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Archive for May, 2010

Overweight, Overwrought and Trying To Conceive (TTC)

By Dr. David Kreiner

May 20th, 2010 at 6:00 pm

The most shocking thing I’ve experienced in my 30 year career in Reproductive Endocrinology has been the consistent “resistance” among specialists to treat women with obesity. This “resistance” has felt at times to both me and many patients to be more like a prejudice. I have heard other REI specialists say that it is harder for women to conceive until they shed their excess weight. “Come back to my office when you have lost 20, 30 or more pounds,” is a typical remark heard by many at their REI’s office. “It’s not healthy to be pregnant at your weight and you risk your health and the health of the baby.” Closing the door to fertility treatment is what most women in this condition experience.

A new article appearing in Medical News Today, “Obese Women Undergoing Infertility Treatment Advised Not To Attempt Rapid Weight Loss”, suggests that weight loss just prior to conception may have adverse effects on the pregnancy, either by disrupting normal physiology or by releasing environmental pollutants stored in the fat. The article points out what is obvious to many who share the lifelong struggle to maintain a reasonable Body Mass Index (BMI): Weight loss is difficult to achieve. Few people adhere to lifestyle intervention and diets which may have no benefit in improving pregnancy in subfertile obese women.

The bias in the field is so strong that when I submitted a research paper demonstrating equivalent IVF pregnancy rates for women with excessive BMIs greater than 35 to the ASRM for presentation, it was rejected based on the notion that there was clear evidence to the contrary. Here’s the point I was trying to prove: IVF care must be customized to optimize the potential for this group.

Women with high BMI need a higher dose of medication. Those with PCOS benefit from treatment with Metformin. Their ultrasounds and retrievals need be performed by the most experienced personnel. Often their follicles will be larger than in women of lower weight. Strategies to retrieve follicles in high BMI women include using a suture in the cervix to manipulate the uterus and an abdominal hand to push the ovaries into view. Most importantly, a two-stage embryo transfer with the cervical suture can insure in utero placement of the transfer catheter and embryos without contamination caused by inadvertent touching of the catheter to the vaginal wall before insertion through the cervical canal. Visualization of the cervix is facilitated by pulling on the cervical suture, straightening the canal and allowing for easier passage of the catheter. The technique calls for placement of one catheter into the cervix through which a separate catheter, loaded with the patient’s embryo, is inserted.

Using this strategy, IVF with high BMI patients is extremely successful. With regard to the health of the high BMI woman and her fetus, it’s critical to counsel patients just as it is when dealing with women who live with diabetes or any other chronic situation that adds risk.

We refuse to share in the prejudice that is nearly universal in this field. It’s horrible and hypocritical to refuse these patients treatment. Clearly, with close attention to the needs of this population, their success is like any others.

Women who have time and motivation to lose significant weight prior to fertility therapy are encouraged to do so and I try to support their efforts. Unfortunately, many have tried and are unable to significantly reduce prior to conception.

What right do we have to deny these women the right to build their families?

It can be hard to deal with obesity and even more so when combined with infertility. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. I advise you to ask your doctor about support groups and for treatment that can help you including fertility treatment.

Remember, though this condition can be annoying, aggravating and even depressing, seek an REI who is interested in supporting you and helping you build your family and reject those who simply tell you to return after you have lost sufficient weight.

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Not another @#*%%! Baby Shower Invitation!

By Tracey Minella

May 12th, 2010 at 6:00 pm

Ahhh. Spring is here. How will you experience the season?

Do you see it as the season of rebirth? The end of the cold and gray isolation of winter?  A time of new hope? Or is it just another season… in a long line of seasons…and you’re not pregnant yet?

It can be so hard to face the spring with all its focus on new life.  Sometimes we don’t even notice the birds singing and the flowers blooming.  And when we do notice, we think, who cares? And other times, we just want to pick up a freakin rock and, hey, where’s that bird? Well, you get the picture…

But the real challenge of the Spring is facing the mailbox each day.  It’s the @*#%! baby shower invitation!

Really, is there anything else in the mailbox that brings such dread? And at this time of year, they are coming in droves!

Are you happy to be included because you believe in your heart that someday it will be your turn?  Or is opening that little confetti-filled envelope like a big, fat paper cut to your heart?

Is the thought of buying, wrapping, and dragging one more @#*%! baby swing to the happy affair enough to send you over the edge? Do you put off shopping until the only things left on the 58 page registry are the $1,200 crib and the $4 nasal aspirator? (And don’t even get me started on the diaper genie…)

And worst of all: How many minutes will it take before some idiot relative corners you and loudly blurts out “the inevitable question”? And, more importantly, after she does, how do you resist shoving her fat #!%@* into the wishing well?

Do you go? If not, what do you say? And if so, what tricks do you have to help you survive it?

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Nature Vs. Nurture

By David Kreiner, MD

May 3rd, 2010 at 4:00 am

Patients selecting donors whether for eggs or sperm often spend endless hours choosing the "best match". On a recent episode of the popular T.V. show "Brothers and Sisters", the couple was beyond themselves trying to decide and at one point, out of desperation toyed with the idea of choosing by posting the possible donors on a dart board and letting the dart decide.

People verbalize concern about both a physical and behavioral match. Patients assume that the child will resemble the donor. The likelihood that the child physically looks like the donor varies. The inheritance from a behavioral standpoint including personality and intelligence, drive and aspirations is less clear. There is a significant contribution that the environment plays and to the extent which factor will dominate, nature vs. nurture, is not known.

I don’t have the answer to this question; it’s one I, myself, have spent much time considering. I’m one of five children and I have four children of my own and, so far, three grandchildren. Though the environment and the genetics of my siblings and my children doe not appear to be so different, each of us has developed unique characters and personalities; some more so than others.

I think the nature vs. nurture question is like a Jackson Pollack painting. When you raise a child, different colors of nature and nurture are tossed randomly up in the air and what we call "life" dresses the canvas below. Sometimes the painting it creates is breathtakingly beautiful and other times, well… you wish you could throw out the old and start with a fresh canvas.

Now, if you are a conscientious parent, then you are most careful about how and what colors of nurture you toss. With nature however, there is no control over what features are inherited.

So, I tell my patients who are screening donors and are so concerned that their donor has a particular color hair, eye color or even personality type, that they are putting too much faith in just one can of paint that they get to choose to toss up in the air. People with blue eyes and blonde hair have other colors from ancestors that randomly did not appear on their body. But their gametes contain them and these cans of paint could potentially have more impact on the canvas than the blue eyes and blonde hair that the recipient is hoping for.

I prefer a recipient be concerned that the donor is healthy with good odds for successful conception and a generally appropriate match of physical and behavioral characteristics.

Then I pray for G-d’s blessing.

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