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Archive for September, 2015

5 Popular Misconceptions Regarding Polycystic Ovary Syndrome (PCOS)

By Joseph Peña, Md, Facog

September 30th, 2015 at 6:41 pm

credit: supertrooper/ freedigitalphotos.net

Like a bedtime story at the end of a long day, let’s end PCOS Awareness Month with a tale of five myths about PCOS as told by Dr. Pena…

Myth #1 – “If I have irregular periods, I have PCOS”.

Women with irregular menstrual periods are often unaware of the reason for their menstrual irregularity.  Many women are placed on hormonal contraceptives (i.e. birth control pills) by their gynecologist to regulate their menstrual periods and prevent an overgrowth of the lining of the uterus that may lead to cancer if left unchecked.  Some women are told they have PCOS as this is the most common etiology for irregular menstrual periods (4-7% of women of reproductive age, ~60-85% of anovulatory women), while others are not given a specific reason for their irregular menstrual periods.

While there is no universally accepted definition for PCOS, there are a few expert groups which have generated diagnostic criteria.  The Rotterdam Consensus Criteria (2006) requires two of the three signs/symptoms of PCOS (hyperandrogenism, irregular menstrual periods, polycystic-appearing ovaries on pelvic ultrasound) to be present for the diagnosis to be made.  The Androgen Excess Society (2006) requires hyperandrogenism plus one of the other two signs/symptoms (irregular menstrual periods, polycystic-appearing ovaries on pelvic ultrasound).  The hyperandrogenism criteria may be satisfied by either the presence of hirsutism (excessive hair growth) or elevated androgen levels, such as testosterone.  However, both criteria recommend excluding other possible causes of these signs and symptoms.  The differential diagnosis of someone with irregular menstrual periods and/or hirsutism is listed in the table below.

Differential Diagnosis of Polycystic Ovary Syndrome (PCOS)
—  Thyroid disease (hypothyroidism, hyperthyroidism)—  Prolactin/Pituitary disorders—  Nonclassical congenital adrenal hyperplasia (Nonclassical CAH)

—  Androgen-secreting tumor (ovary, adrenal gland)

—  Exogenous androgens

—  Primary hypothalamic amenorrhea (stress-related, exercise-related, eating disorders, low body weight)

—  Central nervous system tumors/disorders

—  Primary ovarian failure

—  Cushing syndrome

—  Insulin-receptor defects

 

The proper evaluation of a woman with irregular menstrual periods and confirmation of PCOS is important because this affects treatment (e.g. combined hormonal contraceptives for PCOS, thyroid hormone replacement for hypothyroidism, corticosteroid replacement for nonclassical congenital adrenal hyperplasia, surgery for androgen-secreting tumor, etc.), as well as determining future fertility treatment (e.g. clomiphene citrate for PCOS, dopamine agonist for hyperprolactinemia, in vitro fertilization using donor oocytes for ovarian failure, etc.).  Thus, it is important for women to ask their physicians for a diagnosis for their irregular menstrual cycles.

 

Myth #2 – “Regular menstrual periods means I’m ovulating”.

The menstrual bleeding that occurs in a woman with inconsistent or absent ovulation is more likely due to breakthrough bleeding rather than post-ovulation withdrawal bleeding.  Thus, vaginal bleeding cannot be assumed to be an indication of ovulation in these women.

In addition, while many women and some clinicians use a history of regular menstrual cycles as a predictor of normal ovulatory function, ~40% of normally-menstruating women who exhibit hirsutism (excessive hair growth) are, actually, not ovulating and may be classified as having PCOS or other diagnosis associated with hyperandrogenism.

 

Myth #3 – PCOS is an ovarian cystic problem.

PCOS is an endocrine disorder of androgen excess with defined diagnostic criteria as noted above in Myth #1.  The determination of “the polycystic ovary (PCO)” (in contrast to the syndrome, PCOS) is defined in the table below.

Determination of polycystic appearing ovary (PCO)
—  In one or both ovaries, either:—  >12 follicles measuring 2-9mm in diameter—  Increased ovarian volume > 10 cm3

—  If there is a follicle > 10mm in diameter, scan should be repeated at a time of ovarian quiescence in order to calculate volume/area

—  Presence of one PCO is sufficient for diagnosis

 

From the table above, it can be seen that PCO does not refer to and is very different from clinical ovarian cysts, both physiologic (e.g. corpus luteum) and pathologic (e.g. endometrioma, dermoid tumor), which tend to be larger in size.

The characteristic PCO emerges when a state of anovulation (lack of ovulatory cycles) persists for any length of time.  ~75% of anovulatory women will have PCO.  Since there are many causes of anovulation, there are many causes of PCO (e.g. PCOS, congenital adrenal hyperplasia, hyperprolactinemia, hyperandrogenism, type 2 diabetes mellitus, eating disorders, etc.).   PCO is the result of a problem with the normal functioning of the ovaries, and not necessarily from a specific individual cause.

Last but not least, PCO is not necessarily a pathologic abnormality.  Up to 25% of women who menstruate and ovulate normally will demonstrate PCO on ultrasound.

 

Myth #4 – “PCOS does not occur in thin or normal-weight women, or in women without excessive hair growth”.

While obesity and hirsutism (excessive hair growth) are relatively common in women with PCOS, with a prevalence of 20-60% and 30-80%, respectively, there are many women with PCOS with neither feature.  Again, referring to the diagnostic criteria for PCOS (see above in Myth #1), the presence of obesity is not necessary.  Hirsutism is just one manifestation of hyperandrogenism.  The other is biochemical, such as elevated androgen levels in the blood.  Certain ethnic backgrounds (e.g. Asians) may genetically not manifest hirsutism despite elevated androgen levels.  Thus, being thin or of normal weight and showing no signs of excessive hair growth does not necessarily eliminate PCOS as a diagnostic possibility.  Other common (but not necessarily required) features of PCOS are listed in the table below.

FEATURES OF POLYCYSTIC OVARY SYNDROME

PREVALENCE

CLINICAL
     Hirsutism (excessive hair growth) 30-80% (depends on ethnicity)
     Acne 15-20%
     Androgenic alopecia 5-10%
     Obesity 20-60%
     Anovulation 90-100% (depending on definition)
     Oligo/amenorrhea (irregular/absent menses) 50-70%
OVARIAN
     Polycystic appearing ovaries 70-80%
BIOCHEMICAL
     ­ LH/FSH 35-95%
     ­ free testosterone 60-80%
     ­ total testosterone 30-50%
     ­ DHEAS 25-70%
METABOLIC
     hyperinsulinemia 25-60%

 

 

Myth #5 – “Irregular menstrual periods due to PCOS is only a problem when trying to conceive.”

Obesity, irregular menstrual periods, and elevated insulin levels are common features of PCOS and significant risk factors for the development of an overgrowth of the lining of the uterus (endometrial hyperplasia), which may lead to cancer, if left unchecked.  It is not surprising then that women with PCOS are at an increased lifetime risk for developing endometrial hyperplasia and cancer of the lining of the uterus.  Thus, it is essential for a woman with PCOS who is currently not interested in conceiving, to discuss with her gynecologist the best option for her to decrease her risk for developing endometrial hyperplasia/cancer.   Options that might be considered include the use of [low-dose combined] hormonal contraceptives (e.g. the pill, transdermal patch, vaginal ring), progesterone-only pill, progestin IUD, and/or withdrawing with progesterone at regular intervals.

Women with PCOS are also thought to be at increased lifetime risk for developing type 2 diabetes mellitus and cardiovascular disease (abnormal cholesterol and other lipids, high blood pressure).  Regular screening for pre-diabetes or diabetes (with a 2-hour glucose tolerance test or fasting glucose level), body mass index, fasting lipid profile, and metabolic syndrome risk factors is essential to possibly help improve mortality and morbidity in such individuals.  Early intervention with lifestyle modification (diet, exercise, weight loss) and pharmacological treatment if needed (e.g. insulin-sensitizing agents, statins) may help to accomplish this.

Thus, PCOS is more than simply a problem of infertility.  It is a condition which should be discussed with one’s physician (gynecologist, primary physician, endocrinologist) even when one is not actively trying to conceive.

 

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Did you learn anything from this post that you hadn’t known before? Do you have any other questions about PCOS?

 

 

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Infertility and the Wrong Path Taken

By David Kreiner MD

September 22nd, 2015 at 12:41 pm

Image credit: wpclipart.com


A day of atonement is when people reflect on the choices they’ve made and the goals they’ve set and ponder things like what mistakes or wrong decisions they may have made that have led them down a path they did not intend to take. Sometimes, mistakes may have landed patients on the path of infertility.

Dr. Kreiner examines a common situation he encounters where poor decisions…or indecision…on behalf of patients and their GYNs leads them down a path they certainly did not intend…

A friend of mine was complaining to me about the trouble he got into with his homeowner’s association because he did not hide his empty garbage cans in his garage but left them behind his cars in front of his house.  It was 20 feet from the curb, he claimed, still distraught that he should have been scolded for breaking the rule.  “I didn’t know”.  That phrase, “I didn’t know” clicked in my brain as a recurrent declaration from the frustrated patients who I see every day.

My infertility practice is filled with patients who spent years of their lives all the time assuming that their fertility would be there when they were ready.  Some even mentioned their failed attempts at conceiving to their gynecologist who may have reassured them or if it were a more aggressive clinician, he may have put them on Clomid for 3 to 6 months.  Meanwhile these women got older, many over 40 not realizing that time was chipping away at their fertility.  “They didn’t know”.

A fertility screen is a good way to assess annually what is happening to your fertility independent of your age.  This is accomplished by getting day 2 or 3 FSH and estradiol levels as well as an ultrasonographic antral follicle count.  An AntiMullerian Hormone level can be checked at any point in the cycle and likewise reflect the relative number of eggs left giving some reassurance about a person’s remaining fertility.

What do I as a reproductive endocrinologist who sees the damage done by this benign neglect on a daily basis do to wake people up to the fact that fertility is a temporary state that needs to be taken advantage of when the time is right?  Today, doctors can take ovarian tissue/eggs from a child or adult to preserve her fertility prior to fertility-robbing cancer treatments.  In fact, egg freezing technology is now here for the healthy women who want to preserve their fertility. It’s become acceptable therapy with ever increasing success and lack of problems being noted. Ask your Long Island IVF doctor about egg freezing.

Patients who are not in a position to execute their reproductive rights while they are still fertile should consider egg freezing when they do not have a partner to share in conception.  With a willing and available partner, freezing embryos is another viable option.

But without question, couples who are ready to start a family, should seek assistance from a reproductive endocrinologist who specializes in helping those such as yourselves build your families.  Even when not covered by insurance, there are affordable options such as minimal stimulation IVF, grants, and studies that make the process within reach of most people in need.   So do not become another victim to “I didn’t know”.  Take action, see a reproductive endocrinologist and get on the right path to building that family of your dreams.

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Have you considered egg freezing? Do you wish you had?

 

Photo credit: http://www.wpclipart.com/travel/more_road_signs/road_signs_2/crossroads_sign.jpg

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Companies That May Cover IVF, Infertility Treatment, and/or Adoption Costs

By Tracey Minella

September 18th, 2015 at 9:28 am

 

Credit: Stuart Miles/ freedigitalphotos.net


Can I get a show of hands of people who need IVF but don’t have medical insurance that covers it?

Well, misery loves company and you’ve got lots of it. But that’s no comfort when you’d give anything to have infertility insurance.

If you’re tired of working two jobs, forgoing vacations, and maxing out credit cards to finance your fertility treatments… while the rest of the fertile world is off at Disneyland with their brood… I’ve got a great little resource for you.

Here is a comprehensive, alphabetically-organized list of companies that may offer coverage for infertility and/or adoption costs* according to The International Council on Infertility Information Dissemination, Inc.’s website. Not only that, but it provides details about the purported amounts and particular treatments covered. http://inciid.org/?q=node/252#A

If you would consider a job move or career change in exchange for the potential to have your infertility treatments covered, grab a cup of coffee… and start updating that resume.

Good luck!

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Would you consider changing your job if you got infertility benefits?

 

* LIIVF makes no representations about the accuracy of any information in this list and provides it for informational purposes only.

 

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Explaining a Fertility Doctor’s Job to a Child

By David Kreiner MD

September 16th, 2015 at 9:06 am

 

Dr. Kreiner with his grandson and grand-nephew


Last night I tucked my grandson Jayden into bed. “Saba,” which is Hebrew for grandfather, Jayden said, “What do you do at work?” I thought back to when I first talked to his dad, my son Dan, about the birds and the bees. Well, I thought, I help those in need make babies but how do I explain this to a three year old?

I need to explain that my patients are suffering, some so severely that it affects their marriage, their jobs and often their health. I’m responsible for alleviating their suffering. I share my compassion for their troubles, hoping I may start to develop a bond with them.

I meet with each couple to try to evaluate the presence of any relationship problems. Sometimes these problems are sexual in nature, often related to difficulties with communication and, unfortunately, sometimes include violent behavior on the part of one or both spouses. Working with a program that employs a highly-trained mental health professional and a mind-body team approach helps alleviate stress, works on relationships and helps improve the health of my patients through nutrition, acupuncture and massage, as well as support groups. A healthier, less stressed patient with proper flow of Qi is more likely to conceive with my most advanced scientific infertility treatments available to man.

So I say to Jayden, “Saba is a doctor who helps people become mommies and daddies.” Jayden was not sure he was satisfied. His face frowned. He shrugged his shoulders and raised his arms, palms turned up. “How Saba?” he asked.

“With G-d’s help and the help of all those good dedicated men and women who work with me in the office,” I replied. With that, I looked at my grandson with all the joy and love a grandparent can feel for his grandchild, to which Jayden added, “Can we play another game of Wii?”

 

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Remembering 9/11 Fourteen Years Later

By Tracey Minella

September 11th, 2015 at 12:53 pm

 

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Credit: National Park Service via Wikimedia Commons [Public Domain

I don’t think anything is more appropriate on this anniversary than to remember that day, so I’m sharing this classic.

 

You’ll always remember where you were that fateful day. And so will I.

 

I was working as a medical assistant for Dr. Kreiner. I was also his patient…and about 9 weeks pregnant with my son. Could life be any happier on a blindingly clear, crisp September morning?

 

It started out as a typical day, with the usual morning rush. Lots of busy women…many trying to get their blood and sono done so they cold hurry off to work. A few rushing to catch a train to the city. Men dropping off specimens on their way to the office. Some trying to catch a train to the city.

 

A train to the city.

 

By the time news of the second plane crash hit, most of the morning’s patients had already been seen and were gone. Disbelief was quickly followed by panic as we and the rest of the nation scrambled to figure out if our friends and family who worked in NYC were ok.  And what about our patients?

 

Doesn’t “So-and-So” work downtown? Isn’t “Mr. X” a trader on Wall Street? We spent the morning pouring over the employer info in the patients’ charts, making calls on jammed phone lines, and accounting for everyone’s whereabouts.  We went through the motions of the day on auto-pilot, glued to a 13” black and white TV in the nurse’s station, watching the horror unfold. What kind of world was I bringing this baby into?

 

But just as there were stories of heroism, good deeds, and miracles amid the atrocity of the attacks, there was something positive that day in the IVF office.

 

A patient learned that, despite the chaos unfolding around her, it was indeed going to be her insemination day. When it’s your day, it’s your day. Not even an act of war will intervene. And 9/11 was to be her only day. One insemination. That afternoon. Amid the sadness and silence and sobs of the patient and everyone in the office.

 

And we came to learn a couple weeks later, that on the day the Twin Towers and the lives of so many innocent people were lost, we had participated in one ironically beautiful beginning. That patient got pregnant and had…twins.

 

Usually, it’s the patient who is thankful to the doctor and staff. But I will always be grateful to that patient for giving us one little happy something…well, actually two…to remember from that fateful day. And for being a sign to me that the world would go on, that we’d keep making babies, and that maybe it was going to be all right.

 

 

Photo credit: https://commons.wikimedia.org/wiki/File:National_Park_Service_9-11_Statue_of_Liberty_and_WTC_fire.jpg

 

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Secondary Infertility and “Kindergarten Empty Nest”

By Tracey Minella

September 8th, 2015 at 9:03 am

 

credit: khunaspix/Freedigitalphotos.net


Maybe that first pregnancy came easy. Maybe it didn’t. But, boy did you want that baby.

Your first-born.

She made you a mom. Or a dad. He was the answer to prayers and the realization of dreams that began decades ago. You always expected to become a parent. If you struggled with infertility or losses beforehand, that angel’s birth was the sweet reward for your pain and perseverance.

But you wanted… more. And it hasn’t happened.

For years, you’ve wrestled with the thought of wanting a bigger family. Afraid to speak it aloud. Afraid to be judged ungrateful for the one child you do have. The one child you may’ve bargained with the Universe to have….the one you’d have sold your soul for. The single child that fertile folks and those struggling with infertility believe you should happily settle for.

But why can’t I have another, you often wondered as you savored every single minute of parenthood. Onesies and late-night feedings. First words and steps. Doctor visits. Bedtime stories and snuggles. Happy Mother’s Day and Father’s Day and happy every other holiday. Happy every single ordinary day, as well.

Until last week.

One minute you were at the bus-stop taking Facebook pictures and chatting up the other moms, as your firstborn …sporting a Minions backpack… giggled nervously with the other kids. The next minute a yellow bus whisked your baby away. And ran over your heart in the process.

How did this happen?

You returned to your empty house while the others pushed strollers home… your routine somehow disrupted. For the first time in five years, you may have all the time in the world. And hate it. What will you do to fill the 8 weeks hours until your baby comes home…or the 6 hours for those hovering “helicopter-parents” who covertly followed the bus?  How will you adjust to the new void in your life?

You suddenly realize that you really aren’t so different from the freshman college mom you pitied at Bed Bath & Beyond last month.

You’ve got kindergarten empty nest.

It is the price of secondary infertility. At best, it forces you to face the frustration over the ever-widening age gap between your first and potential second child. At worst, it makes you confront the possibility that what was supposed to be your firstborn may actually be your only child.

Kindergarten can also be tough on “lonely only-s”. Brace yourself for the inevitable plea, prompted by one of those early “All About Me” assignments: “When are you going to give me a little brother or sister?”

Just think…there are only 276 days until summer vacation. Not like anyone’s counting.

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Has anyone experienced Kindergarten Empty Nest? If so, what are your thoughts on coping with the adjustments it brings to you as parents and to your child? How have you handled it? Any tips?

 

 

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Long Island IVF Supports PFLAG

By Tracey Minella

September 4th, 2015 at 6:15 pm

 

Dr. David Kreiner, reproductive endocrinologist and co-founder of Long Island IVF…the infertility practice responsible for bringing Long Island its first IVF baby… is excited and honored to be the guest speaker at the upcoming Long Island PFLAG chapter’s September 20th meeting in Commack. His presentation will be on “Fertility Options for Same Sex Couples”.

 

Since its inception in 1988, Long Island IVF has been committed to the belief that all people have the right to have a family. We have a proud history of supporting LGBT family-building in a way that is sensitive to the unique needs of the community. We go beyond LGBT-friendly…several of our staff members are part of the community. And our experienced psychologist, Bina Benisch, MS, RN, is also the caring and sensitive mother of an adult transgender child. So, we’ve got you covered.

 

If you are a member of the LGBT community…or a parent or loved one of a member…please come down and meet Dr. Kreiner. He will address all of your questions regarding the many fertility preservation and family-building options for the LGBT community.

 

Date: Sunday, September 20, 2015

Time: 2:00 pm

Place: Suffolk Y JCC

74 Hauppauge Rd. Commack, New York

For more information, call PFLAG at 631-462-9800

 

If you can’t wait until then to meet Dr. Kreiner, you can also attend Long Island IVF’s upcoming event, “An Evening of Holistic Approaches to Fertility”, on September 15th at our Melville office. Details are available on our website here: http://www.longislandivf.com/view_event.cfm?id=191

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Do you have any questions for Dr. Kreiner in advance of the PFLAG presentation?

 

 

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September is PCOS Awareness Month

By David Kreiner MD

September 1st, 2015 at 6:09 pm

 

Teal ribbons in September signify PCOS Awareness Month.

PCOS (formally known as Polycystic Ovary Syndrome)  is the most common hormonal disorder of reproductive age women, occurring in over 7% of women at some point in their lifetime.  It usually develops during the teen years.  Treatment can assist women attempting to conceive, help control the symptoms and prevent long term health problems.

The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels.  If a woman does not respond normally to insulin her blood sugar levels rise, triggering the body to produce more insulin.  The insulin stimulates your ovaries to produce male sex hormones called androgens.  Testosterone is a common androgen and is often elevated in women with PCOS.  These androgens block the development and maturation of a woman’s ovarian follicles, preventing ovulation resulting in irregular menses and infertility.  Androgens may also trigger development of acne and extra facial and body hair.  It will increase lipids in the blood.  The elevated blood sugar from insulin resistance can develop into diabetes.

Symptoms may vary but the most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.

Ovaries develop numerous small follicles that look like cysts hence the name polycystic ovary syndrome.  These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as Ovarian Hyperstimulation syndrome, or OHSS.

Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs.  A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots.  Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation.  They may also prescribe aspirin to prevent clot formation.

These cysts may lead to many eggs maturing in response to fertility treatment also placing patients at a high risk of developing a high order multiple pregnancy.  Due to this unique risk it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.

A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries.  A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes.  Hormone assays will also be helpful in making a differential diagnosis.

Treatment starts with regular exercise and a diet including healthy foods with a controlled carbohydrate intake.  This can help lower blood pressure and cholesterol and reduce the risk of diabetes.  It can also help you lose weight if you need to.

Quitting smoking will help reduce androgen levels and reduce the risk for heart disease.  Birth control pills help regulate periods and reduce excess facial hair and acne.  Laser hair removal has also been used successfully to reduce excess hair.

A diabetes medicine called metformin can help control insulin and blood sugar levels.  This can help lower androgen levels, regulate menstrual cycles and improve fertility.  Fertility medications, in particular clomiphene are often needed in addition to metformin to get a woman to ovulate and will assist many women to conceive.

The use of gonadotropin hormone injections without egg removal as performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use.  In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer.   Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

It can be hard to deal with having PCOS.  If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition.  Ask your doctor about support groups and for treatment that can help you with your symptoms.  Remember, PCOS can be annoying, aggravating even depressing but it is fortunately a very treatable disorder.

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Do you suffer from PCOS? Do you have any advice to share for other “cysters”?

 

 

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