Commonly Asked Fertility Questions

My husband and I like to smoke a joint once in a while. I have told him we have to stop if we want a baby, but he says that is not true. What is true? 

Though we do not like to get involved in disagreements among couples, this is a fair question that demands a fair answer. As we have repeatedly pointed out in recent issues of the VOICE, substantial evidence has been accumulating in recent years—especially since cannabis has been legalized in so many states—that today’s cannabis is much more potent than that of your parents’ generation. Consequently, you are likely consuming much more of the psychoactive component of cannabis (called delta9-THC). Indeed, THC does not only affect you and your husband, but also on the baby that you might eventually carry. 

THC is one of two so-called Phyto-cannabinoids in cannabis (also called marijuana). The other one is cannabidiol (CBD). From animal experiments, it has been known for quite some time that brain cells in embryos in utero already have the receptor for THC. Whether this substance, however, affects brain development at such early stages was unknown—until just recently, in an experiment involving a mouse model, where clear evidence was obtained that this is indeed the case.1 Ultimately, cannabis use by a pregnant person has been reported to lead to a newborn baby with low birth weight, preterm birth, and an increased chance of admission to the NICU.2 Researchers were also able to determine that many of these negative effects on the baby were due to changes in placental function of mothers who were using cannabis during pregnancy.3 

Regarding fertility, cannabis has been shown to cause adverse effects on males in reducing sperm quality as well a quantity.4 In female adolescent mice, cannabis depletes the ovarian reserve (i.e. follicle numbers).5 In short, you should definitely stop using cannabis as far ahead of planning a pregnancy as is possible. Your husband’s smoking is less dangerous to the baby, as long as he stays away from you while he smokes, so you don’t get exposed to second-hand smoke. But you can tell him that if he does continue smoking (especially if he consumes a lot), it may take him longer than usual to get you pregnant. 

References 

Verdikt et al., eLife 2023;12:RP88795 

Avalos et al., Am J Obstet Gynecol 2023; 27:S0002-9378(23)02034-3.doi: 10.1016/j.ajog.2023.11.1232.Online ahead of print. 

Metz et al., N Engl J Med 2023;330(22):2191-2199 

Hamed et al., Reprod Biol Endocrinol 2023;21:69 

Lim et al., Toxicol Sci. 2023;193(1):31-47 

I was told by my gynecologist that it is now possible to test embryos to determine whether they are at risk for diseases like diabetes or heart disease. Is this correct?

Your gynecologist is a little bit right—but a lot more wrong. They are right in that some laboratories and IVF clinics have started offering what is called polygenic risk scoring (PRS). This is a technique developed for risk scoring of adults to predict whether they are at increased risk for such diseases as diabetes and heart disease, which are both caused by a constellation of multiple genes. Such risk scores can only be calculated by a full genomic analysis of an individual. Even in adults, this testing is still considered “experimental,” and in embryos, as of this point, it has been declared inappropriate and even unethical (by a European genetics society and ESHRE, as we have previously discussed in these pages).                     

One U.S. center apparently offers this test to select embryos with blue eyes. The Wall Street Journal, on December 14, 2023, reported that a new startup company in San Francisco, California, called Orchid Biosciences, recently also started offering the test. This means that at least three to four genetic testing labs in in the U.S. are offering PRS.  

Since this test, like PGT-A, requires an embryo biopsy at blastocyst-stage, it requires IVF treatment. The CHR, for several reasons that we gladly will explain to couples, currently strongly recommends against using this test, unless you have a strong family history of a life-threatening polygenic disease at relatively young ages. Otherwise, the test is unnecessary and you will spend considerably more on an IVF cycle than you would otherwise, without ever even knowing whether the testing was right or not. What you, however, will have done, especially if you are no longer in your 20s, is reduce your chances of conceiving during your IVF cycle. So, not a good idea, in our opinion! 

References 

Gormley B. The Wall Street Journal, December 23, 2023. https://www.wsj.com/articles/startup-orchid-rolls-out-genetic-testing-service-for-ivf-raises-12-million-8c0753ad 

Our family is complete, but we have four embryos left and don’t know what to do with them. Can you help? 

This is not an infrequent question we receive from patients who have extra embryos left from IVF after achieving their desired number of children. We can indeed help you decide what you want to do with your extra embryos, but this is a very personal choice only you and your partner can make. 

Everybody who goes through IVF is usually asked to sign a written consent which, among many other important issues, addresses what patients want to happen to all embryos the cycle generates. In principle, there always are six potential options: (i) have the embryos transferred into your own uterus; (ii) have the embryos transferred into somebody else’s uterus, usually a so-called gestational carrier; (iii) have the embryos cryopreserved for future use, either by yourself or for other purposes; (iv) donate the embryos anonymously or openly (called a “directed” donation) to another infertile patient; (v) donate the embryos to research (not all IVF clinics can offer this option because they may not have research programs and/or the necessary ethical supervision required for such a process); and (vi) instruct the clinic to ethically dispose of your embryos.

Faced with these options, most patients will first use their embryos to build their own families. Most infertile patients will not have too many embryos left over; the more likely problem is not having enough. To have “leftover” embryos is, therefore, in many ways a lucky problem to have, even though it can certainly lead to a difficult decision-making process (as is carefully detailed in a recent Wall Street Journal article1). 

As a very active research center that also collaborates with several prominent research laboratories at universities in the U.S. and elsewhere, we at the CHR are always interested in receiving “leftover” embryos for research purposes. Because many IVF clinics do not have research programs and, therefore, do not have the administrative ability to dispense such embryos according to accepted ethical and research requirements to IRB-approved research studies, the CHR quite frequently receives inquiries from patients at other IVF centers who are considering donating their embryos, which we very much welcome. The CHR, indeed, offers a free consultation with one of our physicians whenever there is a patient who might wish to donate their leftover embryos—either to research or, anonymously, to another infertile patient. 

For three very distinct reasons, such consultations with physicians are very important. First, the gravity of this decision warrants a detailed reappraisal of available options with patients, reemphasizing all available choices to them all over again, even though they likely heard those before. Second, we feel ethically obliged to discuss the chance of later regrets. Third, not all embryos are suited for donation and, therefore, not all embryos can be accepted for such a purpose, though any such deselection is not necessarily indicative of poor embryo quality. 

Finally, the most sensitive personal as well as ethical decision is, likely, the anonymous donation of embryos to another infertile couple. The decision that such a donation may lead to delivery of a child, of course, means that the couple has another genetic child who will be raised by other parents. Such a circumstance can be difficult to imagine for many potential donors and, as the Journal article demonstrated, in selected cases some couples might insist that should there be birth, they would be given the opportunity to meet the child. The CHR does not accept embryos for anonymous donation to other patients with such conditions attached; the reason is not a lack of understanding the desire of donors to have contact, but the CHR’s inability to guarantee such access at later points. The CHR, therefore, accepts donation of embryos only if they are unconditional for the designated purpose.

As noted before, we welcome inquiries about embryo donations whatever the purpose. Please call the CHR at 1 (212) 994 4400 and tell our staff that you would like a free consultation with a CHR physician to discuss a possible embryo donation, either for clinical use in other infertile patients or for research purposes. 

References 

Dockser Marcus A. Wall Street Journal, December 26, 2023; https://www.wsj.com/lifestyle/relationships/adoption-invitro-foster-care-surrogacy-17400499.