To receive the news from your physician that you may not be able to conceive and bear a child is just as devastating as the diagnosis of cancer, studies show. Those who face such a challenge endure the heartache of so desperately wanting children yet, for some reason, this natural and very basic human experience has been denied to them. If they choose to pursue treatment for infertility, theirs is an emotional rollercoaster journey that may or may not take them where they hope to go.
Fifteen years ago, Steffen Christensen, M.D. (B.S. Med. ’71), left his busy obstetrics-gynecology practice in Fargo to pursue fellowship training in reproductive endocrinology at the University of Illinois/Michael Reese Hospital in Chicago to acquire the expertise necessary to help people with reproductive problems.
“I felt that, if I didn’t do this, I would always have wished I would have,” he says. “We were seeing a lot of infertile patients and not doing a very good job” of treating them.
With support from his employer, MeritCare Health System, he invested two years of his professional life to complete the training that later, on his return to Fargo in 1994, distinguished him as the first obstetrician-gynecologist subspecialist in North Dakota. Stephanie Dahl, M.D. ’99, whom he mentored as a student, joined him last June at the MeritCare Reproductive Medicine Institute (RMI). The RMI opened in January 2006.
“I was always planning to do general obstetrics-gynecology,” says Dahl, who is originally from Bismarck and, as a medical student, received the Humanism in Medicine Award. During her years in medical school at UND, “Dr. Christensen talked to me about it (reproductive endocrinology, RE).”
Practicing obstetrician-gynecologists in North Dakota
(52% are UND alumni)
During residency, she took a rotation in RE and “fell in love with it. It’s a very specialized field, with a very select group of patients,” she says. Only 25 to 30 physicians complete training in this field annually, and “I know all of them.”
“Being able to help a couple achieve a family or build a family” is most rewarding, she says. “I have two little boys who mean the world to me.” She and her husband, Joel Honeyman, who works at the Bobcat Co., are parents to Grant, 4, and Jackson, 16 months.
After four years of residency training at St. Joseph Memorial Hospital, affiliated with the University of Michigan, in Ann Arbor and three years of fellowship training at the University of Cincinnati, the family is finally settled back in North Dakota.
“I am thrilled to be home and back in Fargo,” she says. “It’s great to work for Dr. Christensen; he’s truly a mentor.”
“She’s our new star,” says Christensen, associate professor and vice-chair of obstetrics-gynecology and assistant dean for student affairs, Fargo. “And it only took nine years to get her here!”
Giving up obstetrics was probably the toughest decision for her, he comments. “She rotated with me as a student. She’s the first one we’ve convinced to come back here.
“We’re pretty lucky at MeritCare; most of our OBGYNs are grads of UND or are from North Dakota.”
Their practice delivers personal care
The reproductive endocrinologists have what Christensen calls “not a very big practice; we remember most of the patients” who’ve come to the institute for help. They handle about 125 in vitro fertilization (IVF) cases each year, and have about 500 on-going patients.
“Most of the patients are on medications,” he explains. “Only about 12 to 15 percent will require in vitro fertilization.”
Physicians turn first to oral medications to treat infertility because they are cheaper, easier to administer, cause fewer side effects, and are not as invasive as the IVF process. Certain types of surgery also may be used to solve infertility problems such as fibroids that must be removed or endometriosis. IVF is considered a last resort.
Christensen estimates that, annually, at his clinic “about 50 couples go through IVF one time and do not see us again. Another 100 couples go through IVF two times, and about 50 go through it three times.”
The best part of his practice is seeing the successful result of all the careful work he and his associates have gone through with the patients, he says. “I like seeing the babies when they bring them back.”
The toughest part of his practice is “having to tell the patient that she’s not pregnant or that the process didn’t work.”
There’s tremendous emotion and stress that surrounds the practice of reproductive endocrinology. Patients are often sensitive about needing this kind of treatment and very protective of their privacy, thus the RMI is situated in a residential area in south Fargo, apart from other medical facilities, and does not readily convey the image of a clinic.
To help patients cope with the emotional aspects of their condition, the RMI staff includes the availablity of psychologists who provide counseling. Also employed at the clinic are a nurse practitioner, Jennifer Kringlie (BSN ’95, MSN ’02); registered nurses; an embryologist, and laboratory personnel.
Because nurses develop very close relationships with the patients, and spend a great deal of time communicating with them, the nurse burnout rate is high, Christensen notes.
Variety of patients
Most often, patients with infertility have been referred to the RMI after undergoing treatment from their obstetrician-gynecologist that has not resulted in pregnancy. However, patients do not need a referral, unless their insurance requires it.
“The majority of insurance companies in our area do cover almost everything we do,” Dahl says.
Staff at the RMI also sees patients who have had recurring miscarriages, want to preserve their future fertility, or are cancer survivors.
“Cancer treatments are so much better now,” Dahl says. For example, “we have male patients with testicular cancer” who can become parents in spite of the disease.
To receive care at the RMI, patients travel from all parts of North Dakota and points in Montana, South Dakota, and central and northern Minnesota. After initial consultation in-person in Fargo, Christensen and Dahl go to outlying clinics to see patients in Bismarck and East Grand Forks, MN, as well as northern South Dakota. They are considering Bemidji, MN, as a regional site. Some care also can be provided via telemedicine.
IVF patients, the minority of those seen at RMI, must travel to Fargo because the exacting nature of the process, timing and other factors, is so critical, Dahl says. Both she and Christensen work closely with the patient’s local physician as needed for continuing care.
How IVF works (basically)
In the IVF process, egg production is stimulated by hormone therapy. Eggs are harvested from the female, combined with sperm in the laboratory to allow fertilization, and returned to the uterus in hopes that nature will take its course.
“We stimulate as many eggs as possible,” says Christensen, noting that determining the quality of the embryo is a critical step in the process. “We try to choose the ‘best’ embryos.”
His team usually transfers two embryos into the uterus with the hope that at least one will attach to the uterine wall and continue to develop. (Patients also have the option of freezing their embryos for later use, an important and valuable option for women who have cancer.)
Patients have a 30 to 40 percent chance of becoming pregnant, he says. Ninety percent of his patients are pregnant within 12 months.
During his years of practice, what amazes him most are the advances and refinement in medications, the promotion of optimal conditions for fertilization to occur, and the laboratory advances – changes in the culture media.
“We’re understanding more about what the embryo needs in those first three days” to improve the chances for a successful pregnancy, he says. “Half the job is quality control” in the lab.
Does he ever feel he’s tampering in territory reserved for God or nature?
“No,” he says without hesitation. “I’m providing a better environment” for life to begin.
My, how times have changed
Before the development of effective treatments for infertility, a patient’s only option was adoption which, for domestic adoption, can run from $15,000 to $20,000. Today, several other viable options are available.
For example, Dahl says, a patient who had cancer as a child can receive a donor egg, fertilized by her spouse or partner, and carry that baby to term.
“So often, genetics gets to be a minute issue,” she says. “When you carry that baby for nine months, the idea that ‘it’s not my baby’” soon disappears.
On occasion, but not frequently, the RMI does have to turn away patients, for medical or psychological reasons. The physicians adhere to a professional code of ethics and national guidelines set forth by the American Society of Reproductive Medicine, as well as their own personal ethics to guide them in conducting their practices.
When everything comes together for the patient, “it’s fun to be able to help families,” Dahl said. “We help as many women as possible to achieve pregnancy... and it’s a joy to see them go through it and have a happy outcome.”
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