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Archive for June, 2010

The Perfect Game

By Dr. David Kreiner

June 23rd, 2010 at 6:00 pm

I grew up on baseball in the 1960’s with the likes of Mickey Mantle and Roger Maris.  A few years later Tom Seaver and the Miracle Mets held my fancy.  Over the years I have been intrigued by many baseball spectaculars such as Mark McGwire and his run to break Roger Maris’s homerun record and Barry Bonds’s overcoming Mark McGwire’s record.  Roger Clemens winning his 300th game and pitching his 3000th strikeout was unforgettable.  I was enchanted with these baseball heroes when they achieved their record breaking accomplishments.

Then the story about how modern day athletes were using steroids became public and the glory of those heroes from the past 20 years disappeared.  Many of us lost our youthful innocence with the discovery that steroids had intruded into the daily routines of professional baseball.  But as my bubby (my Russian grandma) used to say; c’est la vie.  At least that was the French translation.

This week someone’s little boy who was pitching in the big leagues for the first year had a perfect game, meaning no batter reached first base the entire game with only one out to go.  This is a rarity in baseball having previously occurred only 20 times in major league history.   The final out was weakly hit, a ground ball to the infield, the pitcher covering first base beat the batter, and the throw was caught before the batter reached the bag.  Replays documented the batter was out but unfortunately, the umpire mistakenly shot his arms out signifying a safe sign thus preventing the last out which would have made this a rare perfect game.

So why should I blog about a botched call ruining a perfect game?  This arbitrary wrong turn of events which prevented a perfect game crushed me emotionally the same day my patient who I wanted so much to have her baby, miscarried after 3 years of trying to conceive.  She, like the rookie, Galarraga, deserved to have their day, the perfect game, the perfect baby.  Randomly, both were denied.  How is an individual who has such hopes, dreams and aspirations focused on the denied event to deal with this catastrophic disappointment?

As an observer of both, I was feeling distraught, angry, pushing me to cry out for justice for some supernatural power to make things right again.

Forty five minutes after the game after umpire, Jim Joyce, had the opportunity to review the play he went to the dugout to speak with pitcher, Armando Galarraga.  He apologized to the pitcher for spoiling his slice of fame. … There were few words, just a deep apology, as tears welled in Joyce’s eyes. "He feels really bad, probably worse than me," said Galaragga, who began the season in the minors in Toledo. "I give a lot of credit to that guy, to say he’s sorry. I gave him a hug. His body English said more than the words. Nobody’s perfect, everybody’s human."

We, in the field of infertility face disappointments as regularly and the menstrual cycle.  When a pregnancy is conceived, in our minds, the “perfect baby” is essentially created.  Miscarriage, the loss of one’s “perfect baby” seems to be a life crushing blow.  Perhaps, we can gain strength from the story about these two men, Armando Galarraga and Jim Joyce, who were able to reconcile this catastrophic schism in their path to obtaining their “perfect” goal and move forward to the next game. 

Thank you, Armando and Jim for helping us to see the way.  After all, if you can get this close once only to miss because of a random mistake, then why can’t we expect that we have a good shot that it will work next time?

In the mean time, again as my Bubby would say, “Play ball”.

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Dear Fertility Doc

By Dr. David Kreiner

June 21st, 2010 at 6:00 pm

Dear The Fertility Doc,

I am 39 years old, single and I am very involved with my career. I want to continue to work but I always dreamed I would have children. I don’t have a partner with whom to get pregnant. What should I do?

Signed,
At My Reproductive Crossroads

I hear this question frequently in my practice. As women age they are forced to consider whether to have their children now rather than delay while they may still be able to use their own eggs versus those of an egg donor, or adopting.

This patient needed to consider the ramifications of taking time off from her career, as well as creating a child with donor sperm. She wanted to know if she were to meet Mr. Right, how would he respond to this child? Were there tests that I could perform to help her make a decision?
Screen Your Fertility

First of all, it’s imperative in cases like this to do a full fertility screen so that we understand from a fertility perspective how much time a woman has left and how urgently she needs to make a decision. To assess fertility, I do a Day 3 serum Estradiol and FSH, an AntiMullerian Hormone and a sonographic antral follicle count. The FSH is regulated by negative feedback from serum Estradiol and inhibin, both of which are produced by the granulosa cells of the ovarian follicles. With diminishing ovarian activity, there are fewer follicles, less estradiol and inhibin, so with less feedback, the FSH level is high.

Occasionally, in patients with low ovarian activity (often called low ovarian reserve), a patient may have an ovarian cyst that produces estradiol. This will lower the FSH level to otherwise normal activity levels even when there is minimal ovarian activity and inhibin. One would misinterpret the low normal FSH in the presence of higher estradiol which is why this must be measured concurrent with FSH.

AntiMullerian Hormone is also produced by the granulosa cells and low levels therefore indicate depleted ovaries. Likewise, few antral follicles seen on ultrasound typically performed during the early follicular phase of the cycle will indicate low ovarian reserve.
Making a Decision

Once we know a patient’s relative fertility through this screen, we need to decide whether she is prepared to delay her career for pregnancy and motherhood or whether she should undergo IVF and freeze her embryos, thereby freezing her fertility potential at its current state.

Since she is single without a participating partner, we would be using the sperm from an anonymous donor. Sperm specimens are obtained from sperm banks that are certified by New York State by virtue of their screening and testing for infectious and hereditary diseases. Patients may review what is available from the sperm banks, reading on the internet the sperm donor’s demographic information, physical attributes, educational and occupational histories, etc.

If a woman does not have any infertility issues, I would attempt donor insemination. However, due to her advanced age, I would progress to more aggressive therapies if we were not successful after a few cycles.

A common concern for women in this circumstance is that they may meet their soul mate in the future and he may not be comfortable with a child produced with someone else’s sperm. This is an issue that is very individual and I can only offer to support my patients as they decide what is best for them.

As a woman prolongs the decision, her fertility is diminishing, and she thereby risks not being able to have a child using her own eggs. If conceiving with her own eggs is crucial, then she must weigh the downside of conceiving a child from an anonymous donor and, if she does so, the potential problems associated with finding a man in the future with whom she may want to have a family.

It’s enormously stressful making these decisions at these reproductive crossroads. I discuss them with my patients and help them arrive at the decision that is right for them.  Everyone who has ever supported a woman making such a difficult decision knows that it can have a heavy toll on a woman’s psyche.

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“What do you think is the biggest change in reproductive medicine since you started?”

By Dr. David Kreiner

June 16th, 2010 at 8:42 am

The other day, I asked Dr. David Kreiner a few questions about his own personal take on the changes in reproductive medicine. Here is our conversation.

"What do you think is the biggest change in reproductive medicine since you started?"

"When I decided to specialize in reproductive endocrinology and infertility (REI) I was looking forward to being on the frontier of fertility medicine. The details of Reproductive physiology were being unraveled in real time and IVF had just reported its first successful pregnancies. In those days, microsurgery of the fallopian tubes was commonly performed by REIs as well as endometriosis and fibroid surgery. 

During my fellowship, surgery was a huge part of my training. I travelled to Nashville to train with one of the world’s experts in laser laparoscopy. I practiced my tubal microsurgery skills weekly on anesthetized rats in a plastic surgical lab. I assisted on reproductive surgery several cases every week throughout my fellowship.

Myself and other fellows performed research on basic reproductive physiology questions that had yet to be worked out.  Personally, my interest was polycystic ovarian disease and its relationship to weight gain. I studied male hormone production in the ovary and the adrenal gland before and after significant weight loss. I discovered that there was an inverse relationship between weight loss and male hormone production and that this was mediated through insulin. These were exciting times.

Today, discoveries in reproductive physiology are much more esoteric than it was when I was a fellow. Reproductive surgery, in particular tubal microsurgery and laser laparoscopy for endometriosis and adhesions is usually replaced with in vitro fertilization (IVF) which has become so much more successful, less invasive and therefore a preferable option. Most causes of infertility, if they are not successfully treated with ovulation induction and intrauterine insemination (IUI) can be overcome with IVF.

Today, we get excited about advances in preembryo genetic screening and diagnosis and contemplate the current and future potential of eliminating hereditary medical disorders".

"What are you the most proud of?"

"In the 1980’s when I was a fellow, IVF was grossly inefficient and we had to transfer multiple embryos to achieve a pregnancy. Consequently, triplets and quadruplets were not rare occurrences. In many programs, they constituted over 10% of all pregnancies. Today, we can often transfer one embryo at a time minimizing the risk of multiple pregnancies. We can freeze excess embryos so many patients need go through only one stimulation and retrieval and still have multiple transfers providing them with an excellent chance of conceiving a baby from their efforts.

What would you change about the field of reproductive medicine today if you had a magic wand?

I wish that REI was not a competitive business but purely a medical service". 

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Dr. David Kreiner Leads Us On a “Journey To The Crib”

By Dr. David Kreiner

June 7th, 2010 at 6:00 pm

Life evolves.  For my patients, thankfully most will transition from a life known to them only as a daughter, a son, a wife or a husband into one in which they learn the meaning of being called mommy and daddy.  Likewise, I did not grow up comfortable with expressing myself with the written word.  My writing in school earned me mediocre grades and was a reason that I focused on my science courses growing up. 

It wasn’t until 10 years ago that I felt a strong need to express myself to others which led me to take a writing course at StonyBrook where I was teaching philosophy of medicine at the time.  I wanted to tell others about my past experiences in medicine and to voice my opinion about some of the problems that I was witnessing first hand.

My patients were always searching for answers and I felt an obligation to put together a book that they could use that would aid them with their fertility quest.  I embarked on writing articles for them about five years ago.  However, last year we were producing a series of educational videos on infertility that my son, Dan, was filming.  We chose to do the first few videos in my living room of my house.  Dan suggested that we entitle the series of videos “Journey To The Crib” using the hip hop term alluding to my house.  As I am fond of corny double entendres, I thought this was a wonderful name for the educational videos on infertility.  When I decided to put my articles together and publish the book for my patients, it was natural for me to use the “Journey To The Crib” title and put some of those videos in the book as well in the form of an attached CD.

During the process of writing the book, I started my blog, Thefertilitydoc.com where I continue to add relevant articles focused on answering questions my patients have asked me over the years as well as dealing with current controversies and explaining my viewpoint for my patient readers.

 As I am now officially a writer, having a published book, my own blog, as well as contribute to numerous other blogs including The Fertility Daily on www.eastcoastfertility.com and www.faceoffertility.com, I wish to continue to work to help my patients transition to their new phase of life as parents.

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