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Archive for December, 2010

Embryo Rejection

By Dr. David Kreiner

December 29th, 2010 at 8:29 am

Dear Fertility Doc:

Two months ago I had my first IVF cycle & it did not work. I was wondering what common reasons there are a body would reject the 2 embryos that seemed to look good on the 3rd day?
A few years ago I had a healthy child that came naturally with out even trying. In the past 2 years I’ve had an ectopic pregnancy resulting in removing a tube as well as a miscarriage. It’s hard to understand why it was so easy to get pregnant naturally a few years back & why everything we have done since that time has not worked. Also, if a fresh embryo transfer didn’t work on day 3, would you recommend trying a frozen transfer or a fresh transfer again.

Still Not Pregnant

Dear Still Not Pregnant,

I often hear patients refer to a failed embryo transfer as an embryo rejection. I suppose it appears to make sense as the embryos that are being transferred appear completely normal. The disconnect between what appears to make sense and the reality of the procedure of IVF is that the creation of life is an enormously complex process truly beyond the level of human understanding.

Great strides have been made in the process resulting in pregnancy rates exceeding 60% for some groups. However, the apparent quality and grade of an embryo predicts the likelihood of a resulting pregnancy. It is far from guaranteeing a pregnancy. New tests for the viability of an embryo are being developed such as metabolomics and proteinomics. These assess an embryo by analyzing products of an embryo in culture. They will further the likelihood of achieving a pregnancy from a transferred embryo.

Remember, that though an embryo may be otherwise viable it may still be abnormal genetically which will diminish pregnancy rates and usually result in miscarriage when implantation does occur. The likelihood of a genetically abnormal embryo developing increases especially as the age of the woman increases as well as with severely decreased sperm counts in the male.

The decision to go forward after a failed fresh transfer with a frozen transfer of sister embryos or a new fresh transfer should be individualized based on the quality and grade of the frozen embryos, the age of the woman, her

insurance coverage and her tolerance for the stimulation and retrieval as well as her motivation and patience. I recommend you have this conversation with your physician who can advise you better about your specific situation.

I wish you the best of luck!

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How Old is Too Old to Get Pregnant?

By Dr. David Kreiner

December 27th, 2010 at 9:21 am

The world’s oldest Mom after IVF, using donated eggs, is dying at age 72. It was just 18 months ago when she gave birth. When she was 70, Rajo Devi Lohan and her husband Balla underwent IVF treatments in Baddhu Patti, India, to conceive their only child, Naveen.

Now 72, Rajo is bedridden and doesn’t have the strength to lift 18-month-old Naveen. She has never recovered from her pregnancy.  Her uterus ruptured after her c-section and she suffered from internal bleeding.

Rajo and Balla, 73, farmers who have not received any education, say they did not know it was high risk to have a baby at their age, and  claim that they were never warned of any possible complications by their doctor.

The National Fertility Centre in Haryana, where Rajo received her treatments, also helped another Indian woman, Bhateri Devi, give birth to triplets through IVF when the woman was 66. The center claimed no wrongdoing in performing IVF in either women.

Last year, another aged IVF “success”, Maria de Carmen Bousada (the oldest mother to conceive at the time with donated eggs) died.

My first thought in both of these cases was to extend my sincere condolences to their families and in particular to their children.   My heart truly goes out to them. It is a great tragedy when a death occurs especially when it is the mother of such young children. I hope and pray that Rajo and Maria’s families and friends find the strength to replace the love and nurturing typically given by a mother to her child. My second thought as a fertility doctor was that once again – the world of infertility was making the news because we continue to push the edges of what society views as acceptable.

This is one of the hardest things about being a doctor in a cutting edge field such as reproductive medicine. We are often put in the position of making decisions with our patients that have even bigger implications to society than the individual patient. I do my best to look at each patient, and each situation individually.

However, there does appear to be a point, even an age at which the risk outweighs any potential benefit of biological motherhood.

Women who have lived their lives with a burden of not being able to conceive a biological child often are psychologically stressed to the point of irrationality.  It is up to the responsible physician to discriminate those individuals who are placing themselves, their potential future child and society at risk through IVF.

We dare not cross the boundary of acceptable societal ethical standards in our utilization of technology without guidance or conscience otherwise we can hurt our patients, our children we help create and society.  There needs to be governmental control preventing aberrant unethical use of technology like performing IVF on senior citizens.

Many critics state that beyond a certain age, it is unnatural to become a mother and that it puts the family at risk that she may not be around to help raise the child as what is occurring in these cased, or even if she is perhaps she lacks the energy and stamina to raise the child properly.

So where does a clinic in good conscience draw the line.  At East Coast Fertility, we have a cutoff of age 50 which is admittedly arbitrary and that limit is often broken when faced with an energetic couple where the woman is healthy enough to go through pregnancy as determined by an internist and high risk maternal fetal medicine physician. We recently celebrated our latest 54 year old patient’s delivery of a healthy baby that was highly reported in the press.

It may be impossible to agree on a proper upper age limit to have a child.   Our policy may be inappropriate for others who have a completely different perspective. My responsibility as the physician offering assistance to patients in need of help with procreation is to the health of my patients, the well being of the child and for the good of society.

Since many women in their 50’s have the health and energy to carry a pregnancy and bear a child with no more increased risk than many woman 10-20 years younger whose interest in achieving pregnancy we would never consider questioning. That being said what about the risk that the mother may not still be around to raise the child to maturity. There is no question that a young healthy couple with sufficient financial support and emotional maturity is ideal for raising a family. But, happy, successful families can take on many different faces. Single parent families exist, survive and often thrive. One can never be certain that the condition of the couple at the time of conception will continue through the child’s birth or for that matter until the child has reached maturity. We do not know that a healthy woman of 30, 40 or 50 may not develop a lethal disease before a child has grown up. In addition, at least 50% of couples in the United States become divorced. One can argue that couples at risk of divorce should not get pregnant. I do not think that society is ready to conclude that any of these women should not be allowed to procreate.

For me, and for our program we have raised our bar to do the proper due diligence that our patients are healthy and will make potentially capable parents and have been adequately counseled regarding any risks. We utilize trained psychotherapists, consent forms, videos and personal discussions with our patients to achieve this. I don’t want to be “The Fertility Police” but as a fertility doctor, my job is to help capable people build their families no matter how different those families may look to you and me and without undue risk to patient, child or society.

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In Today’s World – Doctors Need To Talk About Money

By Dr. David Kreiner

December 19th, 2010 at 6:39 pm

One of the most distressing things I face in practice is when I get negative feedback from a referring physician.  Fortunately, it happens rarely but recently I was shocked about the complaint.  Apparently, his patient was offended that I discussed the finances involved with her treatment.  Her Ob Gyn agreed with her that it was inappropriate for me to discuss the cost of her options.  He told me, “I like you and think East Coast Fertility is an excellent program but I never talk about money directly to patients!  It’s not – I don’t know…seemly!”   “Money issues are discussed with the business office, the doctor only discusses the medicine”.

Perhaps it’s unfortunate that fertility doctors have to be so concerned about their patient’s pocket books unlike other fields of medicine that are usually covered by some measure of insurance.  But in the case of infertility with only a handful of states having some kind of mandated coverage – not everybody in the United States -  mandate or no mandate for infertility  -even has health insurance!  Many fertility patients are in some form or another “cash pay” patients.  One of the most popular places that patients visit when they go to any fertility clinic’s website is the finance page.  This is simply a fact of life.

For this reason I have developed many programs that will create access to fertility care for as many people as possible.  But here is the catch! One program does not fit all. These are simply not over sized tee shirts – each of these programs represent a certain course of  medical care – and each individual and couple needs the assistance of a caring doctor to help them choose the right program that will fit their own particular medical history.  In addition to the NY State DOH Grant Program and our own East Coast Fertility Grant Program, we have the Micro-IVF Program, The Money Back Guarantee Program,  and The Single Embryo Transfer Program.  The most effective treatment and the most efficient is always a full stimulation IVF. However, if someone has insurance coverage for IUI and meds but not IVF then they may prefer to do IUI. If they do not have coverage for IUI either then it may be more cost effective to do the Micro-IVF Program or minimal stimulation IVF at 2-3 x the success of IUI with less risk than gonadotropin IUI and less cost per pregnancy. Yet at a price of $3900 it may be more attractive than a full stimulated IVF. There is also The Single Embryo Transfer Program where we reward patients transferring one embryo at a time by making their cryo, embryo storage and unlimited frozen embryo transfers for free.  Others prefer the insurance of The Money Back Guarantee Program where patients are offered six IVF retrievals and frozen embryo transfers for a fixed fee that is refunded if they do not result in a live birth.   In order to inform patients about our success and programs that make IVF more available to them we offer free consultations.

In today’s world of fertility care – a good doctor will help a patient find not only the right treatment but how to access that care.  In order to do that – a doctor may have to do what some may think is unseemly – and that is to talk about money

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What You Need To Know About a Fertility Work Up

By Dr. David Kreiner

December 19th, 2010 at 6:27 pm

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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The Fertility Doc Talks Weight and Unexplained Infertility

By David Kreiner, Md

December 17th, 2010 at 8:15 am

Dear Fertilty Doc,

I have struggled for a few years now with the term "unexplained infertility". My husband and I have been trying to conceive for several YEARS now with no success. I have had every test under the sun. I have been poked, injected, inseminated, Dye tested, ovarian reserved looked at, both tubes perfect and finally told that I have "unexplained infertility". Your only hope of conceiving will be through IVF I was told and then in the next breathe I heard ‘but your BMI is 44 and we need you to lose 30 pounds and then we can help you.’ This of course was after being told I have ”low ovarian reserve’ and as I approach the infamous age of 35. So, we need you to lose the 30 pounds before you turn 35 ( talk about added pressure) or there won’t be much any REI can do for you, Really, I thought? I guess my question is why is this acceptable? my husband and I have worked hard to be able to afford IVF only to be told ‘good luck with that’. I guess I can’t understand if my ovarian reserve such an issue why is my weight a bigger issue. So we did what anyone receiving this kind of news would do…we got a 2nd and 3rd opinion but all the doctors echoed the same thing just in a different tone. I am trying to lose the weight (down 4 pounds already) but I wonder your thoughts on this and how you would feel if you were me. Thanks for reading!

 Dear Ms Z,

    You bring up three issues that are dear to me and many patients I have encountered over the years. The first is dealing with the diagnosis of "unexplained infertility", as if giving the fact that specialists cannot identify the cause of your inability to conceive a name makes dealing with the frustrations and disappointments any easier. It doesn’t. Fortunately, our field has made much greater strides in the treatment arena than we have with diagnosis. Truly "unexplained infertility" patients have a 60% pregnancy rate per cycle with IVF today. Presumably, the unexplained cause is related to sperm access to the egg or the fertilization process itself. Additionally, the IVF process can sometimes identify covert causes of infertility.

    Second, I have always been offended by the prejudice openly expressed in the field of REI against the obese patient. Sometimes, treatments may be more difficult in these patients but the excuse that they are more dangerous and pregnancy more hazardous need be examined and tested and patients counseled regarding potentially greater risks rather than simply delaying or denying therapy. In my hands, IVF success is equivalent in the normal weight patient as it is to the obese and morbidly obese patient. Medical health to sustain IVF, anesthesia and pregnancy need be evaluated and patients counseled. Options of bariatric surgery could be offered. At ECF we offer discounts to women who undergo such surgery in preparation for their IVF when indicated.

    The third issue is diminished ovarian reserve. Obesity does not cause this problem nor will losing weight fix it. If this is identified in a woman then that is a cause of infertility and this is not "unexplained infertility". AMH in addition to day 3 E2 and FSH as well as antral follicle counts should clear this up. If not a letrizole challenge test or clomid challenge test will do so. In some cases pretreatment with DHEA may improve ovarian responsiveness as may accupuncture.

    I wish you a happy holiday and a better 2011.

 

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