Under Dr. Ellen Greenblatt’s direction, and with the support of the provincial government of Ontario, we will soon have access to public coverage of IVF in Ontario, allowing us to direct patients to this low-risk, highly effective treatment for all our patients.

There are many arguments in favour of public funding, from basic human rights to a reduction of long-term medical complications. Studies have shown that denying public funding is often more costly in the long run than simply offering it.

If you’re in a position to influence policy in your province, perhaps through your local MP, social media, or a professional organization, people will need some proof. Consider supporting your argument with reference to the following document from Alberta Health:

http://www.health.alberta.ca/documents/AHTDP-Assisted-Reproductive-Technologies-2014.pdf

I believe and hope that if funded IVF is recognized as a good idea for Ontario and Alberta, one day it can be recognized as a good idea for every province and territory in Canada.

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The government also reversed its recent move to cut funding for certain OHIP-covered fertility monitoring services (such as blood tests), which is a big relief for doctors and patients alike. It looks like those cuts are now off the table.

Read the government’s news release
Read the expert panel’s recommendations to the government

This is a big day for fertility care in Ontario — but there’s a lot of information we’re still waiting on.

We’ll keep this page updated with any information that comes in about the OHIP-covered IVF process, as well as answers to any questions you may have.

The post Important announcement: OHIP-covered IVF cycle to launch December 2015 appeared first on Fertility.ca.

(If you aren’t caught up, I recommend reading my post on the latest status of OHIP-covered IVF in Ontario.)

So far, all we know is that the expert advisory panel has recommended excluding women over 42, and severely obese women, from eligibility for this coverage — on the basis that they’re medically less likely to see success from IVF, and that IVF could be more risky for their health.

With the failure of Quebec’s provincially-covered IVF program due to ballooning costs, it’s not surprising that the panel is considering cost-efficiency.

However, this is also controversial news. Some experts believe excluding women like this could be unethical. (And, needless to say, heartbreaking and upsetting for women who find themselves ineligible for this free round of treatment.)

The advisory panel had more recommendations, but they won’t be released until sometime this fall. We’ll keep you updated here.

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However, many questions about the coverage were unanswered — and unfortunately, still haven’t been answered. Now that we’re creeping closer to the end of 2015, patients and clinics alike are getting antsy.

From Quebec’s slow rollout, we already guessed that a January 2015 launch was wishful thinking, but we had hopes for a summer launch. Indeed, a very strong source told us that we’d receive more specific direction about offering OHIP-covered IVF by July 2015.

Unfortunately, summer has come and gone, and we still haven’t received critical guidelines or instructions about delivering OHIP-covered IVF to our patients.

So I’m sorry to say that for the moment, the answer is: we still don’t know. But don’t lose hope entirely: a spokesman for the Ministry of Health recently said we’ll learn more about eligibility requirements this fall, and the OHIP-covered IVF program should begin “before the end of the year.”

We expect to hear more from the Ontario government in the coming weeks, and will keep you updated here.

The post It’s September 2015, what’s the status of OHIP-covered IVF in Ontario? appeared first on Fertility.ca.

My suspicion is that this comes down to two reasons. Financial, yes, but importantly, emotional: For all of us, the plan was to achieve pregnancy naturally. It is a difficult step to move the act of fertilization into the laboratory.

But, if it has been more than six months of trying naturally together, there are three situations in which IVF may make the most sense:

1. Sperm

Whenever male factor is present, couples may choose to try to maximize sperm quality. This could be done through lifestyle management, through vitamins to maximize sperm quality, through medication such as Clomid to maximize the stimulation of the testes, and through intrauterine insemination to deliver more sperm to the ends of the fallopian tubes.

But none of the above is as effective as doing IVF. This is because with IVF, we can bypass all concerns associated with count, motility, morphology, or obstructions related to previous vasectomy or a congenital absence of the vas. All are treated with a single procedure, by doing intracytoplasmic sperm injection, or ICSI. ICSI places the sperm into the eggs.

It is an extraordinarily effective treatment, as long as the sperm’s DNA can support a healthy embryo.

And so before doing IVF, you might consider getting a karyotype done to confirm normal genetics, and a DNA fragmentation assay of the sperm, if available, to ensure that the DNA being delivered is well packaged and likely to be easily handled by the eggs.

For these reasons, male factor subfertility may often be a serious frustration, but if sperm’s DNA quality can be confirmed, then your expectations for successful IVF can be very high.

2. Tubes

It’s rare that compromised fallopian tubes will be able to be reopened through a cannulation procedure, very rare. The reality is that IVF is a far more successful approach, because it simply bypasses the fallopian tubes. Pregnancy rates can often be superb for a couple facing a situation where eggs and sperm are of good quality, the uterine structure is healthy, and the maternal health is excellent. If it is just a mechanical issue – sperm could not reach the eggs – IVF is a bypass.

As noted, we can try cannulation, or sometimes, if tubes are only partially compromised, we will look to inseminations.

“Partial compromise” can be very difficult to diagnose. Imaging, such as sonohystogram and HSG (hysterosalpingogram) will routinely miss compromised tubes, and the gold standard of investigation – laparoscopy – is highly interventional and invasive. For that reason, we miss fallopian tube compromise with great frequency, and arguably the number one cause for unexplained infertility will prove to be tubal dysfunction. It is for that reason that unexplained infertility is often also well treated through IVF.

A major risk for tubal compromise is low-grade endometriosis, but any source of pelvic scarring, including pelvic inflammatory disease from a previous STD like Chlamydia, a ruptured appendix, or other bowel surgery, all are risk factors for tubal compromise.

3. High quantity of low quality eggs

This situation is more complex. Many couples, particularly when women are over thirty-five years, increasingly worry about egg quality.

On the face of it, IVF would not seem to be all that beneficial; simply placing a sperm inside the egg does not increase its quality. Ninety-three percent of first trimester losses are related to embryo quality, 90% of which come back to egg. So, egg quality is a serious concern in any fertility setting.

The advantage that IVF can provide is this: Numbers. With high-dose fertility drugs, instead of the two to four eggs we will often encourage people to have intercourse or inseminations with, we would be aiming for ten, fifteen or twenty eggs with IVF.

And so it is a numbers game: If egg quality is a concern, and egg quantity is high, then IVF has a superb chance of being more beneficial than any other therapy for the shear advantages that come when ten to twenty eggs are fertilized at a time. It is like one to two years of trying naturally all focused into a single cycle.

And so when is IVF less successful?

Arguably, IVF is less successful when none of the elements above are present: If egg quality is a potential concern, but egg quantity is low, with all other parameters being normal, then IVF is unlikely to be of great benefit. When the issue is related only to uterine structure or implantation, IVF is unlikely to be successful, and if the issue is related to the couple’s overall health, IVF is unlikely to be successful.

IVF, therefore, may be our gold standard of therapy, but it is not for everybody. Still, if any of the three diagnoses above apply to your situation, and it has been a number of months of trying with other means, then IVF may well be considered as a reasonable option.

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Sperm’s ability to fertilize an egg is dependant on healthy DNA. But some sperm are fragmented.

Healthy DNA is arranged in a double-helix spiral bound by cross-bonds resembling a ladder. DNA damage means the bridges become unstable or broken causing instability in the DNA ladder.

That instability is referred to as fragmentation or damage of the DNA. If there is a high amount, you’ll likely see a reduction in male fertility, poor embryo development and lower rates of implantation.

Scientific literature shows that the extent of DNA fragmentation has little relevance to the basic semen quality parameters (concentration, motility, morphology, etc.) For example, a “good” sperm sample with high concentration, motility and morphology doesn’t guarantee you’ll get pregnant if there’s poor DNA Fragmentation Index (DFI).

Why is DNA Fragmentation important in the assessment of male fertility?

The test (flow-cytometry or TUNEL assays) is used to count the number of sperm cells per sample that contain suboptimal, damaged or fragmented DNA.

What are the values and what do they mean?

DNA Fragmentation Index (DFI) is used to quantify DNA damage in the sperm. DFI is inversely related to sperm’s ability to fertilize an egg and produce a viable embryo. DFI of less than 15% in sample is considered optimal. DFI between 16-29% is considered to be good or fair fertility potential. Sperm with DFI over 30% is considered to have poor fertility potential. Although exceptions do exist, these percent ranges have been established based on numerous scientific publications over many years of research.

What does testing mean for our ability to conceive?

• More accurate assessment of semen sample quality
• May explain previous failed attempts to conceive
• Determine suitability for IUI versus IVF/ISCI
• Assessment of efficacy of medical intervention or treatment of infectious diseases to improve
• Ultimately improve fertility potential of the male partner

What are the causes of DNA damage?

We don’t yet know all of the factors that lead to DNA damage. Most common ones we do know are chemical/toxin exposure, heat exposure, varicocele, age, infection, smoking, alcohol, radiation or testicular cancer.

The post What is DNA Fragmentation? appeared first on Fertility.ca.

We can help you monitor your cycle – we can even make sure you have maximal fertility while taking medications – but we cannot complete a cervical or intrauterine insemination.

This could put you in the difficult position of being tempted to doing inseminations at home yourself. We cannot speak to the medical safety of doing so, or to the emotional risks of the parties involved, nor to the legal risks up to and including the child support implicit in the biological father’s participation.

What alternatives do you have?

Health Canada will approve known-donor insemination, when the sperm is frozen for six months in an approved setting. As noted above, the only approved setting in Canada is at ReproMed. You would need to contact them directly.

Unfortunately, your known donor may not match Health Canada’s criteria for suitability for known sperm donor. Under these circumstances, there is a special release called “DSSAP”. For example, if your potential donor has had homosexual relations, or is over the age of forty, then sperm could only be released through DSSAP. At Hannam Fertility, we do not work with DSSAP sperm, as it is not in our opinion a process regulated and approved by Health Canada. We can, however, forward your care to other clinics that may well be willing to provide this service.

Though we cannot support known donor sperm insemination, we are comfortable supporting your right to understand and maximize your own personal fertility through cycle monitoring and/or medications where necessary.

These, and additional, guidelines were put in place by Assisted Human Reproduction Canada (AHRC) in 2006, to enforce the Assisted Human Reproduction Act of 2004. However, the AHRC was wound down in 2012 in response to a 2010 Supreme Court of Canada ruling. Health Canada now administers the guidelines. Specific limits of jurisdiction continue to be debated and interpreted. These limits are of particular interest to people interested in third party reproduction (donor eggs, donor sperm, and gestational carriers). Since the legal restrictions to clinical care are not always straightforward, different clinics are responding differently. We believe we have a very conservative interpretation of the law that maximizes healthy outcomes for all parties concerned. If you have any specific questions about how the laws of Canada may impact you, you may want to speak with Sherry Levitan (416-784-1222) or Kelly Jordan (416-203-2899 x 29), lawyers with a particular interest in and experience with reproductive medicine.

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However, there are some logistical challenges limiting choice. There is only one Canadian sperm bank: ReproMed, based in Toronto.

To allow for a greater variety of sperm available to Canadians, Health Canada has allowed for the importation of non-altruistically-donated sperm. Including ReproMed, there are three organizations that import sperm, the other two are Outreach Health Service and CanAmCryo. At our clinic we endorse Outreach and ReproMed.

When you choose sperm, Health Canada recommends that women who have never been exposed to Cytomegalovirus (i.e. “CMV negative”) should choose sperm that is also CMV negative. We test for CMV status for all women considering donor sperm.

When you make a purchase you’ll be offered washed and/or unwashed sperm samples. We re-wash the sperm regardless. From our perspective, there’s no functional difference which sample you’d choose to purchase. We see equal pregnancy rates from either approach.

When doing donor sperm inseminations, we ask that women trigger ovulation (usually with Ovidrel), to ensure that the timing of insemination is ideal. We use one sperm unit per cycle.

We’ll provide you with information on the count of the sperm being inseminated, and the average motility. Using fresh samples as a reference frame, we like to see at least 5 million sperm in the washed sample with 80% or greater motility. We won’t always see these numbers with frozen-thawed sperm: you may have a reduced success rate.

The success statistics that support the donor-sperm program are available from your clinical team and can be individualized to your specific situation by your doctor.

Next post, we’ll be covering guidelines for known donors.

The post We’re considering using an anonymous sperm donor. How does it work in Canada? appeared first on Fertility.ca.

We cannot really comment on the necessity of the test. But we can say unequivocally: no procedure should hurt. With modern anaesthesia, there really is no excuse for it. For example, in your case, you could ask about misoprostol (to soften the cervix), Ativan (for you), and a local-freezing-spray for your cervix. The procedure itself should never stand in the way of your desire to become pregnant. Hope that helps.

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