Short Wave - In Light of The Alabama Court Ruling, A Look At The Science Of IVF

Episode Date: February 26, 2024

An Alabama Supreme Court ruling that frozen embryos can be considered "extrauterine children" under state law has major implications for how in vitro fertilization, commonly called IVF, is performed. Since the first successful in vitro fertilization pregnancy and live birth in 1978, nearly half a million babies have been born using IVF in the United States. Reproductive endocrinologist Amanda Adeleye explains the science behind IVF, the barriers to accessing it and her concerns about fertility treatment in the post-Roe landscape.Read more about the science of IVF.Questions or ideas for a future episode of Short Wave? Email us at [e-mail] — we'd love to hear from you!See pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences.NPR Privacy Policy

You're listening to Shortwave from NPR. Hey, shortwavers, Regina Barbara here. Recently, the Alabama Supreme Court ruled that understate law, embryos are, quote, extra uterine children, end quote. So somebody can be held legally responsible if they destroy them. This ruling is on a wrongful death lawsuit involving in vitro fertilization or IVF, the fertility technique, which combines egg and sperm outside of the body. The case was brought by couples whose frozen embryos were destroyed in an accident at a fertility clinic in Mobile, Alabama.

Already in light of this ruling, multiple clinics and Alabama's largest hospital, the University of Alabama at Birmingham Health System, have paused some or all of their IVF treatments for patients. And lawmakers are introducing legislation to protect IVF treatment. And all of this talk of IVF, it has me thinking of a conversation my co-host Emily Kwong had with a real estate. reproductive endocrinologist based at the University of Chicago. We're going to meet Amanda Adelier. She's someone who helps people get pregnant. Amanda's specialty is in vitro fertilization, and it's been growing in popularity in the last few decades. The growth of IVF in particular has been exponential from just the very first IVF cycle that was successful in 1978 with Louise Brown until in 2020, at least,

in the United States, there were over 200,000 IVF cycles that were completed. Since 1985, almost half a million babies have been born using IVF in the United States. This technology has made it possible for so many more people to become parents. But that doesn't mean IVF is accessible to everyone. And Amanda has seen those barriers up close to. I would say number one, financial issues. Sometimes people don't recognize that they have fertility issues. There's also stigma.

Another one that's difficult is literally physically accessing clinics. So today on the show, Emily and Amanda get into the science behind IVF, barriers to accessing it, and one doctor's concerns about fertility treatment in a post-row world. I'm Regina Barber, and you're listening to Shortwave, the science podcast from NPR. Hey, we're back. Here's Emily and Amanda talking in 2022 right after the Supreme Court overruled Roe v. Wade. Years later, everything they discussed is still very much present and important. All right, we're going to trace the journey of IVF, and because we're shortwave, we're going to do it at

the cellular level. IVF, or in vitro fertilization, happens by getting some eggs and sperm together in the lab. But first, you have to get the eggs ready. That's step one, preparing the eggs through ovarian stimulation. A person who's going to do an IVF cycle will take injectable medications, similar to hormones that their brain typically makes in order to start the preparation process of the eggs. The medications prime multiple eggs to mature inside the body in little fluid-filled zaks called follicles. When it looks like the follicles have mature eggs inside of them, they'll take a final medication to make the eggs ready to be retrieved. And that's step two, egg retrieval. So a day or so later, the person with the eggs will go to the clinic to have the merriment.

retrieved, usually under some anesthesia. And then while there is sleep, we put an ultrasound in the vagina, and then a needle through the back of the vagina to the ovaries to remove fluid from each of those follicles and hopefully to get eggs from them. It usually takes like 20 minutes. Really? Yeah. Okay, so harvesting those eggs, it doesn't take so long. No, it's getting them to be ready, which is challenging. But once the eggs are out, there's an embryologist who's going to look through the fluid, find the eggs, and prepare them for fertilization. And that's step three, fertilizing the eggs, and step four, developing an embryo. These steps take place in the lab, where an embryo specialist uses sperm to fertilize the

eggs that were just retrieved, with the hope that an embryo develops a few days later. You can either plop sperm on top of the eggs, so 20, 50,000 sperm on top of each egg, and then let the sperm figure out how to get there, and one sperm will win, or you can actually find a single sperm. You can, like, cut off the tail and you can trap it, and then you can actually shove it into the egg. Okay, and Amanda, tell me more about this embryo development stage, like what it looks like? It's beautiful. It's beautiful. What do you mean? It's beautiful. That's what I love what I do. Oh, my gosh. So it starts, you know, when you fertilize an egg, it starts up as a single cell, and then that cell typically divides once a day on average. And so by the time it gets to be

about day five or six, we call them blastocyst because they'll have like a shell of cells and then also an inner cell mass of cells and then fluid in the middle. And I feel so fortunate because when I do embryo transfers, actually you get to see the embryo on screen. And like who gets to see you know, and like something's so early. It's amazing. It's like one of the best things that I get to do. And this brings us to the final step. Step five, the embryo transfer. That's when the embryo is actually moved from the lab into the uterus of the person planning to carry the pregnancy. And so we put a speculum in the vagina and a tiny, tiny little flexible soft catheter through the cervix into the uterus. And under direct ultrasound guidance on the abdomen, we can see where the catheter is.

And then an embryologist will bring in a smaller catheter that's loaded with the embryo or embryos. So we can't actually see them. but usually the embryologist loads little air bubbles around the embryo, and you can actually watch as the embryo is released, hopefully exactly where we want it. So, Madda, let's take into some of the reasons people have difficulty getting IVF. Like, it's a very advanced treatment option, but it's not available easily to everyone in an equal way. So what are some of the barriers to access? Yeah, we could spend all day talking about this.

So the biggest one, I think, by far, is the financial accessibility of IVF. Yeah, how expensive is this? So on average, it's probably somewhere between $15,000 to $20,000 per IVF cycle if it were to be self-pay. And so part of the issue is although the American Medical Association defines infertility as a disease, it is not covered by most insurance policies. And in fact, there are some states that have laws saying if an employer is in our state, you must provide infertility coverage. we call those mandated states, but that's a minority of the states in the United States. And it's a problem we need to fix.

Okay. So there's cost. What else is there? I think sometimes people don't even recognize when they have fertility issues. And by the time that they do, they're presenting much later when their prognosis is going to be poorer. And honestly, even as a medical community, I think that we don't always talk with patients about what their fertility goals are. And really it should be a part of a conversation you have with your primary care doctor on a regular basis. Like what are your fertility plans? When are you thinking about getting pregnant or when you think about having children? Do they need to be genetically related to you? Like just you don't have to know everything, but at least starting that conversation and then helping people recognize when

there's a problem, I think would do a lot. I think Sigma is an issue as well. It's hard to measure how much of an issue it is. But there are these concepts around. masculinity or femininity, which I'm putting in quotes, because I think it's all kind of very fuzzy and arbitrary, but around, you know, a virile man should be able to have lots of kids. And the definition of femininity is having all of these children. And A, that's not true. But B, infertility affects one in eight, one in seven couples, at least in the United States and probably globally as well. It's very common and people just don't talk about it. Wow. I didn't realize infertility was one in eight couples. One in eight, one in seven to one at one and eight reproductive

aged couples. Wow. So Amanda, given that, if you were to talk directly to a family that wants to pursue this but feel like there are so many barriers, what would you say to them and what would you recommend they do if they're wanting to start this, but honestly, just don't know how? Number one, what I tell my patients and I would tell anybody is, I'm sorry you're going through what you're going through. It sucks. You think that you were going to like, you had a vision for your life and now it's turning out to be quite different. I like to also say that because there are high rates of depression and anxiety in people that have fertility issues. And so the first thing you can do is educate yourself and find good advocates and health care partners. And it doesn't necessarily like to be a doctor.

it can be a mental health provider, speak to somebody in the medical field who can at least direct you towards a fertility clinic that might be able to help you. And then make that appointment. And in general, we say if you are under the age of 35 and you are having penile vaginal intercourse for one year or more, that's infertility. If you're 35 or older and it's been six months, you need to see someone. And if you're over 40, we usually say you should probably just see someone right away just because of the age-related decline in fertility anyway. Yeah. But so if that resonates with you, then it's time for you to see a fertility specialist.

So our last question is about the future of IVF. So in June, you know, the Supreme Court overturned Roe versus Wade, which granted people federal protection to an abortion. Do you have any concerns or do you get the sense that the fertility community has concerns about how this could affect IVF this ruling? I can tell you that my patients are concerned for a good reason because in some states they're either angling towards or have tried to define life starting at conception

when egg meets sperm and that definitely applies to people using IVF. And so I think there are going to be questions around, well, what does that mean if I have excess embryos? What are my choices for what I do with them? Generally, people might choose to discard them when they're done building their families, but that might not be possible. Maybe are people going to be forced to continue to pay storage fees for embryos are never going to use, or what happens to those embryos? We also take care of people with recurrent pregnancy law, so maybe they don't have issues getting pregnant,

but they have issues staying pregnant. And so in the early stages of pregnancy, between the time when you can detect pregnancy on a pregnancy test and before that first ultrasound, we don't know where the pregnancy is. We hope it implants in the uterus, but sometimes it might implant elsewhere. like in a fallopian dude, that's called an ectopic pregnancy. And globally, it's one of the major reasons that people of reproductive age who carry pregnancies die. Okay. If you're letting a pregnancy that should have ended earlier for health reasons go on longer,

it can affect the person carrying the pregnancy, possibly permanently. So from a patient perspective, I know that those are issues that have already been vocalized. And as a health care team, we absolutely agree with them. and we don't want that to happen. Keeping patients safe seems like such a motto for you in your work. Like at every single stage of the journey, as you've been talking this whole time, like patient care is like central to you. Absolutely.

I love what I do. Like when it works well, you get to send somebody off to really start this exciting journey. But in some cases, like the access to be able to have a termination if you really need it in a safe manner, that's a no-brainer to me. A huge thanks to Dr. Amanda Adelaier, reproductive endocrinologist at the University of Chicago. For resources on how to access and pay for IVF, check out our show notes. We've also got a link to a database that keeps track of almost all of the IVF cycles done in the United States. This episode was produced by Burley McCoy, and it was edited and fact-checked by Britt Hansen.

The audio engineer was Josh Newell. I'm Emily Kwong. You are listening to Shortwave. from NPR.