The Post-Standard, (Syracuse, NY)

May 5, 1998

IN VITRO BABY IS AREA'S FIRST-BORN FOR INFERTILE COUPLES, THE JOURNEY TO PARENTHOOD BECOMES A LITTLE EASIER.

by AMBER SMITH The Post-Standard

Central New York has its first baby conceived in a petri dish here.

The baby boy, Matthew, is five weeks old and healthy. His mom and dad owe parenthood to Dr. Robert Kiltz, a Syracuse gynecologist who offers in Central New York infertility services that couples used to have to travel to get.

Matthew's birth from in vitro fertilization comes as the state and others wrestle with the ethics tangled in the grab bag of new ways doctors are helping women have babies.

Is mom the woman who bears the baby, or the woman whose egg was fertilized? Who should pay for infertility treatment? Who owns an embryo? How many embryos should be placed in the womb?

A state task force released a 474-page report last week that suggests some answers to many complicated questions surrounding the field of "assisted reproductive technologies," but many issues remain unresolved.

Kiltz's patients, meanwhile, have their own personal issues to face. They learn that successful in vitro fertilization rates are low. They learn that insurance doesn't pay much. Slapped with the infertility label, they torment themselves with anger and guilt and frustration. But they do face one less roadblock - they don't face a medical commute to Rochester or Baltimore or New York City for treatment.

Kiltz has been in practice here for a year, caring for men and women who are infertile, medically defined as a year of unprotected sex without conception.

The parents of the baby boy - a couple from Auburn who don't want the world to know what they went through to have a child - are his first success story. He's following 15 other women whom he helped become pregnant.

Kiltz moved to Skaneateles from California after medical school, residency and a fellowship in reproductive endocrinology and infertility. He and his wife live there with their 9-year-old daughter. He's board certified in obstetrics and gynecology. But he doesn't have a track record here, so some gynecologists are reluctant to send patients to him, preferring instead to refer patients to established infertility centers out of town.

In his first 12 months of practice, Kiltz reports 17 pregnancies from 40 attempts.

He takes sperm from the man and an egg from the woman and places them in a petri dish to fertilize into embryos. He has tools to help the sperm fertilize the eggs, if needed, and to place the embryo into the uterus. That's called in vitro fertilization. Or he can place the sperm and egg into one of the woman's Fallopian tubes where fertilization then occurs naturally in a process called gamete intra-Fallopian transfer. This is called GIFT fertilization.

Kiltz is the only gynecologist in the area doing in vitro fertilization, but other gynecologists can prescribe medications to induce ovulation or do surgery to correct uterine or tubal defects, and urologists treat men with sperm abnormalities. The Health Science Center had an infertility program in the past, but didn't have any pregnancies. Interest and money faded in the late 1980s; efforts are underway to reestablish a program there.

Kiltz has a laboratory in his office, in a building attached to Community-General Hospital. An anesthesiologist is there during painful procedures, such as removing the eggs. An embryologist he recently hired handles the eggs. A liquid nitrogen cylinder holds frozen embryos and sperm, including sperm from a teen-ager undergoing chemotherapy that will likely render him sterile and embryos from couples who didn't want to place more than four or five in the womb.

He doesn't have a sperm bank, but he tells women where they can order it. They have it shipped to his office and come there for insemination.

Soon he'll offer egg donation. He'll buy eggs from women and sell them to other women. Those women will have the donor egg mixed with sperm and implanted.

Who is mom?

Like many emerging or ever-changing medical technologies, Kiltz's field is ripe with ethical and legal questions.

The state's Task Force on Life and the Law tried to come up with some answers, like who is the mother of an in vitro baby.

It's no longer specific to refer to a "biological" mother, because a child born through use of a donor egg really has two - a gestational mother and a genetic mother, said Samuel Gorovitz, professor of philosophy and public administration at Syracuse University and a member of the task force.

He said most states, including New York, don't have laws to specify which woman has parental rights, and laws are not consistent in other states. The task force recommends the gestational, or birth mother be the legal mother, but that needs to be made law.

It also recommends gynecologists consider the interests of the unborn child before helping someone get pregnant. Take a homeless drug-addicted woman who's HIV-positive with metastatic cancer, working as a prostitute.

"That's almost a cartoon," Gorovitz said. "Its utility is that the social responsibility and moral responsibility in a situation like that is to say no."

He said it would be unconscionable to reserve infertility services as a "privilege of the privileged."

Yet most health insurers exclude infertility services and the task force is opposed to making a law to force insurers to pay for coverage. Costs can easily top $5,000 per try for in vitro; much more if, as usual, repeated attempts are needed.

Consequently, though insurers may cover some of the costs of blood work, ultrasounds and medications, most people have to figure a way to pay for treatment on their own.

"If you smoke and get lung cancer, you will be covered. But infertility, by most insurance companies, is not considered a disease," Kiltz said. They'll pay for surgery to fix a blocked Fallopian tube, which costs $5,000 to $8,000 and leaves a woman with a 3 to 9 percent chance of pregnancy each month. But they typically refuse to pay for in vitro fertilization, which costs $4,200 to $7,000 and has a 14 to 32 percent chance of pregnancy each time.

Traditional health insurance is set up to cover treatment for diseases. Surgery to clear blocked Fallopian tubes falls nicely into that definition because the blockage can be caused by infection, and because the blockage can cause gynecological problems other than infertility.

Tia Patterson and her husband started trying to get pregnant in January 1994. For four years they politely deflected relatives' questions about when they were going to start a family. They got their hopes up each month only to be crushed.

They went through hormone injections, laparoscopy - a minor surgical procedure - two rounds of intrauterine insemination and two rounds of in vitro fertilization before they got the good news. They still don't know why they were infertile. They haven't tallied their portion of the bills, but they know their health insurance covered many of the expenses.

Patterson is a pharmacist at the Rite-Aid in downtown Syracuse. Before the ordeal, she planned on balancing motherhood with her career. Now she's planning to leave her job and devote herself full-time to her child.

"Kids are just trying to absorb this world. I don't think I ever saw that aspect of it," she said. "Parenthood is such a value that many people take for granted."

Patterson's husband, Francis, is a surgeon. So when infertility became an issue, his colleagues pushed them toward the infertility centers with strong reputations. She attended a seminar where Kiltz spoke, and she liked what she heard.

The first time in August 1997, Kiltz removed 18 eggs from Patterson. Mixed with her husband's sperm in a petri dish, six of the eggs fertilized. Two of the embryos died, leaving four.

Patterson, now 29, said she left from the insemination visit thinking she'd soon be a mother. "I have four inside of me," she recalled thinking. "How could one not work?"

She didn't get pregnant.

She waited two or three months and tried again.

This time, they didn't leave fertilization to chance. Kiltz's embryologist, Voyteck Polanski used a procedure called intracytoplasmic sperm injection, actually injecting sperm into the eggs to ensure fertilization. He did that to eight of the eggs. One fertilized on its own.

How many?

Kiltz asked the Pattersons how many eggs they wanted to implant.

The American Society for Reproductive Medicine has guidelines saying no more than three embryos should be placed in women age 35 or younger. The goal is to reduce the number of women who get pregnant with triplets, or quadruplets or more. A pregnancy with multiples is risky for the mother, and for the babies, who are more likely to be born premature.

The science of reproductive technology is working toward one egg, one embryo, one planted in the uterus, and one baby.

But it's not there yet.

For now, Kiltz said, "getting pregnant is an odds game." He thinks the couple, guided by a sensible doctor, should decide how to play.

"They're their embryos. It's their body," he said.

It was December. The McCaughey septuplets had just been born in Iowa. The Pattersons had a decision to make.

"You know what? We have no control over this," she remembers telling Kiltz. "Put them all in."

Weeks later, Patterson found out she was pregnant, and weeks after that she learned one baby was developing. There's no way to tell whether it was the embryo that fertilized without assistance.

She's due Sept. 10.

The first baby

The woman from Auburn gave birth to Matthew March 29.

She's 27. One of her Fallopian tubes was damaged, so the eggs her body produced weren't able to make their way through the tube where they would naturally be fertilized.

Kiltz removed 14 eggs from the woman in January 1997. Over three days in the incubator, sperm from her husband fertilized 11 of the eggs. Judging from symmetry and how much they had divided, nine of the embryos appeared viable. Kiltz planted four embryos, the size of grains of sand, in the woman's uterus. He froze the extras.

She didn't get pregnant in January, nor a couple months later when she returned to have the frozen eggs thawed and implanted.

In June, the couple started over again. Kiltz removed 16 eggs. Eleven were fertilized. Nine of the embryos appeared viable. The couple asked him to plant all nine.

"She was willing to take the risk of multiples," Kiltz said.

A few weeks later, a home pregnancy test showed a faint positive. The woman had received hormone injections that she feared could be causing the pink line. She called Kiltz.

"It's not from the shot," he told her. "Go up to the hospital for a blood test."

An ultrasound done in August showed twins, one of whom died two weeks later. Matthew was delivered healthy, by Cesarean section, March 29.

His mom and dad are already planning for a sibling, maybe a couple of years apart. "I'd like to give it another shot," the woman said.

The ethical issues

The state Task Force on Life and the Law this week released a report to improve legal and professional oversight of assisted reproductive technologies. Here are some of their recommendations:

Who is mom? Clarify legally that the child's mother is the woman who gave birth, as opposed to the woman who provided the egg.

Who pays? Reject legislation that would mandate insurance coverage for infertility treatment.

Reduce multiple births. Ask the American Society for Reproductive Medicine to set strict upper limits on the number of embryos to be transferred, to help reduce the birth rate of triplets and quadruplets.

Embryos. Make stealing an embryo a crime. Also, create regulations regarding the use of frozen embryos, and expand existing regulations that govern the screening of sperm and egg donors. Also, license and certify embryo laboratories.

Sperm donations. Prohibit the retrieval of sperm from dead or comatose men, except with advanced consent or court order. Also, require sperm banks to provide children with medical and genetic information about the donors when the children become adults.

Right of refusal. Realize that gynecologists are entitled to consider the welfare of the child who is born, and can refuse to help people whose behavior creates a high risk of pregnancy complications or of harming the resulting baby.

Infertility treatments

Many health insurers don't cover infertility treatments, but they may pay for blood work, ultrasounds or some medications. Here are the services offered by Dr. Robert Kiltz with his charges. Similar services are available in Rochester, Baltimore and New York City as well as other major cities. Other Central New York doctors provide evaluation and some limited treatments:

Fertility consultation - $200.

Semen evaluation - $100. Determines sperm volume, motility and count.

Intrauterine insemination - $150 to $300 per cycle. Includes washing and placement of sperm into uterus at the time of ovulation. This is done for couples with some sperm abnormalities, or for women who want to become pregnant with donor sperm.

Ovulation induction with medication and intrauterine insemination - $750 to $1,250, plus medication. This is for women whose bodies do not regularly release eggs. The medicine needs vary greatly but generally cost from $1,000 to $2,500. They may be pills or injections.

In vitro fertilization - $3,200 to $4,800, plus medications. Ovulation induction, plus egg retrieval, insemination and transfer of the embryo to the uterus. This is for women with damage to the Fallopian tubes, or who have been unable to become pregnant by other methods.

GIFT (Gamete intrafallopian transfer) - $5,200 to $6,820 plus medications. Ovulation induction, and then laparoscopic placement of the egg and sperm into the fallopian tubes, where they fertilize. A laparoscope is an instrument inserted through a small incision below the navel that allows the doctor to see the ovaries, Fallopian tubes and uterus. This is for men with normal sperm and women whose Fallopian tubes are normal.

ICSI, Intracytoplasmic sperm injection - included in the price of in vitro fertilization. For men with low sperm counts or motility, or previous fertilization difficulty.

Epididimal aspiration - $800 to $1,500. For men who lack the vas deferens that drain sperm into the urethra, urologists can surgical open the testes to draw sperm out.

Embryo freezing - $800 initially, plus $100 per year storage fee. The storage price climbs after the first year to discourage people from leaving the embryos indefinitely. Embryos are kept in a special liquid nitrogen container that has an alarm and backup power supply in case of power failure.

Embryo thawing - $500 to $870. Includes thawing and transfer using ultrasound monitoring.

Sperm freezing - $100 initially, plus $100 per year storage fee.