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Archive for the ‘age-related infertility’ tag

Infertility Podcast Series: Journey to the Crib: Chapter 32: Octomom

By David Kreiner, MD

October 18th, 2012 at 6:47 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Thirty-Two: Octomom. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=146

Octomom 

A year ago, the Medical Board of California revoked the license of Dr. Michael Kamrava, finding he “did not exercise sound judgment” in transferring 12 embryos to Nadya Suleman, who already had six children at home. The ruling, while not surprising, was illuminating, and it’s worth reflecting on the five things we learned from Octomom: 

 

  • Know How to Say “No”: There is a point where physicians have to make a judgment call. Pregnancies with triplets – let alone eight infants – put the mother at high risk of serious medical complications and put unborn children at risk for developmental disabilities. Physicians need to rely on their professional expertise and experience to know when to turn down a patient request no matter how vehemently it is made.

 

  • Beware the Patient with Tunnel Vision: Often when a patient comes to a fertility doctor, unsuccessful pregnancy attempts have made her anxious and determined. She might want to get pregnant regardless of the risks that pregnancy may present.

 

  • Less is More: In 1999, 35 percent of all transfers involved four or more embryos. In 2009, only 10 percent had four or more. And those high-number transfers are generally reserved for patients with significant fertility challenges. In contrast, Octomom already underwent multiple successful IVF (in vitro fertilization) procedures and had given birth to six children when she had her 12-embryo transfer.

 

  • Know When to Deviate: While Dr. Kamrava’s deviation from guidelines was an extreme departure, deviations do occur for specific reasons, such as repeated IVF failure, age-related infertility and poor egg quality. It is important to know when implanting several embryos is appropriate.

 

  • “Reduce” Risk: Dr. Kamrava complained that Octomom refused to undergo “selective reduction,” which would have reduced the number of embryos she carried to term. Here, again, is an argument for fewer transfers. Had he transferred fewer embryos, Octomom would not have had to face such a difficult decision.

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Was this helpful in answering your questions about what could have been done differently to prevent the Octomom case? How much weight do you give your doctor’s recommendation on the number of embryos to transfer?

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

 

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Is Your Biological Clock Running Out?

By Tracey Minella and David Kreiner MD

May 19th, 2011 at 9:02 am

I’ve always hated this term.

It used to nag at me in the back of my mind as I pursued my education and got settled in my career…especially since I married young. And when it wasn’t in the back of my mind, it was being shoved smack in my face by the rude comments of nosy jerks, collectively known as the "masses of asses".

If you’re wondering whether your biological clock is really running out, this post by Dr. David Kreiner of East Coast Fertility may be enlightening:

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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Is Pre-Embryo Genetic Screening YOUR Missing Piece for IVF Success?

By Dr. David Kreiner and Tracey Minella

February 10th, 2011 at 12:00 am

Back in 1978, when the world’s first IVF baby was born in the United Kingdom, I was still a kid. Yet I remember it because all the adults were talking about it. In vitro fertilization was brand spanking new. People were excited… and scared. Conservatives and religious objectors welcomed Louise Brown’s birth with the same warmth as the Frankenstein monster. My, have times changed.

And yet, they remain the same.

Today, IVF is almost as common as root canal. Scientific advances in the field of reproductive endocrinology and genetics have brought technology and tools to the table that continue to amaze, and frighten the general public.

But thanks to these advances, IVF is now more than just the long shot at getting pregnant it was in the 70’s. Now, pre-implantation screening exists that may dramatically improve IVF success rates in several different patient scenarios.

Dr. David Kreiner, of East Coast Fertility, (The Fertility Doc) describes this latest amazing development and how it may help IVF success rates soar for certain patient populations. And it is now available to East Coast Fertility’s IVF patients! Read on to see if it could benefit you!

As Dr. Kreiner explains:

Pre-embryo genetic screening (PGS) was developed to help weed out embryos containing inherited metabolic disorders and genetic abnormalities prior to implantation. It was thought that PGS could be used to minimize the risk of miscarriage and perhaps even increase live birth rates in older women undergoing IVF .

We have thus far been disappointed in our results obtained using the FISH technique, the procedure performed for PGS for the past decade and a half. But an alternative new technology that was recently developed makes me very excited about PGS once again: Array Comparative Genomic Hybridization (aCGH).

ACGH is a technique actually applied to detect deficiencies and excesses of genetic material in the chromosomes. DNA from a test sample and a normal reference sample are labeled using colored fluorophores that hybridize to several thousand probes. These probes are created from most of the known genes of the genome and placed on a glass slide.

The differential color of the test compared to the normal sample DNA reflects the amount of DNA in the test specimen. It can pick up monosomies, trisomies or significant deletions on an embryo’s chromosomes.

The first baby born from this procedure was in September 2009 to a 41-year old woman. When aCGH is performed on a Blastocyst biopsy, it is effective in screening out mosaicism (mixed cell lines in the same organism). ACGH is 20 percent more sensitive than the best FISH assays with an error rate of two to four percent. Fifty percent of the embryos tested were normal with pregnancy rates exceeding Blast transfers without aCGH screening.

So, who could benefit from using this new technology?

1. Patients with repeat miscarriages can eliminate up to 90 percent of their miscarriages.

2. Older patients who naturally have a higher percentage of genetically abnormal embryos may now screen for and only transfer their normal embryos.

3. Patients who want to maximize their success with a single embryo transfer.

4. Patients who have experienced repeat implantation failure can be screened for genetically abnormal embryos.

This technology is available for about the same cost as the FISH procedure yet, since it is performed on a Blastocyst, it is safer with less effect on the integrity of the embryo and without significant risk of wrongly identifying abnormal embryos. A concern with FISH is that embryos identified as abnormal can actually result in a normal fetus. This risk is practically eliminated with aCGH and is another reason making it more successful.

I expect PGS will now become a commonly-used addition to standard IVF to promote more successful single embryo transfers, improve success in older patients, eliminate miscarriages, and treat patients with repeat implantation failure.

We are approaching a new era in IVF. Brace yourselves for a thrilling ride into IVF’s future.

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