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Archive for July, 2010

Fibroids: One of The Most Common Causes of Infertility

By Dr. David Kreiner

July 20th, 2010 at 7:46 am

Fertility is dependent upon so many things!

We must have healthy gametes (eggs and sperm) capable of fertilizing and implanting in a uterus with a normal endometrial lining unimpeded by any uterine or endometrial pathology. The sperm need be in sufficient number and capable of swimming up through a cervix which is not inflamed and provides a mucous medium that promotes sperm motility. The eggs need to ovulate and be picked up by normal healthy fimbriated ends (finger like projections) of the fallopian tubes. The tubes need to be covered with normal micro hairs called cilia that help transport the egg one third of the way down the tube where one of the sperm will fertilize it.

The united egg and sperm (the “conceptus”) then needs to undergo cell division, growth and development as it traverses the tube and makes its way to the uterine cavity by the embryo’s fifth day of life at which point it is a blastocyst. The blastocyst hatches out of its shell (“zona pellucidum”) and implants into the endometrial lining requiring adequate blood flow.

And you wonder why getting pregnant is so hard?

All too often patients, in some groups as many as 30% of women, are told that they have fibroids that may be contributing to their infertility. Fibroids or leiomyomata are non malignant smooth muscle tumors of the uterus. They can vary in number, size and location in the uterus including; the outside facing the pelvic cavity (subserosal), the inside facing the uterine cavity (submucosal) and in between inside the uterine wall (intramural). Fortunately, most fibroids have minimal or no effect on fertility and may be ignored.

The subserosal myoma will rarely cause fertility issues. If it were distorting the tubo- ovarian anatomy so that eggs could not get picked up by the fimbria then it can cause infertility. Otherwise, the subserosal fibroid does not cause problems conceiving.

Occasionally, an intramural myoma may obstruct adequate blood flow to the endometrial lining. The likelihood of this being significant increases with the number and size of the fibroids. The more space occupied by the fibroids, the greater the likelihood of intruding on blood vessels traveling to the endometrium. Diminished blood flow to the uterine lining can prevent implantation or increase the risk of miscarriage. Surgery may be recommended when it is feared that the number and size of fibroids is great enough to have such an impact.
However, it is the submucosal myoma, inside the uterine cavity, that can irritate the endometrium and have the greatest effect on the implanting embryo.

To determine if your fertility is being hindered by these growths you may have a hydrosonogram. A hydrosonogram is a procedure where your doctor or a radiologist injects water through your cervix while performing a transvaginal ultrasound of your uterus. On the ultrasound, the water shows up as black against a white endometrial border. A defect in the smooth edges of the uterine cavity caused by an endometrial polyp or fibroid may be easily seen.

Submucosal as well as intramural myomata can also cause abnormal vaginal bleeding and occasionally cramping. Intramural myomata will usually cause heavy but regular menses that can create fairly severe anemias. Submucosal myomata can cause bleeding throughout the cycle.

Though these submucosal fibroids are almost always benign they need to be removed to allow implantation. A submucosal myoma may be removed by hysteroscopy through cutting, chopping or vaporizing the tissue. A hysteroscopy is performed vaginally, while a patient is asleep under anesthesia. A scope is placed through the cervix into the uterus in order to look inside the uterine cavity. This procedure can be performed as an outpatient in an ambulatory or office based surgery unit. The risk of bleeding, infection or injury to the uterus or pelvic organs is small.

Resection of the submucosal myoma can be difficult especially when the fibroid is large and can sometimes take longer than is safe to be performed in a single procedure. It is not uncommon that when the fibroid is large, it will take multiple procedures in order to remove the fibroid in its entirety. It will be necessary to repeat the hydrosonogram after the fibroid resection to make sure the cavity is satisfactory for implantation.

The good news is, when no other causes of infertility are found, removal of a submucosal fibroid is often successful in allowing conception to occur naturally or at least with assisted reproduction.

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Will IVF Work For Me?

By Dr. David Kreiner

July 13th, 2010 at 12:00 am

What everyone wants to know when they decide to look into invitro ferilization (IVF) as a treatment option is "what is my chance for success?"  It’s a complicated question and the answer varies from  patient to patient. But let me try to break down a little bit for you.

In 2002 about 28% of cycles in the United States in which women underwent IVF and embryo transfer with their own eggs resulted in the live birth of at least one infant. This rate has been improving slowly but steadily over the years.  Patients should be aware, however, that some clinics define "success" as any positive pregnancy test or any pregnancy, even if miscarried or ectopic. These "successes" are irrelevant to patients desiring a baby. To put these figures into perspective, studies have shown that the rate of pregnancy in couples with proven fertility in the past is only about 20% per cycle. Therefore, although a figure of 28% may sound low, it is greater than the chance that a fertile couple will conceive in any given cycle.

Success varies with many factors. The age of the woman is the most important factor, when women are using their own eggs. Success rates decline as women age, and success rates drop off even more dramatically after about age 37. Part of this decline is due to a lower chance of getting pregnant from ART, and part is due to a higher risk of miscarriage with increasing age, especially over age 40. There is, however, no evidence that the risk of birth defects or chromosome abnormalities (such as Down’s syndrome) is any different with ART than with natural conception.

Success rates vary with the number of embryos transferred. However, transferring more embryos at one time not only increases the chance of success with that transfer, but will also increase the risk of a multiple pregnancy, which are much more complicated than a singleton pregnancy. The impact of the number of embryos that are transferred on success rates also varies with the age of the woman.

Pregnancy complications, such as premature birth and low birth weight, tend to be higher with ART pregnancies, primarily because of the much higher rate of multiple pregnancies. Nationally, in 2002-2003 about 30% of ART deliveries were twin deliveries, versus 1-2% of spontaneous pregnancies. The risk of pregnancy containing triplets or more was 6% in 2003.

As women get older, the likelihood of a successful response to ovarian stimulation and progression to egg retrieval decreases. These cycles in older women that have progressed to egg retrieval are also slightly less likely to reach transfer.  The percentage of cycles that progress from transfer to pregnancy significantly decreases as women get older.  As women get older, cycles that have progressed to pregnancy are less likely to result in a live birth because the risk for miscarriage is greater.  This age related decrease in success accelerates after age 35 and even more so after age 40.  Overall, 37% of cycles started in 2003 among women younger than 35 resulted in live births. This percentage decreased to 30% among women 35–37 years of age, 20% among women 38–40, 11% among women 41–42, and 4% among women older than 42.  The proportion of cycles that resulted in singleton live births is even lower for each age group.

The success rates vary in different programs in part because of quality, skill and experience but also based on the above factors of age, number of embryos transferred and patient population.  Patients may also differ by diagnosis and intrinsic fertility which may relate to the number of eggs a patient may be able to stimulate reflected by baseline FSH and antral follicle count as well as the genetics of their gametes.  These differences make it impossible to compare programs.

Another factor often overlooked when considering one’s odds of conceiving and having a healthy baby from an IVF procedure is the success with cryopreserved embryos.

Thus, a program which may have a lower success rate with a fresh transfer but much higher success with a frozen embryo transfer will result in a better chance of conceiving with only a single IVF stimulation and retrieval.  Success with frozen embryos transferred in a subsequent cycle also allows the program to transfer fewer embryos in the fresh cycle minimizing the risk of a riskier multiple pregnancy.  It may be more revealing to examine a program’s success with a combination of the fresh embryo transfer and frozen embryo transfers resulting from a single IVF stimulation and transfer.  For example, at East Coast Fertility, the combined number of fresh and frozen embryo transfers that resulted in pregnancies for women under 35.from January 1, 2002 to December 2008 was 396.  The number of retrievals during that time was 821.  The success rate combining the fresh and frozen pregnancies divided by the number of retrievals was 61%.  The high frozen embryo transfer pregnancy rate allowed us to transfer fewer embryos so that there were 0 triplets from fresh transfers during this time.

What can I do to increase my odds?

Patients often ask if there are any additional procedures we can do in the lab that may improve the odds of conception.  Assisted hatching is the oldest and most commonly added procedure aimed at improving an embryo’s ability to implant.  Embryos must break out or hatch from their shell that has enclosed them since fertilization prior to implanting into the uterine lining.  This can be performed mechanically, chemically and most recently by utilizing a laser microscopically aimed at the zona pellucidum, the shell surrounding the embryo.  Assisted hatching appears to benefit patients who are older than 38 years of age and those with thick zonae.

Recently a protein additive called “Embryo glue” was shown to improve implantation rates in some patients whose embryos were transferred in media containing “Embryo glue”.  Time will tell if the adhesive effect of this supplement is truly increasing success rates and warrants wide scale use in IVF programs.

Embryo co culture is the growth of developing embryos is the same Petri dish as another cell line.  Programs utilize either the woman’s endometrial cells obtained from a previous endometrial biopsy or granulosa cells obtained at the time of the egg retrieval from the same follicles aspirated as the eggs.  Growth factors produced by these endometrial and granulosa cell lines diffuse to the developing embryo and are thought to aid in the growth and development of the embryo.  It appears to help patients who have had previous IVF failures and poor embryo development.

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Stress Reduction and Infertility

By Dr. David Kreiner

July 9th, 2010 at 12:00 am

I see a lot of stress as a reproductive endocrinologist. And let’s face it – we all have stress! Recently I read on a post by Melissa Brisman Esq. (source: tips for reducing infertility stress. And if you’re trying to conceive (TTC), and have been faced with constant disappointment – you are probably getting a little stressed out.  High levels of stress definitely won’t help you get pregnant.

These stress relief tips may increase your chances of getting pregnant, and will definitely improve your mood and relationships.

Before the tips, here’s a hopeful quip:

“Slow down and everything you are chasing will come around and catch you,” said John De Paola.

I don’t know if pregnancy will “catch” you if you slow down…but heck, it’s worth a try! To learn more about sperm, ovulation, and getting pregnant, click Fertility and Infertility for Dummies by Gillian Lockwood and others. And, read on for dozens of tips on reducing the stress of infertility….At East Coast Fertility, join our Mind Body Program where reducing stress and improving your odds is the name of the game.

Social Ways to Reduce Infertility Stress

– Tell your friends what you need. If don’t want people to keep asking if you’re pregnant (I hate that!), then tell them that you’ll give them the good news when you’re ready!

– Accept your way of dealing with infertility. You and your partner’s method of coping with infertility could be much different than mine, or your sister’s – and the sooner that you accept it, the better.

– Talk to your friends about your frustrations and joys.

– Have a relaxing glass of wine or a margarita with friends, but don’t overdo it (though some say you shouldn’t drink alcohol at all when you’re trying to get pregnant…that’s a personal choice).

– Prioritize invitations to reduce stress. Give yourself time to unwind and do what you want to do. Say no to parties or get-togethers, or just make a brief appearance.

– Don’t fall into the trap of comparing your life, situation, relationship, or family to other people’s.

Physical Ways to Reduce Infertility Stress

– Get a full-body massage – and tell your massage therapist that you’re trying to get pregnant.

– Spend time out in nature: walking, skating skiing in the winter, hiking in the summer.

– Take a warm bubble bath (but if you’re a female or male coping with infertility, make sure you check with your doctor first).

– Stop eating before you’re full – don’t gorge on chocolates, chips, or fast food.

– Get enough sleep.

– Reduce your caffeine intake (I’m sure you’ve heard that before!).

– Take your vitamins, supplements, minerals (you’ve heard that before, too, I bet).

– Drinks lots of water.

– Get a manicure or pedicure.

– Make love for the sake of making love.

Mental Ways to Reduce Infertility Stress

– Volunteer at a food bank, hospital, or animal shelter.

– Take downtime to snooze, read, relax.

– Play your favorite card and board games – laughing will reduce the stress of getting pregnant.

– Take a regular crossword puzzle or Suduku break.

– Pick your battles, choose your priorities.

– Let go of the little stuff.

– Watch your favorite TV shows or movies.

– Share your baking or meals with homebound people or lonely neighbors.

Emotional Ways to Reduce Infertility Stress

– Practice gratitude.

– Have realistic expectations.

– Laugh!

– Stay in touch with your authentic emotions.

– Cry, scream, or punch the pillow when you need to.

– Stop to take a deep breath every hour or so throughout the day.

– Let yourself grieve. Reducing stress involves expressing your emotions.

– Keep your old traditions and healthy habits alive, but be open to new ones.

Creative Ways to Reduce Infertility Stress

– Paint, draw or carve your thoughts and feelings.

– Visit a museum or art gallery to reduce holiday stress.

– Go to a movie in the middle of the day by yourself.

– Listen to music that relaxes and/or energizes you.

– Go for a drive in the country; stop for hot chocolate and muffins.

– Write in your journal to reduce stress.

Spiritual Ways to Reduce Infertility Stress

– Pray, and remember the big picture.

– Read the Bible, Torah, or other meaningful book.

– Seek the deep meaning behind church or mass services to reduce holiday stress.

– Remember that your God, Creator or Higher Power is working behind the scenes.

– Adjust your perspective to include peace, compassion, and forgiveness.

Family Ways to Reduce Infertility Stress

– Change your regular responses to aggravating family members, especially if your normal responses haven’t worked in the past!

– Shrug off challenges and criticisms.

– Let go of past betrayals, mistakes, failures – both yours and others’.

– Don’t expect people to change (unless you change first).

– Maintain healthy boundaries to reduce infertility stress.

Readers, how do you let go of the stress of trying to get pregnant? I find that walking in the woods out behind our house is hugely relaxing – it reminds me that life can be beautiful even without kids. There’s something about deep breaths of fresh air that energize me, no matter how bad I’m feeling…

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