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Archive for February, 2015

Fibroids and Fertility

By David Kreiner MD

February 24th, 2015 at 6:59 am

 

photo courtesy of dream designs/freedigitalphotos.net


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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Anyone have a fibroid story to share?

 

Photo credit: http://www.freedigitalphotos.net/images/female-reproductive-system-photo-p284491

 

 

 

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Additional Extended Evening Office Hours at Long Island IVF

By Tracey Minella

February 23rd, 2015 at 11:23 am

 

Did you know that Long Island IVF offered evening office hours? Well not only have we offered extended hours in all of our offices for ages, we’ve added even more!

 

Infertility treatment can be stressful. And while some appointments and blood tests simply need to be done in the early morning hours, there are times when an evening appointment is feasible and might be more convenient. Especially for those who work full-time or who might be taking off certain mornings for less flexible monitoring appointments.

 

We’re pleased to announce that in an effort to be even more accessible to her patients, Dr. Satu Kuokkanen will be available on Wednesday evenings in the Lake Success office, starting in March.

 

The hours, nights, and doctors covering these evening appointments vary for each office so check with your doctor or LIIVF office for the specifics. Or if you are a new patient, contact the office you’re interested in for more information.

 

 

 

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Is the availability of evening doctor appointments an important factor in your decision to choose a reproductive endocrinologist?

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Will You Conceive in the Chinese Year of the Sheep, Um, Goat?

By Tracey Minella

February 19th, 2015 at 8:40 pm

credit: Feelart/ free digitalphotos.net

You don’t have to be Chinese to appreciate the richness of that culture’s traditions and the mystique of the Chinese methods of enhancing fertility.

 

The Chinese zodiac consists of a cycle of 12 years, with each year being named for a different animal, and supposedly bestowing upon those born in that year certain characteristics which are similar to the traits of the featured animal.

 

It’s the celebration of Chinese New Year. The 2014 Year of the Horse is ending. Each year, the passage of one animal year to the next is clear and routine. Except for the year that follows the year of the Horse. This year. Why?

 

An apparent ambiguity in the interpretation of the term “yang” has led to a difference of opinion among Chinese people on whether the year after the horse is the year of the ram, sheep, or goat. But the Chinese zodiac symbol recognizes it as the year of the Goat, so we’re going with that.

 

Children born in the Year of the Goat will be among other things “gentle, mild-mannered, shy, stable, sympathetic, amicable, and brimming with a strong sense of kindheartedness and justice”. * How wonderful!

 

But despite these great Goat qualities, many Chinese people try hard to avoid having children born during the year of the Goat. This is due in part to a popular Chinese folk saying ‘Only one out of ten people born in a year of the Goat finds happiness’ (十羊九不全). While this may seem to be a silly superstition to many…especially to infertile couples who usually wouldn’t care what day or year their baby was born…there is a real concern among many Chinese that Goat babies will be followers, not leaders, and may be destined for failed marriages, unhappy families, and bad luck.*

 

So, in the spirit of seeking all the good luck we can get when trying to conceive, I offer these four tips taken from Chinese New Year traditions.

 

Make Dumplings: On New Year’s Eve, the Chinese often celebrate by eating dumplings called “jiaozi”, which translates literally to “sleep together and have sons” according to http://www.theholidayspot.com. If you’re not “culinarily-challenged”, consider making these challenging dumplings.

 

Sweep Away the Bad Luck: Then, sweep out the house from top to bottom with a broom and give it a good cleaning. It symbolizes the sweeping away of all the bad luck of the past year so the good luck can enter. I do this religiously every single year. It feels authentic. You must try it.

 

Wear Red: Wear something red. It’s the color of good luck and symbolic of wealth. The Chinese elders often give young ones red envelopes with money inside on Chinese New Year. Maybe you can start a new tradition and break out a red envelope and get your relatives to contribute to the IVF fund.

 

Hide the Knives: Put away the knives…this is good advice for hormonal women anyway. Using knives and scissors at this time symbolizes the “cutting off” of the good luck and is an omen of bad luck in the year to come. Remember this one at mealtime.

 

You don’t have to be Chinese to embrace some of the Chinese culture

and have some fun with Chinese New Year traditions. Wear red. If you’re feeling adventurous, try making a batch of jiaozi from an internet recipe. Or just buy some wonton soup! Try your hand at chopsticks. Surround yourself with the richness of red and gold. Sweep out that old bad luck and embrace the New Year that awaits.

 

Basically, do whatever floats your goat.

 

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Do you celebrate Chinese New Year or follow any other cultural traditions with fertility-related traditions? Would the characteristics associated with children born in a particular year of the Chinese zodiac impact your family-building plans in any way?

 

 

* http://www.chinahighlights.com/travelguide/chinese-zodiac/goat.asp

Photo credit: http://www.freedigitalphotos.net/images/Other_Holidays_and_E_g321-Chinese_Lanterns_p140201.html

 

 

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To Single Embryo Transfer (or Not to)?: That is the Question

By Tracey Minella

February 11th, 2015 at 12:24 pm

 

Credit: stockimages/ freedigitalphotos.net


One of the hardest parts of undergoing in vitro fertilization is the difficult decision of how many embryos to transfer back…because each embryo transferred has the potential to implant and develop into a baby.

In the 1980s when IVF was new and success rates were understandably low, it was common to transfer as many as 6 embryos back. Even then, many women did not conceive. Others conceived multiple pregnancies. Still others conceived only one.

Happily, today the technology has been dramatically fine-tuned, resulting in much higher IVF success rates and, because fewer embryos are being transferred, fewer multiple pregnancies.

Some women can’t or don’t want to have a multiple pregnancy and are interested in a program that virtually eliminates the risk of more than a singleton pregnancy. Some of their reasons include possible health risks for the mother or babies, concerns over the higher costs of raising multiples, or the fear of being placed on bed rest and its potential financial impact.

On the other hand, because IVF can be expensive and often not covered by insurance, and because the couples attempting it may have already been trying to conceive for a long time with and without medical assistance and expense, it’s tempting to want to “put all your eggs in one basket”. These couples want to transfer a higher number of embryos back to maximize their chance of conceiving in that one cycle or because they can’t afford to do more cycles. Many couples think of the possibility of twins as a bonus. Two-for-one. Instant family. Dream come true.

But if the financial burden was lessened, and the odds of a live birth from transferring one embryo were nearly comparable to the odds for transferring more, would that make a difference to you? Would you opt for the statistically safer singleton pregnancy vs. the statistically riskier multiple pregnancy? Would you really prefer a multiple pregnancy or would you rather have a succession of singleton pregnancies, the way you originally planned before infertility entered your life?

Deep, emotionally-charged decision. No right answer. Just the right answer for you.

Some good news that may affect your decision is 20-year study of 92,000 patients from Denmark, Norway, Sweden, and Finland, recently published in the on-line Oxford Journal, Human Reproduction, on January 21, 2015. The Nordic study found that the health of children born from IVF has significantly improved and that the risks of pre-term or severely pre-term births have declined dramatically…and it’s primarily due to transferring just one embryo. In addition, the stillborn and infant death rate for singletons and twins born through IVF has declined. http://bit.ly/1Ejgg1o

For those interested, Long Island IVF has a well-established Elective Single Embryo Transfer Program with success rates comparable to traditional IVF in select patients. If you elect to transfer one embryo in your fresh cycle you get free cryopreservation of your embryos and free storage for six months or until a live birth occurs. As an additional incentive to motivate patients to make safer choices, we offer patients transferring a single embryo during their fresh stimulation cycle up to three frozen embryo transfers, within a year of their retrieval or until a live birth occurs, for the price of one. For more details and information on whether SET may be right for you, visit http://www.longislandivf.com/single_embryo_transfer.cfm or ask your LIIVF physician.

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What did/would you consider when deciding how many embryos to transfer? Is the elective SET program something you did/would consider? Why or why not?

 

 

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The IVF Transfer

By Tracey Minella

February 7th, 2015 at 9:24 am

 

photo credit: marin/freedigital photos.net


In vitro fertilization (IVF) is a long process. The transfer is at the end of the line.

When people do IVF, they endure weeks of daily hormone injections and blood work and ultrasounds designed to make the woman produce more than the one egg she would otherwise likely produce. When the time is right, an injection is given that leads to the final maturation of the eggs and the egg retrieval is scheduled for about 34 hours thereafter, so that the eggs will not be ovulated and the cycle lost.

Once the eggs are retrieved, they are placed in a petri dish with the partner’s sperm, and in some cases, Intra-Cytoplasmic Sperm Injection (ICSI) is performed. With ICSI, a single sperm is isolated and injected into a single egg to increase the odds of fertilization, usually in cases where sperm count or quality is an issue. Then, you wait a day for a fertilization report.

If there is fertilization, the resulting embryos are continually monitored and graded based on how they grow and develop. An agreed upon number of Day 3 embryos (or Day 5 blastocysts) get transferred back to the woman’s uterus via catheter. Each embryo or blastocyst has the potential to develop into a baby, or in rare cases, may even split into twins. Excess embryos are usually cryopreserved (frozen) for future use.

In order to make it to Transfer Day, a couple must survive all the prior phases: cycle suppression, ovarian/follicle stimulation with blood work that corresponds to the number and size of the follicles, a uterine lining that is thick enough for embryo implantation, retrieval of quality eggs, fertilization of eggs, development and growth of quality-grade embryos. Then, the transfer.

Optimists may relax more as each hurdle is cleared. Worry-warts hold their breath ‘til the end. And even then, they beg to lay there for the next two weeks with their hips elevated by pillows or they slam their partners’ driving with every bump on the ride home.

The transfer is a magical moment. It’s not only the end of the treatment cycle, but for many it’s the closest they may ever have been to getting pregnant.

The beauty of IVF comes in the knowledge that you did create embryos…they are real and you can literally see them. If you get pregnant you have breathtakingly beautiful photos of your child from the earliest moments of conception. You know the exact date of conception. You even see the glow of the embryos in the uterus after transfer.

There is nothing quite like the feeling of hope on transfer day. You can bask in the literal moment you may be becoming a mom. Visualize implantation happening. Will it to happen. Allow yourself to believe it because you never know what the effect of positive thinking could be.

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What was your transfer day like? What do you most remember about it?

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Age and Fertility

By David Kreiner MD

February 2nd, 2015 at 4:23 pm

 

credit: photostock/free digital photos.net


You’ve heard the “Reproductive Bell” toll and may question “Is it real?”…

You see celebrities getting pregnant well into their 40’s and think “Then why can’t I?” So, is your reproductive clock as critical as modern doctors say?

I have come across fertility advice from non-physician practitioners, such as acupuncturists and Chinese herbalists, who encourage their patients to “question the Western dogma” when it comes to age and fertility. They claim the effect of aging and fertility is “exaggerated by the Medical profession and can be overcome with a shift in an individual’s health and lifestyle”.

Unfortunately, this advice comes without any cited research or statistics in support of it.  According to the Society of Assisted Reproductive Technology, as published on SART.org, a review of the 2012 national statistics, those most recently published of IVF cycles started, the age breakdown for IVF live birth rates are the following:

 

Age <35= 40.2%

 

Age 35-37=31.3%

 

Age 38-40=22.2%

 

Age 41-42=11.8%

 

Age >42=3.2%

 

It is true that a woman’s health and physiology gets worse as she gets older.  Some of these non- physician practitioners argue that perhaps if this can be improved then the diminishing fertility commonly seen with aging can be reversed. But though improving a woman’s general health may help it is not sufficient in most cases.  Fertility rates decrease with increasing age in large part because there is an increase in genetic abnormalities found in gametes (eggs and sperm) as patients (women in particular) age.  This is the result of long-term environmental exposure to toxins, in addition to the increased likelihood of genetic damage over time.  Miscarriage rates increase with age for the same reason in large part due to the greater likelihood of embryos having chromosomal abnormalities.

Many women as they age also will experience a significant drop in their ovarian activity, referred to as diminished ovarian reserve.  This activity can be assessed by your physician with a blood level of Anti Mullerian Hormone (AMH) and day 3 FSH and estradiol levels.  Women with lower AMH levels and elevated FSH in the presence of a normal low estradiol have fewer ovarian follicles, and hence eggs, that will respond to ovarian stimulation.  Since the likelihood of these eggs being genetically normal is less, then fertility is reduced and the probability of IVF and other fertility treatments resulting in a live birth becomes significantly lower.

The challenge to any practitioner dealing with an aging patient attempting to conceive is to optimize their patient’s chance to have a healthy baby which optimally would include an integration of multiple modalities.  Therefore, ideally a physician specially trained in the fertility process (a Reproductive Endocrinologist), should implement state-of-the-art Western therapies with a complementary holistic approach that aims to shift their patient’s health and fertility.  These holistic approaches include diet and lifestyle changes as well as fertility-directed acupuncture and herbal therapy treatments.

Lifestyle changes that may improve fertility primarily include those that reduce stress and improve diet and activity.  Stress at work, at home, and with family and friends can create pathology from both Eastern and Western perspectives.  Diets that do not support adequate blood production or create Eastern patterns of cold or heat can affect fertility.  Excesses or deficiencies of particular foods…such as dairy, fat, or grains… can create imbalances or pathology that may affect fertility or result in obesity or malnutrition which also impact reproduction.

Inactivity may impair fertility. Therefore some level of exercise, combined with an improved diet directed at improving fertility, stress reduction techniques, acupuncture, and supplements (which may include Chinese Herbs as well as Western supplements) will optimize your chances of successfully building your family.

The first step is to seek help from a reproductive endocrinologist skilled in state-of-the-art fertility therapies who can coordinate a program which is ideal for you. But if you are hearing the “Reproductive Bell” tolling, it is important to take that first step soon, because, while these many complementary approaches can optimize your fertility, they may not be enough to overcome the reality of the negative effect of advanced age in fertility.

Long Island IVF offers complementary holistic approaches to achieving pregnancy (See our Mind-Body Program http://www.longislandivf.com/mind_body.cfm ) as well as a well-respected Donor Egg Program http://www.longislandivf.com/donor_programs.cfm  with no wait for pre-screened, multi-ethnic donor eggs, or Donor Embryos.

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Has the increased visibility of older celebrity moms getting pregnant made you think you have more time? Have you considered combining Western and Eastern medicine in your family-building treatment?

 

 

http://www.freedigitalphotos.net/images/Younger_Women_g57-Young_Woman_Holding_Clock_p49428.html

 

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