Dr. Gad Lavy is the Medical Director and Founder of New England Fertility, a non-hospital-based outpatient in vitro fertilization center in Connecticut. He has a wealth of experience in third party reproduction and it was an honor to have him on our Instagram Live to answer all our questions, yours, as well as ones he most commonly receives. We covered COVID-19 vaccine recommendations for patients, intended parents and gestational carriers, changes in the surrogacy process for international intended parents, testing and treatment for unexplained infertility, and decisions around treatment protocols and timing. Dr. Lavy also shared insight on egg freezing, egg donation (anonymous and directed), embryo testing, twin pregnancy, as well as fertility preservation following a cancer diagnosis and options for intended parents where one or both partners are HIV+. Watch the interview to learn more!
You can also check the Q&A below:
1. Do you require that patients are vaccinated prior to starting treatment?
New England Fertility does not require patients to be vaccinated prior to seeking their services. However, Dr. Lavy notes that, with very few exceptions, everyone should get the vaccine, and this is particularly important for women who are planning to become pregnant or women who are already pregnant. The CDC, FDA and ACOG all agree on this. He reminds his patients and gestational carriers that it’s one thing if you’re becoming pregnant yourself and you decide not to get the vaccine, but another thing entirely when you’re carrying a pregnancy for an intended parent. There’s an added responsibility, but even then the clinic cannot mandate – they can encourage the gestational carrier but will not mandate it. There are some intended parents who are fine with their carrier not being vaccinated. That said, and especially with the Delta variant, a pregnant woman has a higher risk of becoming sick with COVID and needing hospitalization. The COVID-19 virus does not cross the placenta so doesn’t cross to the baby but it can affect the pregnancy by increasing the risk of preterm labor if the woman is very sick. Even though there are some who are not willing to get vaccinated, there is the aspect of herd immunity that somewhat protects people who are not vaccinated. Still, Dr. Lavy’s recommendation is for everyone to get the vaccine.
2. Should I get the COVID-19 booster if I’m pregnant or planning a pregnancy?
According to Dr. Lavy, the answer to this question isn’t completely resolved, but some authorities are recommending it. There aren’t many studies about the booster and pregnancy, but in theory it shouldn’t be any different from the other COVID vaccines. Dr. Lavy recommends the booster to anyone who is planning a pregnancy and is eligible to take it, as well as those who are already pregnant.
3. How has COVID-19 impacted the surrogacy journey of international intended parents?
Dr. Lavy notes that the COVID-19 pandemic changed how the clinic works with international intended parents. Prior to the pandemic, male partners were asked to give sperm samples at the clinic. With the travel ban on, the clinic collaborated with other clinics in South America, Europe and Israel and patients could visit those clinics to freeze sperm and for related bloodwork. Dr. Lavy notes that now that travel restrictions have eased up, they’d still be keeping this practice as it’s much easier for patients and intended parents. Consultations take place on Zoom, which also saves intended parents money as they only need to travel to the US for the baby’s birth.
4. Does the clinic provide medical documentation in order to cross the border to travel for treatment?
Yes, the clinic provides all necessary documentation, but then it’s up to the Consulate involved if a visa is granted or not.
5. How does a new patient come well prepared for their first consultation?
Dr. Lavy notes that this is different for everyone – a same sex male couple already knows that this is how they are supposed to have their family, while a heterosexual couple dealing with infertility and loss is coming from an entirely different place. For many of these, egg donation and surrogacy is a last resort. Dr. Lavy shares that the first consultation focuses on educating patients about what the clinic does and ensuring they understand the details of the process. The first consultation is therefore about learning who the patient is, what they need and then showing them how it works. It’s about finding a provider they can trust and someone they can be comfortable with. Dr. Lavy adds that it also helps when patients send their history, treatments, etc., in advance.
6. For those with unexplained infertility, what should they expect and what tests are done?
Dr. Lavy admits that unexplained infertility is one of the most difficult things to handle because it’s very frustrating not knowing what the problem is, both for the patient and their doctor. Dr. Lavy utilizes a systematic approach to try to get all the information needed in a short period of time. It’s called an evaluation cycle and testing is done at different points in the cycle. Hormones, ovulation, the tubes and uterus, and sperm are all checked. By the end of the cycle, the clinic can have a better idea of what is going on. Dr Lavy notes that the most important thing is to have a treatment plan – it helps to know what will happen this month and the next, and then next steps if that doesn’t work. He finds this approach takes off a lot of the patient’s pressure and stress.
7. What is the routine protocol for new patients at New England Fertility?
Dr. Lavy and his team first gather all the information and then discuss treatment options. Depending on the findings, some patients will need ovulation treatment, others might need IVF right away. If nothing wrong is found, it then depends on what the couple wants – some prefer to do IVF right away while others are willing to go through each step consecutively. That basically consists of IUI for two or three months, and eventually IVF. While testing has improved considerably over the years, there are still around 20% of couples whose infertility remains unexplained. Dr. Lavy explains that in this case, it is up to the couple to decide what kind of treatment plan they’re comfortable with.
8. Since some procedures are time-sensitive, does New England Fertility provide services 7 days a week to accommodate a woman’s cycle?
Dr. Gad Lavy notes that yes, the clinic is open 7 days a week – he had to make this decision 30 years ago as it’s an important consideration.
9. How does the clinic modify protocols for advanced maternal age?
Dr. Lavy explains that this is still the biggest question of all: “as much as we’ve advanced in our ability to treat people with infertility, that’s sort of one obstacle that we still don’t have a solution for”. He continues that, in contrast to men, women only have a limited supply of eggs. While women go into menopause at around the age of 50, men continue to make sperm forever. Male fertility decreases slightly with age, but when a woman gets into her 40s, it becomes increasingly more difficult to get pregnant, takes longer, and there’s a higher risk of miscarraige and birth defects. Dr. Lavy observes that, historically, the age of the first period keeps going down but the age of menopause has not changed. Ideally, women do not wait although this is socially hard. Couples where the female is in her early forties who are trying to start a family should immediately go to their doctor for a fertility evaluation. Once there’s a choice of treatment, you may need to be a little more aggressive due to age – this usually means going to IVF right away, but even with IVF there can be challenges as the woman may not respond very well to drugs or egg quality is low. It remains a big challenge, but as Dr. Lavy explains, fertility clinics are trying new things, including: modifying the stimulation protocol and using a growth hormone and other drugs on a very low dose (using less drugs is better – overmedicating could have a bad effect on the eggs); and using platelet rich plasma (PRP), an extract of the woman’s own blood that contains some growth factors. Dr. Lavy notes that there are some very promising studies that show that when PRP is injected into the ovary, it increases activity, egg production and quality. At New England Fertility, they’ve been using this method for a good number of months with mixed results but some which were surprisingly good. Another technique the clinic is using is starting a new cycle right after egg retrieval, rather than waiting for one or two periods before trying again. Sometimes better results are obtained on the second run. There is also the option of egg donation, although this may be a hard switch to make and some couples would want to try other options first.
10. How long do frozen eggs last – what is their durable life?
Egg freezing has come a long way along the years. “The viability, the success with frozen eggs is essentially the same as it is with fresh eggs”, notes Dr. Lavy. The egg cell is the most difficult cell to freeze because the difficulty of freezing the cell is proportional to how much fluid is in that cell. The more water there is the more difficult it is to freeze because ice is created and the ice can damage the cell. In the past, slow freezing was used to freeze egg cells but this damaged the egg. Vitrification, or flash freezing, is the method used nowadays and this freezes the eggs effectively. As Dr. Lavy explains, in vitrification, the temperature is lowered from room temperature to liquid nitrogen temperature very very quickly. Because it happens so quickly, there’s no chance for ice to form and there’s basically no risk of damaging the egg.
Egg freezing is an option for women who are about to lose their ovarian function due to surgery or cancer treatment, to create egg banks with donor eggs, as well as for women who wish to preserve their fertility (known as social freezing). If a woman freezes her eggs now and asks to use them in 5 or 6 years’ time, they will be exactly as they were today. As Dr. Lavy notes though, this can be a double edged sword as it gives women a somewhat false sense of security as pregnancy is not a guarantee. To freeze eggs, a woman starts the IVF process but stops after the egg retrieval. Once the eggs are harvested, the clinic freezes them right away. When you’re ready to use them, you just thaw the eggs and complete the IVF process.
11. How many mature eggs do most people receive from egg donors? How many of these mature eggs fertilize normally?
The clinic will only accept women with above average ovarian reserve – the egg donor must not only be healthy and have good eggs, but they also have to have the ability to produce multiple eggs in response to treatment. The clinic screens women and will only accept those who have the potential to produce about 20 eggs. An egg donor has the potential to produce more but the donor’s safety throughout the process is important. Once the eggs are retrieved, they’re fertilized. The embryos are grown in the lab for almost a week up to blastocyst stage. This is a very simple way to identify the better embryos as some of them don’t grow or stop growing. Typically 30 – 40% of eggs don’t develop all the way to blastocyst. The blastocysts are then put through genetic testing. Chromosomes are checked and about 30-40% of these are usually abnormal. As Dr. Lavy explains, intended parents usually start with 20 eggs and usually end up with 4 – 6 genetically normal embryos. Each of these has an 80% chance of creating a baby. The number of children intended parents want is discussed during the first visit.
Is one round of egg retrieval (using donor eggs) enough for three children? Does the donor receive the same amount of money if a second retrieval is needed?
Dr. Lavy explains that the number of children you can have with one retrieval depends on the donor, but on average you can have 4 to 6 genetically normal embryos – “that’s almost always enough to have two children, and if you’re lucky, maybe a third”. This kind of assessment is done after the egg retrieval is completed and the embryos analyzed. The donor can be asked for a second round – most donors do come back, especially if it is for the same recipient. As for payment, the philosophy at New England Fertility is that donors are paid for their effort not their eggs, so they’re generally paid the same or a little more if they ask.
12. Do you recommend Co-Q10 for egg donors?
Co-Q10 is an antioxidant given as a supplement. Dr. Lavy believes everyone should take it as it’s a healthy, easy thing to do and has no side-effects. It’s recommended to men before they give their sperm, and women before IVF as well as donors.
13. What happens when a family member or friend offers to be an egg donor?
Dr. Lavy explains that this can potentially be a beautiful thing as intended parents feel more comfortable knowing their donor, their genetics and background. That said, Dr. Lavy notes that intended parents must be careful because in contrast to an anonymous donor, a directed donor will always be there in your and your baby’s life. For this reason, the clinic spends more time on psychological counseling for directed donors. As for criteria, the clinic has strict thresholds for donors but if the friend or family member does not meet them (age or AMH levels, for instance), this is discussed with the intended parents and still considered rather than ruled out. Legal counsel will be required regardless.
14. Should I take into consideration antigen found in blood work when choosing an egg donor?
Yes, if there’s anything specific to your case that may affect the pregnancy, you want to take that into consideration. As a clinic, Dr. Lavy explains that they have their standard workup which they then adjust to each individual case.
15. What is embryo testing? Is it safe?
Dr. Lavy explains that embryo testing helps increase success and lowers the risk of miscarraige. A few cells are taken from the part of the embryo which will become the placenta and these are genetically analysed. Genetic testing on a blastocyst is safe – at that point it’s a 200 cell embryo and only 3 to 4 cells are taken for testing. It does not hurt the embryo. The test provides a genetic profile for each embryo, including information on chromosome number so the clinic can identify if there’s an extra chromosome, or a missing one. The test also allows the clinic to identify smaller issues, such as breaks in the chromosomes, deletions with a little piece of the chromosome missing, and duplications and inversions. These are more subtle but can affect the outcome and health of the baby. While not everyone agrees with genetic testing, Dr. Lavy believes that anyone going through IVF, regardless of age, should have it done because it maximizes chances of success.
16. What if intended parents want twins?
As Dr. Lavy explains, there is a difference between women who are doing IVF and carrying their own pregnancy when they’ve never been pregnant before, and gestational carriers. “For someone who’s never been pregnant doing IVF, I think they should not have twins […] It makes the pregnancy high-risk with a significant risk of premature delivery and all the complications that go with that”. Surrogacy is different as the number one criterion for gestational carriers is that they have children and this allows the clinic to look more closely at their pregnancies, any complications, and how and when they delivered. Within a group of carriers, you can identify the ones who are better candidates to carry twins – there will always be a higher risk than carrying just one, but not too heightened. If intended parents would like twins, then they should find a gestational carrier who’s willing to carry twins and who the clinic thinks is able to carry twins.
17. How do you advise first time patients who come to you after a cancer diagnosis as to fertility preservation and next steps?
Each case is unique – Dr. Lavy works with the patient’s oncologist as some cancers are more hormone sensitive. Treatment and medication is adjusted to go around this. Ideally fertility preservation is done prior to starting treatment, but this is often difficult as everything happens very quickly. The fertility clinic works closely with the rest of the woman’s care team to identify the next best steps.
18. What should HIV+ patients who hope to build a family need to know?
Dr. Lavy notes that breakthroughs in treatment have been amazing. The priority is to pursue surrogacy safely for the gestational carrier. Dr. Lavy explains that the clinic works with HIV+ men and collaborates with the Special Program for Assisted Reproduction (SPAR), an international program designed to protect wives, gestational carriers and babies from becoming infected during fertility procedures that use sperm from men living with HIV. There are criteria to meet, levels have to be basically undetectable under treatment. They take a few samples and check that the samples are HIV-free. It’s a team effort and the gestational carrier is reassured that there is no risk of getting HIV from the embryo. Thanks to these developments, it is possible for HIV+ men to have children.
“Technological advancements have been incredible which means [….]that we can help more and more people have children. It may not be what you had originally imagined how you would have your family, but if you’re willing to take advantage of all these different options, including egg donation, including surrogacy, then pretty much anyone can have a child, almost. You have to keep an open mind and accept the fact that it may not happen exactly the way you planned for it to happen.”
We can’t thank Dr. Lavy enough for answering so many of the most common questions new intended parents have – to help them understand and feel more prepared for their journeys ahead. Learn more about Dr. Lavy at nefertility.com.