Alexander Quaas

Reproductive Endocrinology and Infertility, Reproductive Partners San Diego
  • Reproductive Partners San Diego
  • (858) 552-9177
  • United States of America

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Recent Comments

Apr 09, 2020

Hi Courtney,

The document states that "some facilities, such as those that provide only egg banking, are not required to report to SART or the Centers for Disease Control and Prevention (CDC) the outcomes of cycles using oocytes they cryopreserved. This lack of reported data also should be disclosed and explained to prospective patients."

The facilities mentioned are clinics that exclusively provide planned oocyte cryopreservation for women who wish to preserve their fertility. This is in contrast to clinics that offer planned OC as part of their services, but that also provide many other infertility services, such as insemination treatments, in-vitro fertilization (IVF), and third party reproduction services.

To make it more confusing, there are also "egg banks" which cryopreserve donor oocytes with the goal of rapidly providing them for prospective recipients of donor egg-derived embryos. The concept of egg banks allows multiple recipients to benefit from one "batch" of donor eggs (eggs derived from one stimulation cycle) and is described here: https://www.fertstert.org/article/S0015-0282(18)30578-8/fulltext  

(The current status of oocyte banks: domestic and international perspectives. Quaas AM, Pennings G. Fertil Steril. 2018 Dec;110(7):1203-1208. doi: 10.1016/j.fertnstert.2018.07.013. Review.)

Hope that helps a bit,

Alex Quaas 

Mar 20, 2020

This is an excellent summary of the ethical perspective of the COVID-19 pandemic with regards to its impact on IVF. As has been mentioned elsewhere, this is a situation where specific interests of a segment of the population are weighed against overall public health.  Potential benefits of treatments for a subset of patients are offset by their effects on morbidity and mortality of the entire population.  

In other words, the ethical concepts of patient autonomy and "do no harm" are clashing, and it is challenging to decide which one carries more weight.

As the pandemic is unfolding, it is becoming more and more apparent that a large number of people will be affected, and as a consequence many people all over the world will lose their lives due to COVID-19. Any measures proven to prevent loss of life should be taken, including deferring elective procedures if necessary, as hard as it may be for patients and providers affected.  

Mar 19, 2020
Replying to Alexander Quaas

These clinical recommendations during the COVID-19 Pandemic are extremely useful, and ASRM should be applauded for issuing these so quickly.

The core problem at the moment is that the extent and the consequences of the pandemic cannot be reliably predicted. It is possible that the current precautions may be necessary for prolonged periods of time. 

That produces very challenging ethical dilemmas in all areas of life, including the area of assisted reproduction.

In our societies, quests to increase survival and decrease morbity and mortality in the population have the unwanted effect of challenging people's economic livelihoods: many people will lose their jobs, many companies will go bankrupt, many restaurants, bars, theatres etc will not survive this crisis.

 Likewise, the quest to decrease medical risk to our patients and reduce morbidity in our "real" (already existing) and unborn patients has unintended consequences. A large proportion of our patients is right at the edge of a virtual "reproductive cliff" where waiting even a few months will result in decreases in ovarian reserve that make autologous conception impossible. It is impossible to know how many couples will remain childless because of Corona precautions, but depending on the length of the precautions it will be a significant number.

This raises the question: who decides when one risk is weighed against another? Is it up to professional organizations such as ESHRE / ASRM? Up to the doctor? Or up to the patient?

When the patient is given the choice, they may prefer to proceed with treatment while taking recommended (handwashing / social distancing etc) precautions, accepting the risk of Corona exposure and its unknown effects on pregnancy, because the risk of irreversible ovarian insufficiency is perceived as a worse outcome.

Doctors may feel similarly, and may be faced with the dilemma of weighing ethical principles of patient autonomy and "do no harm" against each other.

So should it be taken out of the hands of patients and doctors, and decided by professional societies such as ASRM / ESHRE?

If that is the case, then should the same logic apply to other recommendations such as elective single embryo transfer? Transferring more than one embryo exposes patients to the risk of multiple pregnancy, with the associated potentially devastating public health consequences. However guidelines are just a "guide", and doctors and patients can have educated discussions on how to proceed.

At what point does a "guideline" become a rigid unshakeable mandatory decree that needs to be followed by all doctors and patients? 

The next few days and weeks will tell. Until this unusual period of time, it seemed far-fetched that countries would implement laws to limit people's movement, impose curfews or enforce quarantines in exposed individuals.

All of us will be charged with the difficult task of weighing competing risks to our patients and make the best decisions for them. Staying informed and engaging in the ongoing discussion (for example on this "Dialog" site) forms the basis for evolving treatment recommendations and guidelines going forward.   

Thank you Luis. I sure hope that this crisis is short-lived. However given the projected pandemic dynamics that seems unlikely. In California there is talk about keeping schools shut for the rest of the school year. A vaccine may be available in a year. 

At what point can life return to "normal"? At what point can we provide unrestricted ART treatments?

What are the criteria that would allow us to ease (and not toughen) the restrictions put in place? As long as there are infected people and no vaccine available, I do not see the situation getting better, but worse...

I guess time will tell, and I hope you are correct that this is short-lived. [Not just for the sake of being able to provide REI care for our patients, but in general...] 

Mar 19, 2020

These clinical recommendations during the COVID-19 Pandemic are extremely useful, and ASRM should be applauded for issuing these so quickly.

The core problem at the moment is that the extent and the consequences of the pandemic cannot be reliably predicted. It is possible that the current precautions may be necessary for prolonged periods of time. 

That produces very challenging ethical dilemmas in all areas of life, including the area of assisted reproduction.

In our societies, quests to increase survival and decrease morbity and mortality in the population have the unwanted effect of challenging people's economic livelihoods: many people will lose their jobs, many companies will go bankrupt, many restaurants, bars, theatres etc will not survive this crisis.

 Likewise, the quest to decrease medical risk to our patients and reduce morbidity in our "real" (already existing) and unborn patients has unintended consequences. A large proportion of our patients is right at the edge of a virtual "reproductive cliff" where waiting even a few months will result in decreases in ovarian reserve that make autologous conception impossible. It is impossible to know how many couples will remain childless because of Corona precautions, but depending on the length of the precautions it will be a significant number.

This raises the question: who decides when one risk is weighed against another? Is it up to professional organizations such as ESHRE / ASRM? Up to the doctor? Or up to the patient?

When the patient is given the choice, they may prefer to proceed with treatment while taking recommended (handwashing / social distancing etc) precautions, accepting the risk of Corona exposure and its unknown effects on pregnancy, because the risk of irreversible ovarian insufficiency is perceived as a worse outcome.

Doctors may feel similarly, and may be faced with the dilemma of weighing ethical principles of patient autonomy and "do no harm" against each other.

So should it be taken out of the hands of patients and doctors, and decided by professional societies such as ASRM / ESHRE?

If that is the case, then should the same logic apply to other recommendations such as elective single embryo transfer? Transferring more than one embryo exposes patients to the risk of multiple pregnancy, with the associated potentially devastating public health consequences. However guidelines are just a "guide", and doctors and patients can have educated discussions on how to proceed.

At what point does a "guideline" become a rigid unshakeable mandatory decree that needs to be followed by all doctors and patients? 

The next few days and weeks will tell. Until this unusual period of time, it seemed far-fetched that countries would implement laws to limit people's movement, impose curfews or enforce quarantines in exposed individuals.

All of us will be charged with the difficult task of weighing competing risks to our patients and make the best decisions for them. Staying informed and engaging in the ongoing discussion (for example on this "Dialog" site) forms the basis for evolving treatment recommendations and guidelines going forward.   

Mar 19, 2020

Excellent and timely summary of the current COVID-19 situation, with lessons from the Italian experience.

The core problem at the moment is that the extent and the consequences of the pandemic cannot be reliably predicted. It is possible that the current precautions may be necessary for prolonged periods of time. 

That produces very challenging ethical dilemmas in all areas of life, including the area of assisted reproduction.

In our societies, quests to increase survival and decrease morbity and mortality in the population have the unwanted effect of challenging people's economic livelihoods: many people will lose their jobs, many companies will go bankrupt, many restaurants, bars, theatres etc will not survive this crisis.

 Likewise, the quest to decrease medical risk to our patients and reduce morbidity in our "real" (already existing) and unborn patients has unintended consequences. A large proportion of our patients is right at the edge of a virtual "reproductive cliff" where waiting even a few months will result in decreases in ovarian reserve that make autologous conception impossible. It is impossible to know how many couples will remain childless because of Corona precautions, but depending on the length of the precautions it will be a significant number.

This raises the question: who decides when one risk is weighed against another? Is it up to professional organizations such as ESHRE / ASRM? Up to the doctor? Or up to the patient?

When the patient is given the choice, they may prefer to proceed with treatment while taking recommended (handwashing / social distancing etc) precautions, accepting the risk of Corona exposure and its unknown effects on pregnancy, because the risk of irreversible ovarian insufficiency is perceived as a worse outcome.

Doctors may feel similarly, and may be faced with the dilemma of weighing ethical principles of patient autonomy and "do no harm" against each other.

So should it be taken out of the hands of patients and doctors, and decided by professional societies such as ASRM / ESHRE?

If that is the case, then is it appropriate to ask whether the same logic should apply to other recommendations such as elective single embryo transfer? Transferring more than one embryo exposes patients to the risk of multiple pregnancy, with the associated public health consequences. However guidelines are just a "guide", and doctors and patients can have educated discussions on how to proceed.

At what point does a "guideline" become a rigid unshakeable mandatory decree that needs to be followed by all doctors and patients? 

The next few days and weeks will tell. Until this unusual period of time, it seemed far-fetched that countries would implement laws to limit people's movement, impose curfews or enforce quarantines in exposed individuals.

All of us will be charged with the difficult task of weighing competing risks to our patients and make the best decisions for them. Staying informed and engaging in the ongoing discussion forms the basis for good treatment recommendations and guidelines, whatever they turn out to be.   

 
Mar 13, 2020

This "inklings" piece provides an interesting perspective on the topic of advertising in planned oocyte cryopreservation (pOC). It is the topic of this week's "tweetorial" on the official Fertility+Sterility @Twitter account (Follow @FertStert to see it).

The authors emphasize that physicians face the daunting task of providing adequate balanced counseling about pOC in the face of aggressive marketing and advertising by egg freezing companies, which may misrepresent medical facts.

This is very true and important. However I would point out that physicians are not always completely innocent in this context, and that some providers counsel their patients in biased ways in order to convince patients to undergo pOC. 

Brigitte Adams, the "poster child" of egg freezing in 2014, gave an impressive plenary lecture at the 2019 ASRM meeting, and warned that there would be a rude awakening for all the hopeful women who underwent pOC and were told that it would be a safe "insurance policy" to "stop the biological clock".

Physicians must protect patient autonomy by guiding "balanced, rational decision-making", as the authors of this article point out. They should also "advocate for women- and family-friendly government policies and employer practices". Hopefully the "call to action" by the authors of this inklings' piece will be heard. 

 

Dec 21, 2019
Replying to Alexander Quaas

Very interesting discussion on the ethics and regulation of add-ons in IVF. Since the birth of the new field of assisted reproduction, the rapid progress and evolution would not have been possible if every innovation had been subjected to a rigorous approval process - nobody could provide a guarantee that interventions that revolutionized the field (IVF / ICSI / donor egg-based treatments etc etc etc) would be completely "safe" and without harm before doing them. 

So it appears that progress in our field occurs via a combination of adopting promising new interventions while being prudent and following the "do no harm" principle as much as possible. Regarding add-ons, this means being open to adjunct treatments that may actually improve outcomes, while ensuring that no harm to the patient or the unborn baby is done, and while not making false promises.

Therefore the most important paragraph of this article appears to be "Informed consent when effectiveness is questionable". Prescribing androgens or growth hormone to a "poor responder" seems reasonable to me based on the available evidence - see review article on adjuncts in the same issue- as long as the patient is informed that these treatments are "off-label", still under investigation, and not proven to be beneficial beyond a shadow of a doubt (but showing promise in some studies).   

Absolutely. The editorial for this “Views and Reviews” section brings up the point that patients may be better off saving resources for multiple cycles, as opposed to spending more money on one cycle if the benefit of the add-on is questionable. Likewise, in an ideal world where resources are distributed more evenly, more patients should get access to “bread and butter” IVF, rather than a few privileged ones doing it with lots of expensive bells and whistles.

On the other hand, an IVF cycle is stressful physically and emotionally, and the dropout rate after one failed cycle is high, so it is worth maximizing success as much as possible (that’s why more research on add-ons is useful). And in certain patient populations, such as poor responders / DOR patients, it is feasible that certain adjuvants may represent the difference between live birth or no pregnancy. 

As you wrote, evidence based counseling is crucial, without preying on a vulnerable patient population.


Dec 19, 2019

Very interesting discussion on the ethics and regulation of add-ons in IVF. Since the birth of the new field of assisted reproduction, the rapid progress and evolution would not have been possible if every innovation had been subjected to a rigorous approval process - nobody could provide a guarantee that interventions that revolutionized the field (IVF / ICSI / donor egg-based treatments etc etc etc) would be completely "safe" and without harm before doing them. 

So it appears that progress in our field occurs via a combination of adopting promising new interventions while being prudent and following the "do no harm" principle as much as possible. Regarding add-ons, this means being open to adjunct treatments that may actually improve outcomes, while ensuring that no harm to the patient or the unborn baby is done, and while not making false promises.

Therefore the most important paragraph of this article appears to be "Informed consent when effectiveness is questionable". Prescribing androgens or growth hormone to a "poor responder" seems reasonable to me based on the available evidence - see review article on adjuncts in the same issue- as long as the patient is informed that these treatments are "off-label", still under investigation, and not proven to be beneficial beyond a shadow of a doubt (but showing promise in some studies).   

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