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Archive for November, 2010

Thanksgiving in The Fertility World

By Dr. David Kreiner

November 24th, 2010 at 7:43 am

My mother always told me that when you do good deeds for others it pays off with interest.  Well, I never invested in annuities but helping couples with their struggles to build their families for the past 25 years now pays back with scores of pictures and thank you greeting cards on holidays like Christmas and Thanksgiving.

Some of these kids have even graduated college now and I suspect will be hoping to start a family of their own.  I believe that growing up in an environment where their parents’ love and sacrifice for them was so great that the concept of the family has an even greater meaning to them.

Unfortunately, as those of us in the field know all too well, building one’s family can come at a great expense and with much heartache.  Today, as it was 30 years ago, if you have a medical problem preventing you from getting pregnant, it is still unusual to have the insurance coverage to pay for it.  Success with fertility treatments, in particular IVF, is better than 50% per cycle today, far superior than what it was years ago.  Even so, many cannot take advantage of IVF due to the costs. 

As a result of my mother’s teachings, I try to create paths for my patients to afford IVF.  We utilize income based grants, research studies and discounts for single embryo transfer and minimal stimulation IVF or MicroIVF.  We even instituted a guarantee program for those who would like insurance in case IVF is not successful.

My wish is that any couple or woman who wants to start a family is not denied for financial or medical reasons.  With our innovative programs we are almost there making more and more people’s dreams of building their family a reality.

On this Thanksgiving, I would like to give thanks for my family and for all those who have helped enrich my life by letting me into their lives and allowing me to assist them with their family building.  Let us pray that with each passing Thanksgiving this circle of thanks continues to grow and we can make that many more families a reality.

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Managing Our Food, Infertilty and Anger

By Pamela Madsen

November 23rd, 2010 at 7:32 am

A few weeks ago – my best friend and fellow fertility blogger – Lisa Rosenthal wrote a great true confession blog entry called  "Angry Infertile Woman (me), Baby Showers and Bathrooms".

Lisa has always been good at "feeling her feelings".  Perhaps it is because she is has practiced yoga for years – she has learned to be still enough to let them in. I really don’t know how she mastered the fine art of staying still enough to really feel her emotions – but not everyone is so good at feeling their feelings.  For me – learning to truly feel my emotions has been a journey.  You see – it is not always comfortable to really be alone with our own stuff.

Do you really want to feel how angry you are at your body for not conceiving? Do you really, really want to allow the grief and sorrow to rack through your being at the first sign of blood when you prayed that you wouldn’t be seeing red for nine months? It’s hard to be alone with that kind of pain. In the end – we are alone aren’t we?  No one can really comfort us – not really.  And to really acknowledge that can feel terrifying.

It’s not that you may not cry, vent or throw a vase.  You may – but then you may move those really uncomfortable feelings away as soon as possible – telling yourself and others – that "I am fine – really. It’s okay" – when it’s really not.

So many of us – going through life (not just infertility) look for ways to dull the pain – or the intensity of any emotion. We want to avoid feeling the full intensity of what ever it is that we are going through. It can just feel like too much – so we eat – or over exercise – we may throw our venom at unsuspecting co-workers- or use drugs.  Many of us engage in addictive behavior to dull our senses – and distract ourselves from what is truly going on in our lives. What would happen if we didn’t? How would that change us?

I attended a workshop a few years ago – and we were asked to do this anger exercise.  It was quite cliche’ – we were suppose to hit pillows and scream. We were suppose to "feel our anger".  I ran from the room.  It felt like way too much for me.  I found simply listening to all of that rage being expressed in the room overwhelming – let alone confronting my own head on.

I escaped to the kitchen – and made tea to calm myself.  Why couldn’t I face my anger – I wondered while I absently ate a bag of organic cookies.  I remember waiting for the session to be over – and walking back to the empty workshop space strewn with pillows.  I picked one up and threw it down.  You know what? That felt pretty good. So I did it again – and then I added punching the pillows – and kicking them.  I added my voice and started to scream! I was primal!  I must have gone at it for fifteen minutes.  I actually allowed myself to be alone with my anger and really feel it instead of eating it.

And guess what? I didn’t die.  I didn’t take my anger out on my friends, family or co-workers.  I didn’t eat my anger. I had an experience of simply being in my anger. It was new for me.  I don’t know if you have ever just sat alone with your emotions – really let them. But afterward, I felt amazing.  I had really touched some places deep inside myself and I didn’t die! I could handle it – and just knowing that was amazing.

If you haven’t encouraged yourself to really stay with your feelings instead of pushing them under the carpet or into a pizza -  you might want to try it on.

It might take some courage – after all – who wants to feel all of those hard feelings.  But what you might find out if you do – is that it’s okay.  You don’t need to run from them.  You will make it through whatever it is in your life – and by truly feeling it – you are allowing yourself to heal instead of burying your life under excess weight, or other types of self destruction.

So what do you think? Does this make any sense to you at all? Or do I simply need to go eat a cookie?

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IVF: The Chances of Success

By Dr. David Kreiner

November 19th, 2010 at 10:44 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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Bringing Eastern Medicine to The Fertility Patient

By Dr. David Kreiner

November 15th, 2010 at 7:08 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  The Berkeley Center For Reproductive Wellness at East Coast Fertility has opened it’s doors at East Coast Fertility. It’s our hope to support you in every way to build your family.

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Report From The 2010 American Society for Reproductive Medicine Meeting

By Dr. David Kreiner

November 10th, 2010 at 10:58 pm

It has been two weeks since my return from this year’s national fertility meeting, the ASRM (American Society for Reproductive Medicine) which was held in Denver this year.  It is the time and place that breakthroughs in fertility care are announced, results of research studies are discussed, problems and issues of the day are hammered out.

A few national trends were evident throughout the meeting.  Single embryo transfer is becoming common place and successful.  In some studies, it was as reliable as double embryo transfer in obtaining a baby.  Noteworthy, was a study out of the Cornell program which attempted to dispute the previously reported increase in pregnancy complications associated with IVF pregnancies.  They showed in their study that when only one embryo was transferred there was no increase in preterm birth complications.  They proposed that multiple embryo transfers perhaps with multiple implantations that spontaneously reduce to singletons are the cause for the reported increase in IVF pregnancy complications supposedly seen in singleton pregnancies.  This was yet another argument in addition to reducing the risk to multiple pregnancies proposed for transferring a single embryo at a time. 

Questions were raised as to how to motivate patients to transfer only one embryo at a time.  In addition to education, the concept at East Coast Fertility that is to offer those who transfer one at time free cryopreservation, storage and frozen embryo transfers was being practiced currently by at least one other program.  I believe we will be hearing next year that this became a nationwide practice.

There were several studies showing excellent success with minimal stimulation IVF.  Program directors actively providing minimal stimulation IVF complained that no distinction was made in the SART reporting so that the lower pregnancy rates seen with minimal stimulation still hurt those programs’ pregnancy statistics.   Hopefully, this much less expensive, less invasive, safer alternative will be evaluated separate from full stimulation IVF so programs that offer this service to patients are not discriminated against for doing so.

Perhaps the most exciting advance I heard about during the meeting was the improved pregnancy rates and diminished miscarriage rates seen with the 24 chromosome analysis preembryo genetic diagnosis.  This was being offered at the Blastocyst stage to improve cost effectiveness and reduce error and injury to the embryo.  If this holds up then the promise of improving pregnancy rates of a single embryo transfer known to be genetically normal will become the standard of care not just improving the efficiency of IVF but perhaps making it as safe as a naturally conceived pregnancy

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