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Archive for October, 2010

Understanding Fibroids

By David Kreiner, Md

October 29th, 2010 at 2:11 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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Corporate Denial of Right To Watch Favorite TV Show

By David Kreiner, MD

October 20th, 2010 at 5:13 am

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It’s now official. News Corp. has pulled the plug on Cablevision customers by turned off the signal of FOX and My Nine affecting 3 million viewers in the New York Metropolitan area. My wife and daughters are distraught. Their favorite television show; Glee, not to mention critical sports shows and others are no longer viewable on our TV sets. They like so many others are frustrated and depressed at the prospect that they will be denied those pleasures that we have grown accustomed to expect.

My wife and I never truly experienced infertility. We had a workup for recurrent miscarriages and it took us over a year to conceive a healthy pregnancy in between our two boys and two girls. We were quite fortunate that we were not denied the joy of building our family that we had learned to expect while growing up, observing our own as well as our friends’ and neighbors’ families. It is a way of life that we understand as well as anything else that we experience throughout our lives.

When a couple experiences infertility, this expected right to the pursuit of happiness by creating one’s own family is denied. It is not deserved; the affected are innocent bystanders of a tragedy not of their own making. Someone afflicted with infertility might have just as randomly caught a cold or some other disease or condition. The difference is that if you unfortunately have any other condition or disease requiring medical treatment, the odds are excellent that you have insurance coverage for it. Infertility is not covered by most providers not because of ethical or religious reasons or even lack of sympathy, but instead because it costs money to the providers.

Cablevision and Fox TV are battling over millions of dollars. How I wish they would use the argument that they have increased costs to cover safe, cost effective fertility care like IVF; that they wish to provide for the right for their employees to have a family like they grew up seeing on Fox and My Nine movies and on Cablevision. Senator Kerry, former presidential candidate interceded in the past to try to negotiate a settlement between Disney and Cablevision so that my wife and others would not be denied their TV shows. Why can’t we get a similar hero to negotiate a settlement for coverage so that the infertile couple can get the treatment they need so they are not denied their families?

IVF is now cost effective and safe when used conservatively especially with our single embryo transfer program. We have a greater than 60% live birth rate per retrieval in women under 35. We can avoid multiple pregnancies by transferring one embryo at a time rather than expose a woman to a 35% multiple rate with ovulation induction and intercourse or insemination. Minimal stimulation IVF is a low cost alternative, $3900 at ECF that avoids hyperstimulation and allows for single embryo transfer. Why do politicians ignore the millions of infertile individuals and couples in this country and deny them the right to have their family that they grew up expecting as naturally as tuning into Fox and My Nine and watching a favorite TV show?


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Bringing Acupuncture to The IVF Patient

By Dr. David Kreiner, MD

October 15th, 2010 at 8:17 am

How might it work?

It has been proposed by many that acupuncture could positively impact the results of In vitro Fertilization – IVF.  The mechanisms proposed for this effect are several.

 

Acupuncture affects the levels of pituitary and ovarian hormones as demonstrated in several studies. Other studies show that it may help improve blood flow to the uterus which might improve implantation.

 

Another explanation attractive to me is that acupuncture may "relax" the uterus at the time of embryo transfer. Several studies have demonstrated uterine contractions and that these contractions can expel transferred IVF embryos. If these contractions were reduced by acupuncture then that could improve IVF pregnancy rates.

 

Reducing stress and improving the general health and wellness of an individual undergoing IVF was scientifically demonstrated to improve our IVF success rates.  If acupuncture is able to achieve some reduction in stress and/or some improvement in patient wellness than statistically it should improve the likelihood of achieving a pregnancy.

 

There are claims that acupuncture will help patients respond better to stimulation medication, get more eggs, even healthier eggs, and get higher pregnancy rates. Many women with diminished ovarian reserve and a high FSH level or history of miscarriages have been promised that acupuncture can cure these problems. The challenge has been to objectively prove these claims with scientific studies.

 

Thus far, there have been a few studies examining the use of acupuncture as an adjunctive therapy to IVF.  A relatively new study, published in 2008, combined the results of many of these smaller studies, concluding that one additional live birth would be obtained for every 10 IVF embryo transfers performed when acupuncture was added to the therapeutic regimen.

Acupuncture and IVF Studies

Study 1

 

The first published study, which received a great deal of attention, was conducted by Paulus and published in Fertility and Sterility.

 

The study looked at 160 women aged 21 to 43.  In this study, IVF patients received acupuncture 25 minutes before and 25 minutes after the embryo transfer. No patients received acupuncture before or during treatment with fertility medications.

 

The acupuncture points chosen for the study were supposed to result in:

  • Better blood perfusion and "energy" in the uterus
  • Sedation of the patient
  • "Stabilization" of the endocrine system

IVF patients who had acupuncture had a 42% pregnancy rate. IVF patients who did not have acupuncture had a 26% rate.

Some critics claimed that improvement was due to the placebo effect. To examine this Paulus presented a placebo-controlled study at the annual meeting of the European Society for Human Reproduction and Embryology. Two hundred patients with good embryo quality were randomized to receive either real or faked acupuncture for 25 minutes before and after ET. There were clinical pregnancies in 43% of the real and 37% of the faked acupuncture patients. Statistical analysis of the results was not significant but there was the trend towards improved success with the acupuncture.

 

Study 2

 

The study was conducted on 300 couples and was randomized to one of three groups on the day of egg retrieval. After randomization, 27 patients were excluded for various reasons. Of the remaining 273 patients, 87 were allocated to no acupuncture (control group), 95 to acupuncture on the day of embryo transfer, and 91 to receive acupuncture on the day of ET and again 2 days later.

 

There was no difference between the three groups in the number of eggs retrieved or the number of embryos available to transfer to the uterus.

The ongoing pregnancy rate was higher in both of the acupuncture groups compared to the control group. The ongoing pregnancy rate in the group which received acupuncture once was 36%, in the group that received acupuncture twice, the rate was 33% and in the group that did not receive acupuncture at all it was 22%.

Study 3

In this third acupuncture study, a total of 225 infertile patients were included: 116 women were randomized into group I (the acupuncture group), and 109 women were randomized into group II (the no acupuncture group). The physician who performed the embryo transfer was not aware of which couples were in which group. On the day of embryo transfer, the patients in the study group received acupuncture.  At the same time, a special Chinese medical drug (the seed of Caryophyllaceae) was placed on the patient’s ear. The seeds remained in place for 2 days and were pressed twice daily for 10 minutes. Three days after the embryo transfer, the patients received a second acupuncture treatment. In addition, the same ear points were pressed at the opposite ear twice daily. The seeds were removed after 2 days.

 

The control group received a faked acupuncture. As in the treatment group, patients received the phony acupuncture treatment for 30 minutes. This placebo treatment was repeated three days after the embryo transfer. Equal numbers of needles were applied to the study and control groups. The placebo acupuncture treatment was designed not to influence fertility.

 

Both groups were similar in terms of age, weight, duration of infertility, cause of infertility, and number of previous IVF attempts. No differences were found in the specifics of the ovarian stimulation, the number of eggs retrieved, the fertilization rate, or the number of embryos transferred.

The real acupuncture group had an implantation rate per embryo of 14.2% whereas the faked acupuncture group’s implantation rate was only 5.9%. The ongoing pregnancy rate was 28.4% in the real acupuncture group compared to 13.8% in the control group.

 

Study 4

 

This next acupuncture and in vitro fertilization study subjected the patients to three acupuncture treatment sessions. The first took place before the egg retrieval on the 9th day of ovarian stimulation, and the second and third acupuncture treatments were performed immediately before and after the embryo transfer. Women were randomly allocated to receive treatment with either real therapeutic acupuncture or with faked acupuncture.

 

Of the 228 subjects randomized, 15% were unable to complete the treatment protocol because their IVF cycle was cancelled prior to the embryo transfer. No difference in the grading of embryos was found between groups. The pregnancy rate, defined by a positive fetal heart beat, was 31% in the acupuncture group and 23% in the control group.

 

I am very proud that as of today, The Berkeley Center For Reproductive Wellness at East Coast Fertility is opening it’s door. It’s our hope to support you in every way to build your family. 

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Should You Disclose The Identity of a Donor?

By Dr. David Kreiner

October 13th, 2010 at 8:38 am

It has been my experience as well as that of others in the field that many individuals conceived through gamete donation are curious about their donor and the donor’s other offspring.  They may fantasize about their genetic parent and siblings.  They are curious if they look like them and have similar behavioral traits. They want to know why their donor donated.  They almost ubiquitously are curious to meet their donor whether they may want to have ongoing contact or not.  The degree of interest is variable where some may simply be satisfied with a picture and information, others may feel comfortable with maintaining anonymity whereas still others feel a strong desire to physically meet their donor.  These feelings typically change over time and may become more significant during certain stages of life, such as at the prospect of an individual starting their own family.

Donor conceived individuals may be looking to fill in the blanks in their identity.   Rebecca Hamilton, conceived through donation, wrote in Behind Closed Doors: Moving Beyond Secrecy and Shame, edited by Mikki Morrissette, “It’s not a ‘Dad’ I’m after. I had a wonderful Dad who raised me. I’m not looking for a replacement. Nor, incidentally, is any other donor-conceived person I have ever met….Wanting to understand one’s genetic roots is a unique longing that remains no matter how great life is going on other levels.” 

Universally, it appears that those individuals who were conceived through donation do not look at the donor as a parent.  The donor does not replace the role of the parent.  Instead having an open relationship with a donor can provide answers to questions many donor conceived individuals have about their own identity.

So how do I answer the question, “should I help my child find her donor?”

Professionals in the field tell us that based on research, developmental theory, and my own clinical experience, that it is best for parents to be honest with their children about their origins.   In some cases I may recommend providing them with options for obtaining information about their donor. Although many sperm banks and egg donor agencies only facilitate anonymous donations. Some sperm banks offer the possibility of working with a donor who is willing to be identified to your child any time after your child turns eighteen. The sperm bank stores data and provides it upon request. Your adult child is the only one in control of this information. If she wants identity information, it is available for her. If she does not desire to know her donor’s identity, the information is never revealed.

However, it is most common at least in the Northeast that a definitive plan is not established at the outset for how a donor’s identity would be released.  Most programs maintain strict anonymity.  There is no guarantee that this information will be available for their child. A third party, which could be an agency, medical office, or attorney must obtain the information, and a formal contract, signed by the donor, must state when and how identity information will be released to the donor conceived individual.  

Ultimately, as future parents it is vital to examine your feelings and concerns regarding disclosure of the donor’s identity. Disclosure of the donor’s identity may affect the donor conceived individual and his sense of self.  Though the donor does not replace the parent there is potential for creating friction in the relationship.  There is also the donor’s family to consider which will also be impacted by revealing one’s identity to the donor conceived individual.  One must weigh the potential benefit of satisfying curiosities with the risk of causing harm to the relationship with the individual’s parents as well the risk of causing harm to the donor’s family.

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Is Disclosure To My Child About Her Donor Parentage Wise?

By Dr. David Kreiner

October 6th, 2010 at 7:09 am

I received this letter from a former donor egg recipient.  It made me think about what it might be like, years after the actual procedure for a child who grows up wondering about his/her donor parent.

Dear Dr. Kreiner,

I want to thank you and your wonderfully caring staff for all you did to help me have my daughter, Jessica.  There was not a moment that I did not feel supported during the process and for this I sing your praises constantly. 

My daughter is truly a blessing and I will always cherish that you helped bring her into this world for me.

We informed Jessica about her genetic parentage a few years ago with the help of a psychologist who saw my husband and I first and then with Jessica for two or three more visits.  I thought it went well.  Jess seemed to understand that we loved her and that Russ and I were truly her father and mother and I cannot say that our relationship had changed in any significant way since then. 

However, Jessica is now 14 years old and has recently been asking me about what I know about her genetic mom which is how she referred to her.  I, took offense to her use of the term ”mom” and immediately corrected her, saying “you mean donor, honey”.  This started a huge argument and has created a tense rift that still exists.  I know that she has been doing research to identify her donor including calling your program.  I don’t know what to do.  Did we make a mistake by telling her?  Should we seek out the donor and ask if she is willing to reveal herself to my daughter?  Is it even legal or moral for us to ask?  Should we tell my daughter that it is not possible to identify her and just leave it like that?  I am afraid not to try as it seems to be so important to her and if I appear to be resisting she will get angry with me again.

What should we do Dr. Kreiner?

Still thankful but with some remorse,

Former donor egg recipient

I have been involved in these donor egg cases since 1985 and this type of question is rare for me to receive but now I wonder if that is because patients do not feel close enough to me to discuss these problems years after my services have been performed.

It is not uncommon for potential donor egg recipients to say to me ”I’m not going to tell my child about the donor. I’m going to carry him. I’m the mom”.  We have always recommended that parents disclose that they had utilized donation to their child since it is thought that honesty is better than trying to shoulder “the big lie” which ultimately would be found out and lead to much larger problems.


If you are planning to build a family with a sperm or egg donor, you may be thinking about these very issues. Many patients believe that by disclosing their child’s donor origins will damage the parent-child bond that is so precious to them. They fear that a genetic connection to a donor could trump their relationship with their child. Most commonly, my patients plan to tell their child about the donor but want the donor’s identity to remain anonymous. They worry that an identified donor could disrupt the integrity of their family by inserting herself or himself into it.

Professionals in the field of infertility tell us that patients who need help to have a child often feel vulnerable and may view donors as threatening.

To Disclose or Not to Disclose That is The First Question

Unlike heterosexual couples, same sex couples and single individuals understand that from the moment they decide to build their family that they require assisted reproduction. These families openly disclose their children’s donor origins because it is the only way to explain their conception and birth.  Inevitably, the children look at other families around them and wonder if they have a mommy or a daddy.   It does not appear that disclosure in these cases has a negative impact on the families.

However, the heterosexual couples seek assistance only after failed attempts to have a child on their own and sometimes even after multiple IVF attempts using the woman’s own eggs.  These couples typically experience incredible loss, frequently feel inadequate, and often become clinically depressed. Assisted reproduction with outside help with their family building was not something they ever imagined. Many feel a sense of shame that may add additional motivation to keep the donor parentage a secret from their child. We are told by those professionals in the field who study this that many former donor recipients turned parents fear their child will see the donor as the “real” mom or dad and believe they are preventing potential problems by keeping the secret from their child.

Interestingly, many individuals who are the result of gamete donation report feeling like they don’t fit in with their families. I have heard that when they ultimately are informed of their donor origin that it often makes sense to them and not infrequently is received by the child with a degree of relief to explain their uniqueness from their family.  Sometimes donor conceived individuals inadvertently learn about their origins under less than ideal circumstances such as from a family friend or relative. Nondisclosure, in these cases, usually undermines trust and honesty within a family and may lead to psychological harm.

Professionals studying donation tell us that when children have been told about their donor origins, they are typically accepting of the recipient moms and dads. In fact, it appears that when children learn of their donor origins at a young age, they are more likely to have a more positive experience. Their donor conception is integrated from the beginning into their life story.   It becomes who they are at an early stage when they develop their own identity and sense of self.  Individuals told later in life are more likely to have more negative feelings about their donor conception than those told earlier. They may become angry about being deceived and often feel betrayed by the very people they thought were the most trustworthy in their lives, their moms and dads.  Hence, disclosure at an early age is recommended by professionals studying this issue.

I will address the question of disclosing the identity of the donor in my next blog.

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Nobel Prize to Dr. Robert Edwards, IVF Pioneer

By David Kreiner MD

October 5th, 2010 at 10:00 am


Yesterday, Dr. Robert Edwards, the IVF pioneer responsible for the first successful IVF in the world, was announced as the recipient of the 2010 Nobel Prize for physiology.  Dr. Edwards’ successful development of IVF technology was originally received by the public media as more science fiction than science.  As a first year medical student in 1977, interested in women’s health, I became motivated by writings on his work to become an IVF physician.  In 1980, I spent a month with Zev Rosenwaks at StonyBrook and started my reproductive endocrinology training.  By that time Howard and Georgeanna Jones had successfully started the IVF program in Norfolk, Virginia, duplicating Dr. Edwards work.

The Joneses had just moved to Norfolk after a forced retirement at Johns Hopkins and hadn’t finished unpacking when the greatest fertility event of all time hit the news.  Patrick Steptoe and Robert Edwards had succeeded in Great Britain with creating a new life through a process they called In Vitro Fertilization that the media had termed “test tube babies”. 

I had the great fortune to study REI (reproductive endocrinology, infertility) with the Joneses and Zev Rosenwaks in Norfolk from 1985-1988.  In 1988, I started IVF on Long Island which was successful then in about 25% of cases.  In 1990, I met Dr. Robert Edwards who impressed me with his wit, his charm as well as his great intellect.  I told him about my softball team named East Coast IVF that Dr. Edwards found particularly amusing.  After all the scientific and political challenges he overcame to successfully achieve a live birth through IVF, he was struck by the irony that IVF had become routine as a commonplace alternative for those with difficulty building their own families.

Today, IVF is now successful 50% of the time.  Four million babies have been born who if not for the technology of IVF would not be here today.  What a remarkable testimony to his scientific accomplishments.  Dr. Edwards truly deserved the Nobel Prize for developing this technology that led to the creation of so many lives.

As someone who owes his career to the man I am forever grateful and to those who have been touched through the birth of one of the 4 million we owe him much more than we can ever give.

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