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Archive for the ‘Endometriosis’ Category

March is Endometriosis Awareness Month

By David Kreiner MD

March 1st, 2017 at 12:20 pm

 

photo: Ryan McGuire/gratisography.com


I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.

If you have endometriosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.

Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.

Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.

The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.

There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman’s age, length of infertility, and the presence of pain or other symptoms.

Treatment for Mild Endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three – six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).

Treatment for Severe Endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.

Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging.

Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.

Recommendations

As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.

Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.

* * * * * * * * * ** * * * * * * * * **

Do you suffer from endometriosis? How has it impacted your fertility journey? Do you have any advice for others who are suffering?

 

 

Photo credit: Ryan McGuire at http://www.gratisography.com/

 

 

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6 Potential Causes of Miscarriage and Recurrent Pregnancy Loss (RPL)

By Satu Kuokkanen, MD, PhD

May 2nd, 2016 at 11:31 am

image courtesy of David Castillo Dominici/ freedigitlaphotos.net

Experiencing a pregnancy loss is always devastating for individuals hoping to establish or expand their family. Patients describe a range of grieving emotions related to the loss of a person they never had a chance to meet, love and share the future.  This grieving process may last anywhere from few weeks up to several years.  Not surprisingly, I have heard from many patients that one of the most difficult coping times was around the expected due date of the pregnancy that they miscarried.

 

It may be somewhat comforting for patients to know that they are not alone. In fact, miscarriage is the most common pregnancy complication and it affects 1 in every 6-8 confirmed pregnancies, that’s 12-15%. The risk of miscarriage increases with maternal age. While women younger than 30 years old have a 10-12% risk of pregnancy loss, the risk is four fold higher for women in their 40’s. Identifying a potential cause may help with the emotional impact of the pregnancy loss whether it is isolated or recurrent loss.

 

Recurrent pregnancy loss (RPL) is diagnosed after a woman has had two or more consecutive miscarriages and RPL affects 1 in 20 couples who are attempting to conceive. While isolated miscarriages are commonly due to chromosomal and genetic abnormalities, other factors are responsible for RPL. These factors vary depending on the gestational age of the pregnancy loss. Evaluation of potential RPL causes is important in determining whether therapy is available to the patient.

 

6 Potential causes of RPL:

 

  1. Congenital and acquired structural uterine factors. A uterine septum, a partial or complete division of the uterine cavity, is the most common congenital structural uterine abnormality.  Uterine septum and bicornuate uterus (“heart shaped womb”) have been linked to RPL. Acquired structural uterine pathologies that distort the normal uterine cavity include endometrial polyps that are skin tag-like growths of the uterine lining, fibroids that are affecting the uterine cavity, and intrauterine scarring that can develop after surgical procedures, such as dilatation and curettage (also known as D&C).  Radiology studies of the uterus with saline ultrasound (‘water sonogram”) or magnetic resonance imaging (MRI) are standard methods to evaluate the womb.

 

  1. Chronic endometritis is inflammation of the uterine lining. This condition is diagnosed by sampling of the uterine lining with an endometrial biopsy or D&C.

 

  1. Structural chromosome abnormalities of the parents is a rare but known cause of RPL. A simple blood test of both parents to assess numeric and structural chromosomal component (karyotype) is done.

 

  1. Abnormalities of blood clotting.  The well-known condition in this category is anti-phospholipid antibody syndrome (APAS) which women can acquire during their reproductive years. Anti-phospholipid antibody levels can be measured in blood for diagnostic purposes.

 

  1. Endocrine-related abnormalities include elevation in alterations in thyroid hormone secretion and diabetes with uncontrolled blood sugar levels.  Also, women with polycystic ovary syndrome (PCOS) appear to have heightened risk of pregnancy losses.

 

  1. Environmental and lifestyle factors have also been linked to an increased risk of miscarriages. Such factors may include maternal obesity, cigarette smoking, and exposure to environmental toxins. How these factors may impact pregnancy or pregnancy loss differs and is still being studied at the current time.

 

It is important to remember that, although painful, an isolated miscarriage may often be followed by a healthy and successful pregnancy. And that, RPL, while devastating, can be caused by a factor that may be treated with proper, specialized medical care. In either case, your dream of parenthood may still be within reach.

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Have you suffered one or miscarriages, been treated for an underlying cause, and gone on to have a successful pregnancy?

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Long Island IVF-WINNER: Best in Vitro Fertility Practice 2015 AND 2016

It is with humble yet excited hearts that we announce that Long Island IVF was voted the Best In Vitro Fertility Practice in the Best Of Long Island 2015 and 2016 contest…two years in a row!

The doctors, nurses, embryologists, and the rest of the Long Island IVF staff are so proud of this honor and so thankful to every one of you who took the time to vote. From the moms juggling LIIVF babies… to the dads coaching LIIVF teens…to the parents sending LIIVF adults off to college or down the aisles… to the LIIVF patients still on their journeys to parenthood who are confident in the care they’re receiving…we thank you all.

We love what we’ve gotten to do every day more than 28 years…build families. If you are having trouble conceiving, please call us. Many of our nurses and staff were also our patients, so we really do understand what you’re going through. And we’d like to help. 631-752-0606.

 

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March is Endometriosis Awareness Month

By David Kreiner MD

February 29th, 2016 at 11:14 pm

 

image credit: ohmega1982/freedigitalphotos.net


I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.

If you have endometriosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.

Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.

Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.

The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.

There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman’s age, length of infertility, and the presence of pain or other symptoms.

Treatment for Mild Endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three – six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).

Treatment for Severe Endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.

Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging.

Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.

Recommendations

As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.

Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.

* * * * * * * * * ** * * * * * * * * **

Do you suffer from endometriosis? How has it impacted your fertility journey? Do you have any advice for others who are suffering?

no comments

March is Endometriosis Awareness Month

By David Kreiner MD

March 24th, 2015 at 10:34 pm

 

photo: OhMega1982/ freesigitalphotos.net


I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.

If you have endometriosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.

Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.

Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.

The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.

There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman’s age, length of infertility, and the presence of pain or other symptoms.

Treatment for Mild Endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three – six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).

Treatment for Severe Endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.

Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging.

Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.

Recommendations

As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.

Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.

* * * * * * * * * ** * * * * * * * * **

Do you suffer from endometriosis? How has it impacted your fertility journey? Do you have any advice for others who are suffering?

no comments

TTC? Everything You Ever Wanted to Know About Clomid

By David Kreiner MD

December 7th, 2014 at 5:23 pm

credit: taoty/ freedigitalphotos.net

It has become commonplace for women who have been frustrated with repeated unsuccessful attempts to conceive naturally on their own to see their gynecologist who often times will try clomid therapy on them. Clomid, the traditional brand name for clomiphene citrate, is a competitive inhibitor of estrogen. It stimulates the pituitary gland to produce follicle stimulating hormone (FSH) which in turn will stimulate the ovaries to mature follicle(s) containing eggs. Estrogen normally has a negative effect on the pituitary: Clomid blocks estrogen and leads to pituitary FSH production and ovarian stimulation.

Infertility patients — those under 35 having one year and of unprotected intercourse without a resulting pregnancy and those over 35 having six months without pregnancy — have a two to five percent pregnancy rate each month trying on their own without treatment. Clomid therapy increases a couple’s fertility by increasing the number of eggs matured in a cycle and by producing a healthier egg and follicle. The pregnancy rate with clomid therapy alone is approximately ten percent per cycle and 12 -15 percent when combined with intrauterine insemination (IUI). Women who are unable to ovulate on their own experience a 20 percent pregnancy rate per cycle with clomid, the equivalent to that of a fertile couple trying on their own.

Clomid and Your Cervical Mucus

Women who are likely to conceive with clomid usually do so in the first three months of therapy, with very few conceiving after six months. As clomid has an anti-estrogen effect, the cervical mucus and endometrial lining may be adversely affected.

Cervical mucus is normally produced just prior to ovulation and may be noticed as a stringy egg white like discharge unique to the middle of a woman’s cycle just prior to and during ovulation. It provides the perfect environment for the sperm to swim through to gain access to a woman’s reproductive tract and find her egg. Unfortunately, clomid may thin out her cervical mucus, preventing the sperm’s entrance into her womb. IUI overcomes this issue through bypassing the cervical barrier and depositing the sperm directly into the uterus.

However, when the uterine lining or endometrium is affected by the anti-estrogic properties of clomid, an egg may be fertilized but implantation is unsuccessful due to the lack of secretory gland development in the uterus. The lining does not thicken as it normally would during the cycle. Attempts to overcome this problem with estrogen therapy are rarely successful.

Side Effects

Many women who take clomid experience no side effects. Others have complained of headache, mood changes, spots in front of their eyes, blurry vision, hot flashes and occasional cyst development (which normally resolves on its own). Most of these effects last no longer than the five or seven days that you take the clomid and have no permanent side effect. The incidence of twins is eight to ten percent with a one percent risk of triplet development.

Limit Your Clomid Cycles

Yet another deterrent to clomid use was a study performed years ago that suggested that women who used clomid for more than twelve cycles developed an increased incidence of ovarian tumors. It is therefore recommended by the American Society of Reproductive Medicine as well as the manufacturer of clomiphene that clomid be used for no more than six months after which it is recommended by both groups that patients proceed with treatment including gonadotropins (injectable hormones containing FSH and LH) to stimulate the ovaries in combination with intrauterine insemination or in vitro fertilization.

Success rates

For patients who fail to ovulate, clomid is successful in achieving a pregnancy in nearly 70 percent of cases. All other patients average close to a 50 percent pregnancy rate if they attempt six cycles with clomid, especially when they combine it with IUI. After six months, the success is less than five percent per month.

In vitro fertilization (IVF) is a successful alternative therapy when other pelvic factors such as tubal disease, tubal ligation, adhesions or scar tissue and endometriosis exist or there is a deficient number, volume or motility of sperm. Success rates with IVF are age, exam and history dependent. The average pregnancy rate with a single fresh IVF cycle is greater than 50 percent. For women under 35, the pregnancy rate for women after a single stimulation and retrieval is greater than 70 percent with a greater than 60 percent live birth rate at Long Island IVF.

Young patients sometimes choose a minimal stimulation IVF or MicroIVF as an alternative to clomid/IUI cycles as a more successful and cost effective option as many of these patients experience a 40 percent pregnancy rate per retrieval at a cost today of about $3,900.

Today, with all these options available to patients, a woman desiring to build her family will usually succeed in becoming a mom.

* * * * * * * * * * *

Do you have any other questions for Dr. Kreiner about Clomid?

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March is Endometriosis Awareness Month

By David Kreiner MD

March 5th, 2014 at 6:35 am

 

credit: wikipedia

 

I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.

If you have endometriosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.

Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.

Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.

The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.

There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman’s age, length of infertility, and the presence of pain or other symptoms.

Treatment for Mild Endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies
 have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three – six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).

Treatment for Severe Endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.

Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.

Recommendations

As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.

Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.

* * * * * * * * * * * *  *

Do you suffer from endometriosis?

 

Photo credit: http://en.wikipedia.org/wiki/File:Endometriosis,_abdominal_wall.jpg

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Is Your Biological Clock Running Out?

By David Kreiner, MD

January 10th, 2014 at 10:35 pm

 

image courtesy of photo stock/freedigital photos.net

Tears start to course down the cheeks of my patient, her immediate response to the message I just conveyed to her. Minutes before, with great angst anticipating the depressing effect my words will have on her, I proceeded to explain how her FSH was slightly elevated and her antral follicle count was a disappointing 3-6 follicles. I was careful to say that though this is a screen that correlates with a woman’s fertility, sometimes a woman may be more fertile than suspected based on the hormone tests and ovarian ultrasound. I also said that even when the tests accurately show diminishing ovarian reserve (follicle number), we are often successful in achieving a pregnancy and obtaining a baby through in vitro fertilization especially when age is not a significant factor.

These encounters I have with patients are more frequent than they should be. Unfortunately, many women delay seeking help in their efforts to conceive until their age has become significant both because they have fewer healthy genetically normal eggs and because their ability to respond to fertility drugs with numerous mature eggs is depressed. Women often do not realize that fertility drops as they age starting in their 20s but at an increasing rate in their 30s and to a point that may often be barely treatable in their 40s.

A common reason women delay seeking help is the trend in society to have children at an older age. In the 1960’s it was much less common that women would go to college and seek a career as is typical of women today. The delayed childbearing increases the exposure of women to more sexual partners and a consequent increased risk of developing pelvic inflammatory disease with resulting fallopian tube adhesions.

When patients have endometriosis, delaying pregnancy allows the endometriosis to develop further and cause damage to a woman’s ovaries and fallopian tubes. They are more likely to develop diminished ovarian reserve at a younger age due to the destruction of normal ovarian tissue by the endometriosis.

Even more important is that aging results in natural depletion of the number of follicles and eggs with an increase in the percentage of these residual eggs that are unhealthy and/or genetically abnormal.

Diminished ovarian reserve is associated with decreased inhibin levels which decreases the negative feedback on the pituitary gland. FSH produced by the pituitary is elevated in response to the diminished ovarian reserve and inhibin levels unless a woman has a cyst producing high estradiol levels which also lowers FSH. This is why we assess estradiol levels at the same time as FSH. Anti-Mullerian Hormone (AMH) can be tested throughout a woman’s menstrual cycle and levels correlate with ovarian reserve. Early follicular ultrasound can be performed to evaluate a woman’s antral follicle count. The antral follicle count also correlates with ovarian reserve.

By screening women annually with hormone tests and ultrasounds a physician may assess whether a woman is at high risk of developing diminished ovarian reserve in the subsequent year. Alerting a woman to her individual fertility status would allow women to adjust their family planning to fit their individual needs.

Aggressive fertility therapy may be the best option when it appears that one is running out of time. Ovulation induction with intrauterine insemination, MicroIVF and IVF are all considerations that speed up the process and allow a patient to take advantage of her residual fertility.

With fertility screening of day 3 estradiol and FSH, AMH and early follicular ultrasound antral follicle counts, the biological clock may still be ticking but at least one may keep an eye on it and know what time it is and act accordingly.

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Did you realize that aging is not the only factor in the biological clock race? Did you know that certain conditions, like endometriosis, can play a part, too?

 

Photo credit: http://www.freedigitalphotos.net/images/agree-terms.php?id=10049499

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Fertile Food Friday- Blueberries

By Tracey Minella

July 5th, 2013 at 8:50 pm

 

image courtesy of Mr GC/freedigitalphotos.net

Welcome back to Long Island IVF’s “Fertile Food Fridays”*! This is our second week of focusing on foods that can potentially boost male and female fertility. If you missed it, be sure to check out last Friday’s Avocado post with a mean guacamole demonstration and a testicle tree. With the Fourth of July holiday celebrations continuing over the next few days, we’ve got the perfect food for you to add to your barbeque (or take to a potluck) this week.

So without further ado, the second first fertile food will be Blueberries.

Blueberries  are one of the best sources of antioxidants you can find. Only have raspberries, strawberries or blackberries on hand? No problem. Most berries are high in antioxidants, so feel free to eat them all or substitute your favorites in the accompanying recipe. The antioxidants in berries protect against cell damage and cell aging, so help keep those reproductive cells at their peak by loading up on these healthy fruits.  

Blueberries have anthocyanins which give them their namesake color. [“Cyan” means blue in Greek] and are a great source of Vitamin C. Studies show that compounds and vitamins in blueberries may help with some of the symptoms of endometriosis and uterine fibroids by easing some of the pain and heavy bleeding… and blueberries may even positively affect the uterine lining which may help with implantation**.

Ready for an easy blueberry recipe?

A popular use for fresh blueberries is in Fresh Berry Kebobs and Fruit Dip, served with a creamy fruit dip. This dip is one of my own creations and is also great whenever you’re serving a platter of fresh fruit instead of the fruit kebobs. All you need for the kebobs are wooden skewers, blueberries (and strawberries or other fruits that work well on sticks) to thread onto the skewers and the following easy dip ingredients, which you combine in a bowl and refrigerate until ready to use:

1- 15 oz. can of frozen Bacardi® pina colada mixer (there is no alcohol in it), thawed,

1- 8 oz. container of Cool Whip®, thawed and

1- 8 oz. can of crushed pineapple, drained.

Another great blueberry recipe that is really patriotic and easy is this gorgeous 4th of July Strawberry (and Blueberry) Shortcake Kabobs from Foods 101 with Deronda . Check out the quick video here: http://www.youtube.com/watch?v=YpqVNEFzF-s  You will be a hit at any summer gathering with this one!

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Did you make either of these eye catching patriotic treats? Have another blueberry recipe to share?


*Disclaimer:Any recipe we offer is only meant for those who aren’t sensitive or allergic to the ingredients. Recipes are shared simply for fun only and nothing contained herein constitutes medical advice or a guarantee that eating any particular food will have any affect on your fertility.

 * http://www.livestrong.com/article/543691-blueberries-the-uterus/

photo credit: Grant Cohrane http://www.freedigitalphotos.net/images/agree-terms.php?id=10047219

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Infertility Podcast Series: Journey to the Crib: Chapter 11 Endometriosis and Your Infertility

By David Kreiner MD

April 29th, 2013 at 9:50 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Eleven: Endometriosis and Your Infertility. You, the listener, are invited to ask questions and make comments.  You can access the podcast here:http://podcast.longislandivf.com/?p=70

Endometriosis and Your Infertility

Endometriosis is caused by tissue which is normally lining the inside of the uterine cavity.  Instead it implants outside the uterus, most often in the lining of the pelvis or ovaries.  Five to ten per cent of women have endometriosis, though of infertile women 30% are afflicted with it.

Scar tissue often forms where the endometriosis implants grow that can exacerbate pain and increase the likelihood of infertility.  The only way to be certain when making a diagnosis is to perform a surgical procedure called a laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope.  Absent a laparoscopy, the appearance of an ovarian cyst with a characteristic homogeneous appearance showing echoes in the cyst is highly suspicious for endometriosis.

Women with any stage of endometriosis, from minimal (few small implants) to severe (cysts and scarring), can have severe lower abdominal and pelvic pain or they may have no pain whatsoever.  In the absence of scarring, it is thought that infertility caused by mild stages of endometriosis may be chemically transmitted perhaps affecting sperm motility, fertilization, embryo development or even implantation.

Treatment is individualized based on symptoms, infertility and whether a woman is interested in future fertility.  Medical or drug therapy (usually monthly depot lupron) can suppress endometriosis and relieve pain in many women especially when dealing with the milder stages of endometriosis.    Surgical removal of lesions and/or ablation may also reduce pain temporarily.  However, studies fail to show significant improvement in pregnancy rates as compared to expectant management in these mild stages.  Ovulation induction with intrauterine insemination (IUI) increases conception when no other significant fertility factors are present.

Surgical treatment of more advanced conditions of endometriosis improves pregnancy rates to about two per cent per month.  There remains controversy over whether postoperative medical treatment may be helpful for fertility as the greatest success of surgery exists in the first 6 to 12 months post-op and the medical therapy reduces the time a patient may conceive as they cannot ovulate with the usual therapy of lupron.  IUI is rarely successful in these advanced stages necessitating In Vitro Fertilization in order to conceive.

As endometriosis is a progressive condition it is recommended that women so afflicted become proactive with their procreation before the endometriosis destroys too much ovarian tissue and prevents them from being able to achieve a pregnancy with their own eggs.

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Was this helpful in answering your questions about Endometriosis and its effects on a woman’s fertility?

Please share your thoughts about this podcast here. And ask any questions. Dr. Kreiner will be happy to answer them.

If you’ve been diagnosed with Endometriosis, do you have any advice to share?

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Infertility Podcast Series: Journey to the Crib: Chapter 10 Endometriosis

By David Kreiner MD

April 23rd, 2013 at 7:53 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Ten: Endometriosis. You, the listener, are invited to ask questions and make comments.  You can access the podcast here:

http://podcast.longislandivf.com/?p=66

 

Endometriosis

Endometriosis is a disease state in which the lining of the uterus, endometrium, is found outside the uterus, most often lining the pelvis behind the uterus and by the ovaries.  Endometriosis can cause pain and/or infertility in some women.  Among women who have infertility, as many as 30% may have endometriosis and this is not always associated with pain.

Though cysts of endometriosis may be suspected by a pelvic ultrasound, the diagnosis is typically made at the time of a laparoscopy by visual inspection and biopsy.  Endometriosis may be minimal or mild with no more than flat implants noted in the pelvic lining.  These are thought to contribute to infertility through chemicals that these implants produce which can cause scarring or adhesions of the ovaries and fallopian tubes thus affecting egg pickup by the tubes.  They may affect egg/embryo transport down the tube, sperm motility, fertilization, embryo cell cleavage and implantation.

Moderate and Severe endometriosis involving ovarian cysts containing old blood from cycles of menstrual-like bleeding from the implants, commonly impact egg pickup by the tubes due to the scar tissue that they cause.  They could affect egg maturation as well as cause all of the other factors that mild endometriosis may cause.

Treatment should be tailored to the major problems caused by the endometriosis. 

When pain is the main issue, medication that suppresses ovulation and estrogen production may be helpful, as can surgical resection or vaporization of the implants.

When infertility is the main issue, the benefits of surgery and medicine must be compared to the downside limitations caused by them, such as the inability to conceive during medical therapy and the risk of destroying limited normal ovarian tissue along with the endometriosis.  This can be a particular issue in cases of more severe endometriosis where the cysts of endometriosis and prior surgery to re-sect them have already diminished the remaining ovarian reserve.  In such cases, aggressive fertility treatment such as In Vitro Fertilization would be the recommended course of therapy to optimize an individual’s chance for successful childbearing.  

Patients with endometriosis and infertility are unfortunately in a race to conceive before the endometriosis destroys too much ovarian tissue and makes achieving a pregnancy with one’s own eggs impossible.

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Was this helpful in answering your questions about Endometriosis and its effects on a woman’s fertility?

Please share your thoughts about this podcast here. And ask any questions.

Or, if you are in the Long Island area, please come down to our Melville office for one or more of our “Evenings of Education” seminars this week. Details are here:  http://blog.longislandivf.com/2013/long-island-ivfs-national-infertility-awareness-week-events/

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