Chat Transcript: US Father of IVF -Howard Jones, M.D.

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Howard Jones, M.D.:
US Father of IVF Chat Transcript

Welcome to the INCIID Celebrity Chat Series with Moderator Sherry Sontag. Sherry is a long time member and volunteer for INCIID as well as author of the best-seller "Blind Man's Bluff." Sherry has set up a series of Celebrity Chats for INCIID in the coming weeks.

INCIID Nancy: This afternoon please welcome Howard Jones, MD - known sometimes as the father of IVF in the United States.

INCIID Nancy: Welcome to INCIID. This is the first in a series of Celebrity Chats moderated by Sherry Sontag. Sherry is the best selling author of "Blind Man's Bluff -- a novel about Submarine Spying.

INCIID Sherry: Dr. Jones was the doctor for the first successful IVF in the U.S., back when it was free and experimental. He has been involved both scientifically and politically ever since. You can ask him questions about medicine, about scientific progress or about the political environment then and now.

bb: Dr. Jones, can you explain premature luteinization? Does an LH rise ruin the follicles? How long from LH rise to progesterone rise? Thanks!

Howard Jones MD: From the LH rise to the progesterone rise is very short, but the rise starts very low and it takes about five days to reach its maximum.

INCIID Sherry: Does it ruin follicles when it happens early?

Howard Jones MD: It does not ruin follicles but there is a little detail. If there is too much progesterone prior to ovulation, there is some evidence to indicate that this is harmful.

INCIID Sherry: is there a way to avoid this?

bb: My progesterone was 0.5 yesterday and my OPK was positive today. I did HCG at 9a.m. Will I make it to IUI tomorrow morning?

Howard Jones MD: This is inherent in a particular cycle and once it occurs it is difficult to avoid it in that cycle.

Howard Jones MD: I would not abandon the cycle on the basis of a .5 value.

bb: How can you tell if this is happening frequently?

Howard Jones MD: She will make it. Only by having a progesterone assay in a particular cycle in question. There is no way to test it except in the cycle under treatment.

bb: thanks!

excel: I am 46 years old and have been trying to concieve #1 for four years without success. Any chance without going to donor egg with today's technology? I'm unexplained except for age. Thank you!

Howard Jones MD: I would say at the age 46 the possibility is almost zero but not completely so. I cannot tell from the question wehther we are talking about with normal reproduction or with assisted reproduction, but there have been pregnancies reported later than 46 but they are very very very rare. With assisted reproduction I am unaware of any pregnancies occurring in a patient who carried to term at the age of 46. I am telling her that if she is comfortable with donor egg I would think she would be well advised to expend her emotional and financial resources in a donor egg.

excel: thank you!

INCIID Sherry: is there a better chance with donor egg than donor embryo?

Howard Jones MD: depends on entirely how old the egg was that formed the donor embryo. But we don't know what the age was that formed the donor embryo.

Campbell: Hi everyone! If I have a one time high FSH, is IVF of DIUI the best treatment to seek?

Howard Jones MD: Depends on how high FSH was. What is exact number?

INCIID Sherry: Dr. Jones, would you agree if there are other tests besides FSH that give a better idea of ovarian reserve?

Howard Jones MD: I don't think there is any test that is better than a basal FSH.

INCIID Sherry: And is one time enough to knock you out of the ball park?

Howard Jones MD: I would think that it deserves repeating to be sure.

INCIID Sherry: FSH will tell you if you things are bad, but a good FSH doesn't mean things are good either right?

bb: How high is high?

Howard Jones MD: Well there can be a number of other things that keep you from getting pregnant than the high FSH problem but the height depends on the laboratory. You must know the laboratory to give that answer. Most labs have a system which has a cut-off point at around 15 iU/liter. 15 and above is bad.

bb: If the cut off is 10 and yours is 13, is it all over?

Howard Jones MD: Not completely over but probabilities are greatly diminished Fri May 24, 2002 12:38:44 PM> I

karen m: What is your biggest piece of advice to women who are trying to "have it all" in terms of career and childbearing? I mean those that are choosing to delay starting their families and believe that IVF will be the answer when they are 40.

Howard Jones MD: I think the general advice is to understand that age is a major enemy of fertility, and to integrate that into your plan for a family. You must make choices. Would you rather be sure of a family or do you want to risk that in favor of your career? Each person must make this decision.

delia1: Just a comment. I have been a patient at the Jones Institute and will be there again late next week. Your staff are wonderful! Thanks for all of the hard work you do!

INCIID Sherry: is there an age where you can be sure of a family? An age to start by.

Howard Jones MD: If you are talking about individual where everything else is normal, husband, everything else, fertility begins to decrease around 20 years of age, but it doesn't serious decrease until the mid-to-late 30s---I mean 37 or 38. At that point, the curve changes its slope until it becomes zero in the early 40s.

INCIID Sherry: How early?

Howard Jones MD: It depends on the individual, and that's why it's important for the individual to understand what their ovarian age is as compared to their chronological age. And the most important single determination about ovarian age is the basal FSH. However, there are families where early menopause is common and this needs to be put in the formula if you are in a family with that situation.

kim_p: I have PCOS and my husband has borderline low counts/motility. IVF is a probability in our future. Is the ICSI procedure a good idea for us and are there any benefits/risks to having a child born using the ICSI process?

Howard Jones MD: I see no reason to use ICSI unless there is a male problem that can be overcome by ICSI. I don't think we have enough information. We would need to know the morphology. We would in that case need to know the result of special tests. If she does not need ICSI there is certainly no reason to use it.

kim_p: Like what tests?

Howard Jones MD: The hemizona assay which measures the ability of the sperm to attach to the egg.

ksenya: When do you think preimplantation genetic testing will be widely available?

Howard Jones MD: I think its widely available now for particular problems. Anyone who has a problem that can be tested by preimplantation genetic diagnosis, as for instance Tay Sachs disease or other genetically identified problems.

INCIID Sherry: do you recommend it for age related issues?

Howard Jones MD: no point in using it for an age related situation

lauramc: As the father of IVF, what is your view of today's cloning debate? Do you feel that you received the same kind of attention and criticism that current cloning advocates are receiving today?

Howard Jones MD: The current cloning debate arises from not understanding exactly what is meant by cloning. Reproductive cloning is, in a sense, a misnomer because reproduction in the ideal sense involves genetic contribution from both parents. Cloning does not do that. Cloning should be called twinning so that it is no substitute for normal reproduction. And I don't think would be widely used even it were available and safe to use which it is not at the present time. The debate about cloning now is very similar to, and reminiscent of, the concerns and debates which occurred 20 years ago when IVF was being introduced. There is a deja vu about this whole debate.

lost1: I have had two miscarriages. Testing showed a +cardiolipin antibodies (cardiolipin igm that is) and borderline protein resistant C. I am now prenant again---four weeks today. I am on baby aspirin and progesterone. suppositories -- 200mg BID. Is there anything else I should be doing?

Howard Jones MD: it would be risky for me to make a suggestion without the total pictures, but from little I know about this it seems she has had good advice.

INCIID Sherry: so you don't see anything lacking here?

Howard Jones MD: i would be hesitate to advise further without knowing more details which I think are inappropriate to display.

Mary Lou: I just wanted to say I did donor egg at the Jones Institute last year and now have 2 beautiful children who will turn 1 in 1 month. Thank you, Dr. Jones, for all your work.

Howard Jones MD: Thank you, Mary Lou.

nph39: I am almost 42 and my husband is 59. He has four healthy adult children with a previous partner but now has low count and motility. We've done three IVFs with first two being chemical pregnancies, and last got pregnant with identical twins but miscarried at eight weeks. No other problems. Highest FSH was 5-ish. Always ICSI and AH. Is it time to call it a day or is there more technology that can help us?

Howard Jones MD: The doctor cannot tell you when you have had enough. You must make that decision after gathering all the information you can. your doctor is much more familiar with the details of your case than I am. You must spend time with you and he with you and only you can make the decision of whether enough is enough. It is not hopeless. It's up to her circumstances, details which are not known to us, including her emotional resources, financial resources.

pattyc: Dr. Jones, when do you think egg freezing will become the norm?

Howard Jones MD: I don't know answer to that. There are a number of programs working on that including ours. When we will have the answer is unknown.

peggy jo: I am starting lupron on 5/28 for my fist IVF. I am 34 and have had two miscarriages. I have an 11 year old son. I feel menstruation coming and wonder if I can still cycle if my period comes before cycle day 21 blood work. And what are the chances of IVF working for age 34. I am cycling at NYU. My miscarriages were due to +apa, and I recently had septum removed from my uterus on 4/11. My RE thinks 10 years of infertility could have been caused by the septum..

Howard Jones MD: It's difficult to say without seeing an x-ray of uterus, but I see no reason why not at age 34 if other things are ok and if the septum has been removed. I should think her chances are reasonable.

peggy jo: Will I be able to proceed with IVF if my period comes before cycle day 21?

Howard Jones MD: If you have a period before cycle day 21, you will probably have to skip that cycle and pick up next one.

peggy jo: All pregnancies were natural. My son was born 7 weeks early 11 years ago, and then struggled with infertility for 10 years.

Howard Jones MD: You want to be sure of facts before going ahead.

INCIID Sherry: could the RE be right about the septum?

peggy jo: He removed it.

Howard Jones MD: A septum does not generally cause primary infertility. The septum generally causes miscarriages.

peggy jo: I had one miscarriage at 12 wks and an ectopic at 6.5 weeks.

Howard Jones MD: There's been a lot of discussion about whether this is important or not.

peggy jo: But I'm sure the miscarriage at 12 weeks was due to +apa.

Howard Jones MD: At 12 weeks it could have been due to septum and you would need to know whether the conceptus was examined, did it have a chromosome study and other things to be able to answer the question.

peggy jo: Yes, all was normal. I had a major bleeding episode at 6.5 weeks and then lost baby at 12.

Howard Jones MD: The bleeding episode could be associated with miscarriage problem/

peggy jo: An ultrasound showed baby was fine at 6.5 weeks. By the 12-week appointment the baby had died.

Howard Jones MD: That tends to point to septum being problem.

peggy jo: Okay, thank you very much.

Pookie3: I am 37, my husband is 26 (excellent s/a), our diagnosis is unexplained SIF, FSH is 2.4. I have had 2 IUI/Clomid so far --- 2 mature follicles at time of IUI. First IUI was a success, miscarried at 6 weeks, 2days; Second failed. I am starting a third IUI cycle next month but using Gonal-F instead of Clomid. My question is: I've heard you should give IUI at least three tries before switching to IVF because the first one worked. should I give it longer?

Howard Jones MD: I think three tries is a reasonable figure. It is true that some pregnancies occur on four or five IUI tries, but most people who are going to get pregnant from ovulation induction do so during the first three trials so that, as a general rule, one needs to seriously think about IVF after three failed trials.

sraj: I am 32. My RE said I have PCO, no cysts, but have facial hair and irregular cycles all the time. I got pregnant naturally in 1993, then conceived my son in 1997 on 100mg clomid. I have been trying to conceive #2 for 2 years. Two cancelled clomid cycles, three failed ovulation induction IUIs and two failed IVFs later, here I am. For PCO, my RE put me on metformin, 1700mg, and I 've been on it for two months now, responding great to meds. I need only two amps of Gonal-F to retrieve 15 eggs and 8 eggs. The quality seemed good -- No lining or husband problems. My FSH is very low - no other problems. My RE did not want to do AHA etc ...What could account for the repeated failures? What should I test for now, implantation-wise?

Howard Jones MD: I don't think anyone can answer that question. The history described is an extremely familiar one and the only thing we can do is point out the fact that persistence pays off.

INCIID Sherry: Test for more?

Howard Jones MD: I don't have history in front of me and can't answer exactly but from what I remember of history it seemed that she was pretty well worked up.

sraj: What causes implantation failure?

Howard Jones MD: No we cannot explain that. We generally think that human reproduction is inefficient because normally only one pregnancy occurs in every five exposures. This is average so that in some people it requires 10 exposures, in other people it requires one.

sraj: after 2 failed IVFs, how many more to try before giving up?

Howard Jones MD: This goes back to the question of when is enough enough and this is a very individual decision depend on many variables, including emotional and financial and other characteristics which are different for each individual.

yodster: I have a low FSH, we have done four IVFs. Each time we have done it the egg quality is vastly different. Is there a reason why this is so? We do IVF for male factor, by the way. Two of the four IVFs have been successful, but I have had so-so eggs three out of the four times. One time all the embryos stunted at 2pn. I was 29 at the time. I am just curious as to what causes egg quality to differ cycle to cycle?

Howard Jones MD: This is an unanswerable question. It goes back to the inefficiency of human reproduction with tremendous variables that express themselves sporadically and irregularly and I think we are observing that natural phenomenon.

INCIID Sherry: Can the ovarian stimulation affect this?

Howard Jones MD: Generally speaking, it's unlikely that stimulation, as generally practiced today, could do that. This is not to say that grossly abnormal stimulation couldn't be a possibility, but I think we are talking historically now and we are in an era where stimulation is quite satisfactory.

cindi: Hello Dr. Jones, I got pregnant with IVF using ICSI (even though No male factor) when I was 38 - I was a very low responder - even on a very high dose of injectables I only ended up with one embryo to implant - It did produce a healthy child.. Now that I am forty I am wondering if I should even bother trying this again- if I only produced one or two eggs three years ago and only one ovary responded. At forty I'm assuming my egg production will be even worse. Also just discovered that I am at high risk......

Howard Jones MD: You certainly are high risk, but I doubt if the possibility is she has got to judge whether she wishes to expend her resources knowing that the risk is high but not zero.

INCIID Sherry: the risk of failure?

Howard Jones MD: The risk of failure is very high but her chances of success are not zero.

INCIID Sherry: cindi... are you at high for something else?

Oh, I see--- high risk for breast cancer.

Howard Jones MD: That's a different situation.

cindi: two sisters diagnosed. I'm afraid of injectables.

Howard Jones MD: I think she has multiple issues that she needs to consider, and again I go back to my basic philosophy that she needs to sit down with her physician and hash over these various conflicting facts and she must come to a decision.

daj3198: I just have one question. Do the odds of success based on age depend on the egg quality?

Howard Jones MD: Yes.

INCIID Sherry: Over 42, is it better to try a more natural approach than IVF and if so what?

daj3198: Egg quality only or are there other factors too? Sorry for the 2nd question.

Howard Jones MD: Again it depends on situation . IVF cannot overcome eggs that are damaged by age.

INCIID Sherry: does IVF hurt more than it helps sometimes?

Howard Jones MD: I wouldn't say it would hurt--- just wouldn't help something damaged.

INCIID Sherry: Are there other factors other than egg quality.

Howard Jones MD: Of course there are several.

daj3198: I don't think that is my case - I had 3 pretty good quality eggs and I am only 30, would I stand a decent chance?

Howard Jones MD: Egg quality is certainly one of the most important. I would say if a person who is age 30 with three pretty good quality eggs would probably succeed with persistence.

INCIID Sherry: How can you judge egg quality? Isn't it sometimes media or lab?

Howard Jones MD: At the present time, the only available way that egg quality can be ascertained is by their appearance under the microscope

daj3198: Is it likely all 3 would implant?

INCIID Sherry: Can't media used, the stim, or the lab effect how the eggs look and behave?

Howard Jones MD: Of course improper media or other laboratory conditions can spoil a good egg.

INCIID Sherry: So egg quality can be subjective?

Howard Jones MD: If we are talking about the egg that is what is obtained immediately by aspiration and its quality is judged by the microscope. Now what happens to it after that can depend on lab condition, but these are pretty well standardized now.

daj3198: Can male factor cause the egg to not look too good once fertilization has occurred?

Howard Jones MD: This has been a debatable question and there is no clear answer. But in general, the thinking now is that immediately after injection the quality of the early developing conceptus is more related to egg quality than it is to sperm quality.

INCIID Sherry: But not entirely, right?

Howard Jones MD: That's a debatable point. We are talking about the first couple of cell divisions. You absolutely cannot tell that

bb: Does APA cause infertility? Do you use preovulation heparin? Do you have a maximum number of stim cycles for your patients? I've done a lot and I tend to get pregnant on natural cycles following stim cycles. Could the HCG or high estradiol prevent implantation and might recombinant LH be better for trigger?

Howard Jones MD: There are lots of different questions there. The maximum number of stim cycles per patient depends on factors that I have discussed--- namely the emotional resources of the patient and particularly what the cause of the problem is we are trying to overcome.

INCIID Sherry: Can high E-2 prevent implantation?

Howard Jones MD: High E-2 can prevent implantation. That's the basis of the morning after pill where there is high estradiol which does prevent implantation.

bb: like over 1000?

Howard Jones MD: Well at what day?

bb: At HCG.

Howard Jones MD: The E-2 varies on day to day basis --- over 5000 would be high. It doesn't mean anything unless you know what day we are talking about.

INCIID Sherry: At trigger.

Howard Jones MD: 1000 is a modest amount.

bb: Could the HCG itself prevent implantation or APA? Do you think recombinant LH will be used to trigger soon?

Howard Jones MD: HCG cannot prevent implantation if there is only one shot. If you keep giving HCG it would prevent it, but as normally used no. And the APA has been very controversial and the most current thinking is that it is unrelated to reproductive problems

bb: APA causes miscarriage, though.

Howard Jones MD: Very controversial subject - it used to be thought important. More recent thought is that it's doubtful.

sraj: Dr., a few questions: Does metformin have any positive affects for PCOS women doing IVF (fresh & frozen)? If so, what? Second, is it true that immune testing for antibodies is done only for women with repeated miscarriages, not someone having implantation issues? Third is it worth doing AH, though not tested for thick zona - and does medrol help in any way? What is minimum number of days to stimulate? Does it affect the outcome? I stimmed for 7 days and 9 days for each IVF.

Howard Jones MD: Metformin is current therapy. We used to be very interested in antibodies for implantation but the evidence did not show any relation. When there is a good indication they are probably helpful.

INCIID Sherry: Both AH and Medrol.

peggy jo: Wait? What is medrol?

INCIID Sherry: it is a steroid a lot of clinics use before transfer.

Howard Jones MD: Minimum days three or four.

Tash: I'm sure I know the answer to this already, but is there any way to do gender selection with IVF?

Howard Jones MD: there is no way to do it for absolute results except for preimplantation genetic diagnosis only done for health issues.

INCIID Sherry: Which is never done unless there is a health issue.

Sherry: What about microsorting?

Tash: Oooh, that's what I'm looking for...what is microsorting?

Howard Jones MD: It helps but is not perfect.

INCIID Sherry: Is the 90 percent female chance accurate?

Howard Jones MD: I have no way of confirming that figure which is the figure that is generally used.

mlfern: I am 41+3 mos. Just failed an 2 IVF cycle where everything looked fine except negative result.

INCIID Sherry: mlfern, are you asking your chances?

Howard Jones MD: They are very low but not zero.

mlfern: Questions: I have to blast made it to freeze but my doctor only gives me a 10 percent chance. Does this seem right?

Howard Jones MD: Low because of age. That seems about correct. Absolutely.

INCIID Sherry: but she should go for it

INCIID Sherry: INCIID would like to hear about the atmosphere of when IVF started in the US and how it compares to now, and where we go from here.

Howard Jones MD: its difficult to answer in a short time. However, the atmosphere for IVF now is very clear and there are essentially no problems. But 20 years ago there were many problems comparable to the discussion about stem cells and cloning. I believe the cloning situation will clear up---or rather should say the stem cell situation will---clear up if and when there is success with stem cell therapy.

INCIID Sherry: Thank you Dr.Jones and everyone here for making our event so successful.

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