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Archive for August, 2010

The Fertility Work Up

By Dr. David Kreiner

August 23rd, 2010 at 12:00 am

I have received an enormous amount of email from patients over the years asking for information about how they should get started with their infertility workup.  Apparently, they are women, men and couples who have experienced difficulty conceiving and now want some direction about how they should proceed.  Building a family was something they had imagined their entire lives to be a natural progression–from student to career, getting married then having a family–and they’re frustrated that their difficulty conceiving has affected their lives.  For many—some of whom have never experienced a health problem– it prevents them from appreciating or even doing anything else.

See an RE for a Fertility Workup

My response to these emails has been to tell the patients to seek assistance from a reproductive endocrinologist, whose specialty and experience is in helping infertility patients conceive.  A reproductive endocrinologist, who has two to three years of additional specialty fellowship training in infertility after completing an OB/GYN residency.

The RE will conduct a history and physical examination during your initial consultation.  This exam typically includes a pelvic ultrasound of a woman’s ovaries and uterus.  He/she can tell if there are any uterine abnormalities that may affect implantation or pregnancy as well as assess ovarian activity and rule out cases of moderate or severe endometriosis.

Pelvic Inflammatory Disease

If he elicits a history of previous abdominal or pelvic surgery, a physician may suspect that scarring may have developed that typically interferes with fallopian tube transport of the egg to the sperm and the conceptus to the uterus.  An infection that develops after a pregnancy may lead to pelvic adhesions affecting the tubes as well as scarring within the uterine cavity itself which can prevent implantation.  Pelvic inflammatory disease, PID, can lead to tubal disease and may be associated with other sexually transmitted diseases including HPV, Herpes and especially Chlamydia.

Semen Analysis

The semen analysis is the simplest test to perform and will reveal a male factor in 50% of cases.  A post coital test performed midcycle around the time of ovulation when the cervical mucus should be optimal can detect a male factor or cervical factor when few motile sperm are detected within hours of intercourse.

Hysterosalpingogram

A hysterosalpingogram, HSG, is a radiograph x-ray of the uterus and fallopian tubes after radio opaque contrast is injected vaginally through the cervix directly into the uterus.  It can detect uterine abnormalities that can affect implantation and pregnancy as well as tubal patency.  Unfortunately, this exam may be painful and in some patients with PID can result in serious infection.  Some physicians will administer antibiotics prophylactically for this reason.

Hydrosonogram

A hydrosonogram is an ultrasound of the uterine cavity performed after injecting water vaginally through the cervix directly into the uterus.  It can also detect uterine abnormalities and shares some of the risks seen with HSG but to a lesser extent and usually with less associated discomfort.

Hysteroscopy

A hysteroscopy is a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus.  The physician can visually inspect the cavity to detect uterine abnormalities.  The risks of pain and infection are also seen with hysteroscopy.

Blood Tests

Blood tests may be run to identify if a patient is ovulating with adequate progesterone stimulation of the uterine lining.  Day 3 E2, FSH and LH levels can give information regarding ovarian activity and ovulatory dysfunction.  AntiMullerian Hormone (AMH) levels correlate with ovarian reserve.   That is the number of eggs remaining in the ovaries.  Hormones that can affect fertility such as thyroid and prolactin are also assessed to ensure that extraneous endocrine problems are not the cause of the infertility.

Laparoscopy

Laparoscopy is a surgical procedure in which a telescope is placed abdominally through the navel thereby allowing a physician to inspect the pelvic organs.  He/she can identify endometriosis, cysts, adhesions, infection, fibroids etc. that may be causing the infertility.  Unfortunately, only about 25% of cases in women who have a laparoscopy performed will conceive because of treatment performed at the time of the laparoscopy.

Workup Results and Treatment

Treatment can be directed at the cause such as surgery to correct adhesions or remove endometriosis, uterine polyps or fibroids.  Treatment can also be independent of the cause but improve fertility nonetheless.   Ovulation induction increases the number of eggs and therefore the likelihood that an egg will fertilize.  Gonadotropin injections stimulate many more eggs to develop in a cycle than clomid fertility pills.  IVF with minimal or full stimulation is the most successful treatment for any cause of infertility.  The decision as to what treatment to undertake will depend on numerous factors including your age, duration of infertility, cause of infertility, cost of treatment and success of treatment as well as your insurance coverage for the treatment and your motivation to conceive and willingness to accept the risks associated with the treatment.   Today, there is a highly successful treatment available for nearly all women.


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Over 40, and High FSH? What’s a Girl To Do?

By Dr. David Kreiner

August 20th, 2010 at 12:00 am

You have that dreaded infertility diagnosis, “Over 40 With High FSH Levels.” And there’s no cure or magic herb that will turn back the hands of time. You’re desperate so you are willing to try it all anyway, including acupuncture and some internet recommendations such as DHEA (dehydroepiendosterone).

You hear that you can lower your FSH with DHEA or estrogen. The fact is, however, elevated FSH levels do not cause a problem with conceiving. They are merely a marker of diminishing ovarian reserve, a depletion of ovarian follicles and eggs that, combined with increasing age, means you have very few genetically normal eggs available in your ovaries to achieve a healthy child.

Reproductive endocrinologists typically counsel “Over 40 With High FSH Levels” patients that their chance of successfully achieving a live birth using their own eggs is small and that by using a donated egg from a young, fertile woman they can increase their odds of giving birth to greater than 70 percent per donation. Unfortunately, this comes as a shocking disappointment to most women. It’s often a reason for them to drop out of a doctor’s practice or even quit trying to conceive.

So what do you do when faced with this situation? Your answer needs to be individualized, based on your emotional and financial resources, your motivation and your comfort with using a donated egg.

At our clinic, we try to come up with a strategy with our patients that includes counseling to begin the discussion about donor eggs, as opposed to trying with less chance for successful outcome using a patient’s own eggs, or stopping therapy completely and adopting or living child-free.

Perhaps you will choose a low tech option such as insemination with or without hormonal therapy. Sometimes, the plan will be to blast ahead with the big guns using IVF with full stimulation or with less medication and cost using MicroIVF or Minimal Stimulation IVF. Some patients respond better to different stimulations such as sensitizing with estrace or even DHEA prior to stimulation, using a lupron flare or even using clomid in combination with gonadotropins. Unfortunately, it is hard to predict what will be the optimal stimulation for you until we give it a shot.

The bottom line? There’s no right or wrong choice for you. Remember, a family can look many different ways and still be a healthy, loving unit. Your physician, nurses and counselors are available to assist you and support you with whatever decision you make.

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When Infertility Arrives After a Baby: Understanding Secondary Infertility

By Dr. David Kreiner

August 9th, 2010 at 8:19 am

Sometimes my patients who have difficulty conceiving their second child feel like second class citizens in the infertility world. Unlike their infertile peers without a child they perceive that friends, family and even their doctor’s offices do not have the same sympathy and concern for them as they observe others without a child receive. I have had patients express guilt and anger in addition to the routine sadness often associated with the inability to conceive.

Those of you with secondary infertility need to know that you are not alone in feeling this way. My patients all express this alienation which exacerbates the depressing effects of infertility universally experienced among those affected. You have as much a right to fertility care as anyone else as well as the respect and care.

There are some unique characteristics to patients with secondary infertility that are worth discussion. Those of you who have had a caesarian section, ectopic pregnancy or abdominal surgery are more likely to have a tubal factor causing your infertility. Scar tissue can form that can obstruct, or displace a fallopian tube making it more difficult for the tube to pick up an ovulating egg or the fertilized egg to make it to the uterus.

Borderline sperm counts and endometriosis typically make it more difficult to conceive so that it is not unusual that it took longer than expected to conceive the first time and now you are not experiencing any success at all.

We perform a semen analysis and hysterosalpingogram and consider the potential benefit of laparoscopic investigation. Alternatively, if the semen analysis is not too bad and the HSG is normal, patients may benefit from insemination with hormonal stimulation. Otherwise, in vitro fertilization either with minimal or full stimulation will offer significantly superior success rates.

Facing secondary infertility may be as difficult emotionally as infertility for those without prior pregnancies. However, treatment options are available that are highly successful in delivering you the family of your dreams.

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