situation likely will result in new laws or requirements for REIs and clinics that specialize in infertility. Thomas F. Purdon, MD FACOG No need to apologize. Many of us were curious about this individual, and you gave us what you had. I didn't see it as flashy or trashy--it was a legitimate interview about a relevant topic. Remember, curious people want to know.Steven Nelson MDPhoenix, AZ Dear Madam: Greetings! The interview was done as if we are condoning this procedure. Maybe this is becoming a moral issue like doctors playing God. Yes the interview was done in poor taste the interviewer allowing himself to be manipulated. Thank you and more power.Dr. Ferry AnolinManila, Phillipines I think it sounds like a very innovative procedure that may improve outcomes. (Obviously using only 1 or 2 embryos) Ginger H. Riley

Comments from Specialists

I heard from a reliable newspaper or television station that he implanted 6 and two of the embryos split into twins.

Allen Worrall, RDMS

Intra - endometrial implantation is evolving to be a superior method and Dr Kamrava deserves recognition for this contribution but......if hysteroscopic embryo implantation is supposed to be 70% more effective than the "blind technique", why then would Dr Kamrava aim to obtain 8 pregnancies??????

George Haber, MD

Regardless of the media hype and not knowing the inside story of why so many embryos were implanted, we have apparently a high success rate technique with zero ectopics, this is worth considering.

Let's separate science from entertainment.

Mario E. Domenzain, M.D., F.A.C.O.G.

What we so far know about implantation is that it is a very complex process, where a sequence of events happens with a very delicate synchronization (selection of the site of implantation by Selectin molecules which help the blastocyst "roll" to the right spot, MUC-1 repelling it from the "bad" ones, chemokines and cytokines -LIF, IL-1. Integrins- attracting it, adhesion molecules attaching it to pinopodes, to cite a few). I doubt that forcibly "implanting" an embryo into a self-selected spot in the endometrium could really improve pregnancy rates; it is bypassing the natural selection process (for example: embryos do not "take" on endometrium without pinopodes either because of poor timing or because of endometrium defect).  Hysteroscopic embryo implantation might reduce the rate for ectopic pregnancies. But unless the hysteroscopic process in itself stimulates the release of these molecules on the spot (like the repeated Pipelle might be doing???), it should not improve the overall pregnancy rate.

I of course -and all my IVF team in Jerusalem, where we do see several very religious women "pushing" for many children!!!, cannot agree with replacing 8 embryos by ANY type of woman (especially if she is young and proven fertile !!!!)

Dr Hava-Yael Schreiber, M.D
OB/GYN and Fertility specialist
Zir Chemed Medical Center and Bikur Holim Hospital, Jerusalem

Roberta and friends,

There has been such a media frenzy about this, and for good reason. While any licensed practitioner is theoretically entitled to their own opinion about procedures, standard of care dictates the concept of evidence-based medicine, i.e. do no harm and do what is reasonable based on the best interpretation of peer-reviewed medical literature.

When Dr. Kavarna gave this interview awhile ago, perhaps he had a hypothesis that hysteroscopic assistance of embryo transfers would aid the success of implantation. To my knowledge, he hasn't proven the value of this technique, nor has anyone else. And in fact, the standard of care has become ultrasound-assisted embryo transfer, which is hardly a blind technique. In fact, many centers (such as ours) utilize echo-tip catheters which allow for excellent visualization of transfer catheter placement via abdominal ultrasound, especially when the patient has a moderately full bladder.

Now as far as results, prospective patients who are looking into IVF, along with their physicians, should be strongly urged to evaluate data published annually online by the Society for Assisted Reproductive Technology (SART) at www.sart.org

Although there is a lag in SART's ability to compile and post data, both patients and physicians can get an idea of who is doing what, practice-by-practice, and both nationally and regionally. Currently, the latest data listed on the SART website is from 2006, but I believe 2007 will be available soon. Most SART clinics have already compiled preliminary 2008 data but have not yet submitted, mainly because final results are not in yet for live births generated from 2008 cycles.

Now, you asked about our data. And here is what I can share, which is available already publicly (2006) and will soon be available publicly (2007):

For women under 35 using fresh non-donor eggs, the live birth rate per transfer in 2006 was 51.4 percent, and we transferred an average of 1.8 embryos for those patients. For that group, 22.2 percent had elective single embryo transfer. The overall implantation rate was 43.1% (see https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=2442 for the full summary)

In 2007 for the same group, the live birth rate per transfer was 55.1%, and we transferred an average of 1.4 embryos. Approximately 60% of our patients < 35 had a single embryo transfer. SART calculates the implantation rate after the data is submitted, but I would estimate it to be around 45-50%. This trend towards "fewer is better" is again seen in our preliminary 2008 results. We had an abstract at ASRM in 2007 which also concluded this, based on the results we had at that time.

There is so much focus these days on clinics that are doing a substandard job, I think it's time for the media to infuse some hope into those who could benefit from great fertility care, and by letting people know there are some centers that are exceeding national averages and have the data to prove it. There are many important factors that go into generating high success rates, and I'm happy to discuss this further with anyone in the media who might be interested.

Regards to all,

Ronald F. Feinberg MD, PhD
IVF Medical Director
Reproductive Associates of Delaware
Suite 3217, Medical Arts Pavilion 2
4735 Ogletown-Stanton Road
Newark, DE 19713
302-623-4242
FAX 302-623-4241
www.ivf-de.org
"The ethical, personal care that helps families grow."

Dear Editor of Ob-Gyn Net:

I was appalled and saddened when I heard that a physician had intentionally transferred multiple embryos into a woman who had already had a multiples birth. This showed very poor judgment, in my opinion. It is also contrary to the guidelines of SART for infertility clinics. Because of all of the potential problems for these ultra-light babies, now and in the future, it is against the ethical principle of justice or “community good”. I am sure the California Board of Medical Examiners will be looking into this and well they should. The public is rightly infuriated over this situation and should demand an investigation by the Board if it is not forthcoming. Even the old caution that doctors have tried to follow for centuries, “primum non-nocere”, first, do no harm, has been breached. This whole situation likely will result in new laws or requirements for REIs and clinics that specialize in infertility.

Thomas F. Purdon, MD FACOG

No need to apologize. Many of us were curious about this individual, and you gave us what you had. I didn't see it as flashy or trashy--it was a legitimate interview about a relevant topic.

Remember, curious people want to know.

Steven Nelson MD
Phoenix, AZ

Dear Madam:

Greetings! The interview was done as if we are condoning this procedure. Maybe this is becoming a moral issue like doctors playing God. Yes the interview was done in poor taste the interviewer allowing himself to be manipulated. Thank you and more power.

Dr. Ferry Anolin
Manila, Phillipines

I think it sounds like a very innovative procedure that may improve outcomes.

(Obviously using only 1 or 2 embryos)

Ginger H. Riley