CALL US AT: (877) 838.BABY


Archive for the ‘David Kreiner’ tag

When Will You Be in Menopause? Do You Even Want to Know?

By Pamela Madsen

September 27th, 2010 at 8:22 am

As a peri-menopausal woman – the answer is yes. In fact I would like to know in advance that the period I am getting is my last one – so I can celebrate it. But the way things stand now – I won’t know that I am getting my last period until a year passes.  Kind of takes a lot of the ritual possibilities out of it. My girlfriend has a "Goddess Party" for her daughters when each of the got their first period – why shouldn’t we celebrate the last?

Now a new study released during 26th annual meeting of the European Society of Human Reproduction and Embryology in Rome  states that researchers  have developed an  accurate way to predict the age when women will hit the menopause using a simple blood test.

The average difference between the predicted age and the actual age that the women in their study reached the menopause was only a third of a year, and the maximum margin of error was between three and four years.

The  implications of this test for women and their doctors; if the results of the research are supported by larger studies,  means that women will be able to discover early on in their reproductive life what their expected age at menopause will be, so that they can plan when to start a family.

Knowing you fertility life span – is huge for women. That’s why Dr. David Kreiner at East Coast Fertility and I have been trying to get the word out about "Fertility Evaluations". Right now we can’t predict when a woman will hit menopause but technology does exist right now for women to get a reading on where they are now in their own biological clock.

In this new study – they are taking blood samples from 266 women, aged 20-49, who had been enrolled in the much larger Tehran Lipid and Glucose Study, Dr Ramezani Tehrani and her colleagues were able to measure the concentrations of a hormone that is produced by cells in women’s ovaries – anti-Mullerian Hormone (AMH). AMH controls the development of follicles in the ovaries, from which oocytes (eggs) develop and it has been suggested that AMH could be used for measuring ovarian function. The researchers took two further blood samples at three yearly intervals, and they also collected information on the women’s socioeconomic background and reproductive history. In addition, the women had physical examinations every three years. The Tehran Lipid and Glucose Study is a prospective study that started in 1998 and is still continuing.

Dr Ramezani Tehrani, who is President of the Reproductive Endocrinology Department of the Endocrine Research Centre and a faculty member and Associate Professor of Shahid Beheshti University of Medical Sciences in Tehran, Iran, said: "We developed a statistical model for estimating the age at menopause from a single measurement of AMH concentration in serum from blood samples. Using this model, we estimated mean average ages at menopause for women at different time points in their reproductive life span from varying levels of serum AMH concentration. We were able to show that there was a good level of agreement between ages at menopause estimated by our model and the actual age at menopause for a subgroup of 63 women who reached menopause during the study. The average difference between the predicted age at menopause using our model and the women’s actual age was only a third of a year and the maximum margin of error for our model was only three to four years.

"The results from our study could enable us to make a more realistic assessment of women’s reproductive status many years before they reach menopause. For example, if a 20-year-old woman has a concentration of serum AMH of 2.8 ng/ml [nanograms per millilitre], we estimate that she will become menopausal between 35-38 years old. To the best of our knowledge this is the first prediction of age at menopause that has resulted from a population-based cohort study. We believe that our estimates of ages at menopause based on AMH levels are of sufficient validity to guide medical practitioners in their day-to-day practice, so that they can help women with their family planning."

Dr Ramezani Tehrani was able to use the statistical model to identify AMH levels at different ages that would predict if women were likely to have an early menopause (before the age of 45). She found that, for instance, AMH levels of 4.1 ng/ml or less predicted early menopause in 20-year-olds, AMH levels of 3.3 ng/ml predicted it in 25-year-olds, and AMH levels of 2.4 ng/ml predicted it in 30-year-olds.

In contrast, AMH levels of at least 4.5 ng/ml at the age of 20, 3.8 ngl/ml at 25 and 2.9 ng/ml at 30 all predicted an age at menopause of over 50 years old. The researchers found that the average age at menopause for the women in their study was approximately 52.

Dr Ramezani Tehrani concluded: "Our findings indicate that AMH is capable of specifying a woman’s reproductive status more realistically than chronological age per se. Considering that this is a small study that has looked at women over a period of time, larger studies starting with women in their twenties and following them for several years are needed to validate the accuracy of serum AMH concentration for the prediction of menopause in young women."
Who knows – maybe one day we will be able to celebrate our last period – just as some people celebrate the first.

no comments

The Fertility Work Up

By Dr. David Kreiner

August 23rd, 2010 at 12:00 am

I have received an enormous amount of email from patients over the years asking for information about how they should get started with their infertility workup.  Apparently, they are women, men and couples who have experienced difficulty conceiving and now want some direction about how they should proceed.  Building a family was something they had imagined their entire lives to be a natural progression–from student to career, getting married then having a family–and they’re frustrated that their difficulty conceiving has affected their lives.  For many—some of whom have never experienced a health problem– it prevents them from appreciating or even doing anything else.

See an RE for a Fertility Workup

My response to these emails has been to tell the patients to seek assistance from a reproductive endocrinologist, whose specialty and experience is in helping infertility patients conceive.  A reproductive endocrinologist, who has two to three years of additional specialty fellowship training in infertility after completing an OB/GYN residency.

The RE will conduct a history and physical examination during your initial consultation.  This exam typically includes a pelvic ultrasound of a woman’s ovaries and uterus.  He/she can tell if there are any uterine abnormalities that may affect implantation or pregnancy as well as assess ovarian activity and rule out cases of moderate or severe endometriosis.

Pelvic Inflammatory Disease

If he elicits a history of previous abdominal or pelvic surgery, a physician may suspect that scarring may have developed that typically interferes with fallopian tube transport of the egg to the sperm and the conceptus to the uterus.  An infection that develops after a pregnancy may lead to pelvic adhesions affecting the tubes as well as scarring within the uterine cavity itself which can prevent implantation.  Pelvic inflammatory disease, PID, can lead to tubal disease and may be associated with other sexually transmitted diseases including HPV, Herpes and especially Chlamydia.

Semen Analysis

The semen analysis is the simplest test to perform and will reveal a male factor in 50% of cases.  A post coital test performed midcycle around the time of ovulation when the cervical mucus should be optimal can detect a male factor or cervical factor when few motile sperm are detected within hours of intercourse.

Hysterosalpingogram

A hysterosalpingogram, HSG, is a radiograph x-ray of the uterus and fallopian tubes after radio opaque contrast is injected vaginally through the cervix directly into the uterus.  It can detect uterine abnormalities that can affect implantation and pregnancy as well as tubal patency.  Unfortunately, this exam may be painful and in some patients with PID can result in serious infection.  Some physicians will administer antibiotics prophylactically for this reason.

Hydrosonogram

A hydrosonogram is an ultrasound of the uterine cavity performed after injecting water vaginally through the cervix directly into the uterus.  It can also detect uterine abnormalities and shares some of the risks seen with HSG but to a lesser extent and usually with less associated discomfort.

Hysteroscopy

A hysteroscopy is a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus.  The physician can visually inspect the cavity to detect uterine abnormalities.  The risks of pain and infection are also seen with hysteroscopy.

Blood Tests

Blood tests may be run to identify if a patient is ovulating with adequate progesterone stimulation of the uterine lining.  Day 3 E2, FSH and LH levels can give information regarding ovarian activity and ovulatory dysfunction.  AntiMullerian Hormone (AMH) levels correlate with ovarian reserve.   That is the number of eggs remaining in the ovaries.  Hormones that can affect fertility such as thyroid and prolactin are also assessed to ensure that extraneous endocrine problems are not the cause of the infertility.

Laparoscopy

Laparoscopy is a surgical procedure in which a telescope is placed abdominally through the navel thereby allowing a physician to inspect the pelvic organs.  He/she can identify endometriosis, cysts, adhesions, infection, fibroids etc. that may be causing the infertility.  Unfortunately, only about 25% of cases in women who have a laparoscopy performed will conceive because of treatment performed at the time of the laparoscopy.

Workup Results and Treatment

Treatment can be directed at the cause such as surgery to correct adhesions or remove endometriosis, uterine polyps or fibroids.  Treatment can also be independent of the cause but improve fertility nonetheless.   Ovulation induction increases the number of eggs and therefore the likelihood that an egg will fertilize.  Gonadotropin injections stimulate many more eggs to develop in a cycle than clomid fertility pills.  IVF with minimal or full stimulation is the most successful treatment for any cause of infertility.  The decision as to what treatment to undertake will depend on numerous factors including your age, duration of infertility, cause of infertility, cost of treatment and success of treatment as well as your insurance coverage for the treatment and your motivation to conceive and willingness to accept the risks associated with the treatment.   Today, there is a highly successful treatment available for nearly all women.


no comments

Dear Fertility Doc

By Dr. David Kreiner

June 21st, 2010 at 6:00 pm

Dear The Fertility Doc,

I am 39 years old, single and I am very involved with my career. I want to continue to work but I always dreamed I would have children. I don’t have a partner with whom to get pregnant. What should I do?

Signed,
At My Reproductive Crossroads

I hear this question frequently in my practice. As women age they are forced to consider whether to have their children now rather than delay while they may still be able to use their own eggs versus those of an egg donor, or adopting.

This patient needed to consider the ramifications of taking time off from her career, as well as creating a child with donor sperm. She wanted to know if she were to meet Mr. Right, how would he respond to this child? Were there tests that I could perform to help her make a decision?
Screen Your Fertility

First of all, it’s imperative in cases like this to do a full fertility screen so that we understand from a fertility perspective how much time a woman has left and how urgently she needs to make a decision. To assess fertility, I do a Day 3 serum Estradiol and FSH, an AntiMullerian Hormone and a sonographic antral follicle count. The FSH is regulated by negative feedback from serum Estradiol and inhibin, both of which are produced by the granulosa cells of the ovarian follicles. With diminishing ovarian activity, there are fewer follicles, less estradiol and inhibin, so with less feedback, the FSH level is high.

Occasionally, in patients with low ovarian activity (often called low ovarian reserve), a patient may have an ovarian cyst that produces estradiol. This will lower the FSH level to otherwise normal activity levels even when there is minimal ovarian activity and inhibin. One would misinterpret the low normal FSH in the presence of higher estradiol which is why this must be measured concurrent with FSH.

AntiMullerian Hormone is also produced by the granulosa cells and low levels therefore indicate depleted ovaries. Likewise, few antral follicles seen on ultrasound typically performed during the early follicular phase of the cycle will indicate low ovarian reserve.
Making a Decision

Once we know a patient’s relative fertility through this screen, we need to decide whether she is prepared to delay her career for pregnancy and motherhood or whether she should undergo IVF and freeze her embryos, thereby freezing her fertility potential at its current state.

Since she is single without a participating partner, we would be using the sperm from an anonymous donor. Sperm specimens are obtained from sperm banks that are certified by New York State by virtue of their screening and testing for infectious and hereditary diseases. Patients may review what is available from the sperm banks, reading on the internet the sperm donor’s demographic information, physical attributes, educational and occupational histories, etc.

If a woman does not have any infertility issues, I would attempt donor insemination. However, due to her advanced age, I would progress to more aggressive therapies if we were not successful after a few cycles.

A common concern for women in this circumstance is that they may meet their soul mate in the future and he may not be comfortable with a child produced with someone else’s sperm. This is an issue that is very individual and I can only offer to support my patients as they decide what is best for them.

As a woman prolongs the decision, her fertility is diminishing, and she thereby risks not being able to have a child using her own eggs. If conceiving with her own eggs is crucial, then she must weigh the downside of conceiving a child from an anonymous donor and, if she does so, the potential problems associated with finding a man in the future with whom she may want to have a family.

It’s enormously stressful making these decisions at these reproductive crossroads. I discuss them with my patients and help them arrive at the decision that is right for them.  Everyone who has ever supported a woman making such a difficult decision knows that it can have a heavy toll on a woman’s psyche.

no comments


The Fertility Daily Blog by Long Island IVF
© Copyright 2010-2012