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Archive for the ‘Fertility Medications’ tag

Is There a Relationship Between Infertility Treatment and Autism?

By admin

April 3rd, 2015 at 7:11 pm

 

image courtesy njaj/free digitalphotos.net


April is Autism Awareness Month. As it ends, much of the discussion regarding the potential causes of autism have centered on the debate over a possible vaccine connection.

Understandably, the world is searching for the cause of what some call the epidemic of autism in the United States. Current stats show that one out of 68 children is diagnosed with the disorder which typically manifests itself in various ways, impacting or causing developmental delays, communication and behavioral challenges. Because the symptoms and degree of severity vary so wildly from case to case, autism is a spectrum disorder.

And, although practically eclipsed by the vaccine headlines, every year another question is raised:

Does IVF… or fertility medications… cause autism?

A recent study*sparked some pretty sensational headlines that boldly claimed that IVF doubles the risk of having autism. Reading further into the articles…or even reading the small print caption right below the accompanying photo… you could find facts and quotes that explained and/or contradicted the claim of the headline. But not everyone reads the article beyond the headline. Certainly not someone who is now hysterical with fear. In my opinion, misleading headlines in journalism dealt a sucker punch to IVF.

Consider this article**, entitled “Children conceived via IVF have double the autism rates of others: study”, wherein the caption right below the headline and photo states:

“While researchers didn’t find a direct link between reproductive treatments like IVF and autism, they said higher rates among children born that way might be due to multiple births or complications during pregnancy that can follow such treatments.” (emphasis added)

Notably, if you read further, the risk disappears completely for those who elect IVF with a Single Embryo Transfer, or for those who do not have multiple pregnancies! The article continues:

For moms giving birth to just one baby, there’s no increased risk of the neurodevelopmental disorder, researchers said.”(emphasis added)

This clarification may relieve the fears of many IVF patients… especially in light of the growing popularity and competitive success rates of Single Embryo Transfer programs like the one at Long Island IVF. Even for those who do not elect SET, advances in reproductive technology have led to a significant decrease in the number of embryos most clinics will routinely transfer, and that has also contributed to a dramatic reduction in the incidence of high order multiple pregnancies as well.

Obviously, more research is necessary. And careful dissemination of information and findings as it unfolds is, as well.

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Do you think publications have a duty to use headlines that don’t mislead? Does the study in question impact your family-building decision and if so, in what way?

* http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2014.302383

**http://www.nydailynews.com/life-style/health/kids-conceived-ivf-double-autism-rates-study-article-1.2163153

photo credit: http://www.freedigitalphotos.net/images/Toys_and_games_g80-Blue_Puzzle_p104185.html

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Long Island “Brew For the Family” Event- June 4, 2015

Would winning a FREE IVF Cycle door prize help you or a loved one build a family?

Join us on Thursday, June 4th, 2015 from 7:30-10PM at the Long Island Brew for the Family event hosted in partnership with the Tinina Q. Cade Foundation.

We have come together to spread the message that infertility can be overcome! Enjoy a night out and forget the stress of infertility as we sample craft beers at one of Long Island’s premier microbreweries, The Great South Bay Brewery. The evening will include a sampling of 6 beers, guided brewery tours with a master brewer, great food, music, and a silent auction.

Each admission ticket will include one entry into the drawing for a FREE IVF CYCLE* door prize. Be sure to invite your family and friends for even more chances to win, as the prize is transferrable.

To purchase tickets and learn more about this event please visit: www.librewforthefamily.eventbrite.com.

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

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 contest.

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 27 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.

 

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The ABCs of IVF

By David Kreiner MD

May 9th, 2014 at 9:15 am

 

credit: digitalart/freedigitalphotos.net

If you’re not pregnant yet and you’re wondering what to do, this post may shed some light on infertility diagnoses and treatments. Yes, there’s a lot to learn. Yes, it can be overwhelming. But the good news is that you can go to the head of the class by the time you finish reading this post.

Dr. David Kreiner of Long Island IVF gives you the low-down and the lingo. It’s everything you need to know, from A to… well… P. And what better letter to stop at? “P” is for pregnant:

“Why me? My wife never had any infections, surgery or any other problem? I have no difficulty ejaculating and there’s plenty to work with so why can my friends and neighbors and coworkers get pregnant and we can’t?”

I hear these questions daily and understand the frustrations, anger and stress felt by my patients expressing these feelings through such questions. There are many reasons why couples do not conceive. An infertility workup will identify some of these. A semen analysis will pick up a male factor in 50-60% of cases. A hysterosalpingogram will locate tubal disease in about 20% of cases. Another 20-30% of women do not ovulate or ovulate dysfunctionally. A post coital test may identify that the problem is that the sperm is not reaching the egg. It may not be able to swim up the cervical canal into the womb and up the tubes where it should normally find an egg to fertilize. When these tests are normal a laparoscopy may be performed to identify the 20-25% of infertile women with endometriosis. However, even when this is normal and there is no test that logically explains the lack of success in achieving a pregnancy; an IVF procedure may both identify the cause and treat it successfully.

What is IVF?

In Vitro Fertilization, IVF, is the process of fertilizing a woman’s eggs outside the body in a Petri dish. Typically, a woman’s ovaries are stimulated to superovulate multiple eggs with gonadotropin hormones, the same hormones that normally make a woman ovulate every month. Injections of these hormones are usually performed by either the husband or wife subcutaneously in the skin of the lower belly with a very tiny needle. It takes 9-14 days for the eggs to mature. She will then take an HCG injection which triggers the final stage of maturation 35-36 hours prior to the egg retrieval. This is performed in an operating room, usually with some anesthetic. The eggs are inseminated in the lab and 3-5 days later, embryos are transferred into the uterus with a catheter placed transvaginally through the cervix into the womb.

What is ICSI?

Some times even in the presence of a normal semen analysis, and normal results on all the infertility tests, fertilization may not occur without microsurgically injecting the sperm directly into the egg. This procedure is called Intracytoplasmic Sperm Injection or ICSI and may achieve fertilization in almost all circumstances where there is otherwise a sperm cause for lack of fertilization.

If it looks like a sperm and swims like a sperm, why doesn’t it work like a sperm?

A South African gynecologist, Thinus Kruger, discovered that small differences in the appearance of sperm affected the sperm’s ability to fertilize an egg. In 1987, Thinus demonstrated that when we used the very strict Kruger criteria for identifying a normal sperm, we were able to identify most men who had normal semen analyses and were yet unable to fertilize their wife’s eggs. Most of these couples suffered from unexplained infertility except now utilizing the Kruger criteria for sperm morphology we were able to identify the problem. Today, these couples are successfully treated with the ICSI procedure.

Old eggs?

As women age, the percentage of genetically abnormal eggs increases. These older eggs are less likely to fertilize, divide normally into healthy embryos or result in a pregnancy. When older women do conceive they are more likely to miscarry then when they were younger. Aging of eggs begins in the 20’s but accelerates after age 35. This is why a woman’s fertility drops as she gets older. The age at which it becomes significant for a woman varies. Some women in their 30’s have significant aging of their egg. Others less so and may have a good number of healthy eggs into their 40’s.

ABC’s of IVF

Assisted Hatching is when the embryologist makes a hole in the shell around the embryo called the zona pellucidum. This is performed minutes prior to embryo transfer and may be performed chemically with acid tyrodes, mechanically with a micropipette or with a laser. It is commonly believed that older eggs may lead to embryos with a thicker or harder shell that may prevent the natural hatching of an embryo that must occur prior to the embryo implanting into a woman’s lining of her womb.

Blastocyt embryo transfers occur on day 5 or 6 after the egg retrieval. This is the embryonic stage when an embryo normally implants into the womb. These embryos have been selected to be healthier by virtue of the fact that they have made it to this stage. Statistically, the pregnancy rates for women who have had blastocysts transferred is higher than when the same number is transferred on day 3 using “cleaved” embryos of 4-10 cells. As the advantage of the blastocyst transfer may be only a matter of selection, it is thought that there may be no advantage if the embryologist is able to select just as well the best embryos to transfer on day 3 which is typically the case when there are not excess numbers of high quality embryos which will vary according to the patient and be dependent on the age of the patient.

Bravelle – Brand of FSH, follicle stimulating hormone which is a gonadotropin used to stimulate a woman’s ovaries to superovulate and make multiple eggs mature during the IVF cycle.

Cetrotide – Brand of Gonadotropin Releasing Hormone Antagonist that prevents a woman’s pituitary gland from producing LH, luteinizing hormone. LH increases can trigger premature ovulation and stimulate testosterone and progesterone production which can be harmful to a woman’s egg production and prematurely mature the lining of womb potentially affecting implantation.

Co-culture of a woman’s endometrial cells from the uterine lining or granulosa cells from aspirated ovarian follicles along with the embryos in the same culture dish is thought to provide growth factors for the embryos which may improve the health and growth of the embryos.

Cleavage Stage Embryos are 2-10 cell embryos transferred on day 2 or 3. They are often graded by their lack of fragmentation and granularity of the inside of the cell cytoplasm; A to D or 1to 5 with A or 1 being the best grade.

Cryopreservation or freezing can be performed on individual eggs where it may serve as a way to preserve a woman’s fertility either due to aging or in preparation for surgery, chemotherapy or radiation which may affect future access to a woman’s eggs.  It may be performed on cleaved embryos or blastocyst embryos that are already fertilized either because they are in excess of the desired number of embryos to be transferred fresh or to bank for a future PGS/PGD or to improve implantation by delaying transfer to a subsequent unstimulated cycle.

Embryo Glue is a protein supplement to the transfer media prepared minutes prior to transfer to make the embryo more likely to stick to the lining of the womb. It is believed that some embryos may not implant since they are not adhering to the lining and do not get an opportunity to burrow into the endometrium.

Estradiol is produced by the granulosa cells of the follicle which surround the egg in the ovary. As follicles are stimulated and grow they produce more estradiol. We measure estradiol to monitor development of the follicles. It also helps to prepare the lining of the womb for implantation.

Follistim – Brand of FSH, follicle stimulating hormone which is a gonadotropin used to stimulate a woman’s ovaries to superovulate and make multiple eggs mature during the IVF cycle.

Ganirelix – Brand of Gonadotropin Releasing Hormone Antagonist that prevents a woman’s pituitary gland from producing LH, luteinizing hormone. LH increases can trigger premature ovulation and stimulate testosterone and progesterone production which can be harmful to a woman’s egg production and prematurely mature the lining of womb potentially affecting implantation

Gonal F – Brand of FSH, follicle stimulating hormone which is a gonadotropin used to stimulate a woman’s ovaries to superovulate and make multiple eggs mature during the IVF cycle.

Gonadotropins – FSH, follicle stimulating hormone and LH, luteinizing hormone stimulate the follicles in the ovary to mature and produce ovarian hormones, estradiol, testosterone and progesterone. It also is used to stimulate a woman’s ovaries to superovulate and make multiple eggs mature during the IVF cycle. We adjust the ratio of FSH and LH to achieve goals of optimal follicular development and maturation while trying to minimize the risk of hyperstimulation. Typically we administer the gonadotropins to the woman for 8-14 days before giving her HCG 35-36 hours prior to the egg retrieval

HCG is human chorionic gonadotropin, the pregnancy hormone we measure to see if your wife is pregnant. We follow the numbers to monitor the growth and health of the pregnancy. HCG has the same biological effect as LH and therefore can be used to mature the egg in the same way as if it were getting ready to ovulate. We therefore administer HCG to women 35-36 hours prior to the egg retrieval. Brand names for HCG include Pregnyl and Ovidrel.  HCG is occasionally used in place of HMG (Menopur, see below) with similar effects.

HMG – Human Menopausal Gonadotropins are purified from the urine of menopausal women since they have high levels of FSH and LH. Menopur is the brand of HMG used in IVF stimulations containing a 1:1 ratio of FSH to LH. We adjust the ratio of FSH and LH to achieve goals of optimal follicular development and maturation while trying to minimize the risk of hyperstimulation. Adding pure FSH, i.e. Bravelle, Follistim or Gonal F will increase the ratio of FSH to LH which may be desirable especially early in a stimulation. Some patients may not need any supplemental LH and are stimulated with FSH only. HMG is sometimes added towards the end of a stimulation to minimize the risk of hyperstimulation syndrome.

Hyperstimulation syndrome is a condition which occurs approximately 3% of the time as a result of superovulation of a woman’s ovaries with gonadotropins. A woman’s ovaries become enlarged and cystic, fluid accumulates in her belly, and occasionally around her lungs. When it becomes excessive, it may make it uncomfortable to breathe. We remove this excess fluid with a needle. Women can also become dehydrated and put them at risk of developing blood clots. We therefore recommend fluids high in salt content like V 8 and Campbell’s chicken soup. We give patients baby aspirin to prevent clot formation and a medication called cabergoline which helps prevent the development of Hyperstimulation.  It may also be recommended to freeze all the embryos and postpone the transfer to a later cycle as pregnancy can significantly exacerbate Hyperstimulation syndrome as well as potentially be more likely to implant in a subsequent cycle.

ICSI – Some times even in the presence of a normal semen analysis, and normal results on all the infertility tests, fertilization may not occur without microsurgically injecting the sperm directly into the egg. This procedure is called Intracytoplasmic Sperm Injection or ICSI and may achieve fertilization in almost all circumstances where there is otherwise a sperm cause for lack of fertilization

Lupron is a Gonadotropin Releasing Hormone Agonist that must be administered after a woman ovulates or concurrent with progesterone or oral contraceptive pills to effectively suppress gonadotropins. Lupron prevents a woman’s pituitary gland from producing LH, luteinizing hormone. LH increases can trigger premature ovulation and stimulate testosterone and progesterone production which can be harmful to a woman’s egg production and prematurely mature the lining of womb potentially affecting implantation

Monitoring of a woman’s stimulation with gonadotropins is performed by transvaginal ultrasound examination of her ovarian follicles and blood hormone levels. The gonadotropin doses can be adjusted according to the results of the monitoring. The timing of the HCG and subsequent egg retrieval are likewise based on the monitoring. Typically, a woman need not be monitored more frequent than every 3 days initially but may need daily monitoring as she approaches follicular maturation to determine timing of the HCG injection and retrieval.

Morula is the stage between the cleavage stage embryo and blastocyst. It is when the embryo is a ball of cells and is usually achieved by the 4th day after insemination.

Oral contraceptive pills are often given prior to the stimulation to help time stimulation starts and bring a woman’s reproductive system to a baseline state from which the stimulation may be initiated.

PGD/PGS is preembryo genetic diagnosis and screening.  PGD refers to diagnosing the presence of a single gene disorder in the embryo.  Typically, patients with a prior history of producing a child with this disorder or where both partners are known carriers for a genetic disease are candidates for PGD.  Alternatively, patients could make the diagnosis in pregnancy by chorionic villus sampling or amnioscentesis.  PGS is screening for chromosomal abnormalities and has been used to improve success after embryo banking, to prevent chromosomally caused recurrent miscarriages, to improve success with older patients’ IVF cycles and for family balancing/gender selection.  Embryos are biopsied 3 days after retrieval in the cleaved state or 5 or 6 days after retrieval in the blastocyst state. 

Progesterone is an ovarian hormone that prepares the lining of the womb for implantation. We measure it during stimulation to check if the lining is getting prematurely stimulated. We add it to the woman after the retrieval to better prepare the lining and continue it as needed to help sustain the implanted embryo until the placenta takes over production of its own progesterone.  It may be administered as an intramuscular injection in which it is placed in various oil media to facilitate absorption.  It may also be administered as vaginal suppositories or tablets either as compounded micronized progesterone or in the commercially prepared brands; Endometrin and Crinone.

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Did you find this helpful?

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“Attention. This is Your Captain Speaking…”

By David Kreiner MD

December 20th, 2013 at 11:07 am

 

“Scuza,scuza , Signore e signori we are experiencing technical difficulties…”

While I sit uncomfortably detained aboard an Al Italia jet on the tarmac at the Sicilian airport waiting for the mechanics to determine if they can repair the mechanical troubles, my mind drifts to the plight my patients experience while they go through their fertility treatments.

Frustrated, with no control over my situation I reflected upon what it must feel like for my patients who must place their trust in people more experienced than them who routinely deal with those issues that are so significantly impacting them.

Like my pilots and their support staff, the fertility doctors, nurses and their staff have dealt with problems identical to or extremely similar to the ones my patients face on a daily basis. As such I felt that I should trust that the pilots and maintenance staff would only proceed with the flight once they were assured the problem was satisfactorily repaired and that the plane was safe.

However, I figured that if we were to be delayed for takeoff that I could take out my iPad and make myself more comfortable during the wait. Immediately, I heard from the flight attendant, in angry Italian, scolding me to turn off my electronics.  Actually, I did not understand but several other passengers quickly added in English to shut off my iPad.   Did I not hear the prior instruction to turn off the electronics?

I did not understand the reasoning behind this as we were obviously delayed for takeoff. I was frustrated with my lack of control and understanding.  I would have felt more comfortable if I understood what was going on and even better if I were able to participate in the process in some way.

I am sure that my patients must also have this great desire to understand and obtain some control.  I believe that many do… often by gaining more knowledge on the subject through the Internet, our orientation sessions, and directly through questioning the doctors and nurses.

The fact was for me I had no knowledge of our problem with the plane and was therefore utterly helpless other than to offer my complete cooperation.  My patients on the other hand do have opportunities to attain some control and an ability to assist on their own behalf achieving their goal of a pregnancy.

What can patients do to improve their success?

Listening carefully to instructions and following them religiously such as obtaining and administering medications, regarding dosages and times is essential.  It is important to their ultimate success if they arrive to monitoring visits, retrievals and transfers at stated times.  Patients’ responses to medications vary over time and are considered when their doctors interpret their hormone levels.  The egg matures over the course of time passed from the hCG shot but if this time is extended too long a patient may ovulate before the retrieval is performed and the egg is lost.

How else can patients improve their outcome?

Studies have shown that stress reduction through support groups, mind body programs, massage and especially acupuncture improve success rates essentially by improving a body’s ability to respond in a healthy fashion to the fertility process.

As my reflections on the unique ability of my patients to impact their fertility were now complete and committed to paper (my iPad safely turned off and stowed away), over an hour later we finally pulled away from the gate and safely took flight.  One hour later we landed in Rome, excited to move on to the next leg of our trip. I thought as I reflected on my successful journey how I wished for my patients to be as successful in theirs.

Yet as we are about to deplane, I hear “Signore e signori I am very sorry…” the pilot announced that the bus transportation to the gate had not yet arrived and it would be another short while.

“I apologize for the inconvenience”.  Yes, this is very familiar.

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How does your infertility journey make you feel out of control or like a traveller in a foreign land?

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=3466&picture=fasten-seat-belts

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Infertility Podcast Series: Journey to the Crib: Chapter 18 Medications for IVF Treatment

By David Kreiner MD

July 24th, 2012 at 3:29 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Eighteen: Medications for IVF Treatment. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.eastcoastfertility.com/?p=106 

 Medications for IVF Treatment 

Prior to Dr. Georgeanna Seegar Jones initiating gonadotropin therapy for IVF, success rates were a pitiful 1%.  Utilizing Follicle Stimulating hormone (FSH) and Leuteinizing Hormone (LH) to stimulate the ovaries and recruit a number of eggs improved pregnancy rates for IVF  to a more respectable 10% by 1980 in Norfolk, Virginia in what later became known as the Jones Institute for Reproductive Medicine at Eastern Virginia Medical School. 

Dr. Jones had pioneered the use of FSH and LH in the U.S. for ovulation induction in the 1960′s.  Today, nearly 50 years later, these hormones are used annually in hundreds of thousands of cycles and have resulted in over 5 million births by IVF alone with success rates for IVF at Long Island IVF for example greater than 50% live birth rate per fresh embryo transfer. 

Still, concern has been expressed regarding the safety of these hormones.  Multiple pregnancies, a common side effect of IVF in the 1980′s and 1990′s due to the inefficiency of the procedure necessitating multiple embryo transfer is seen in less than 25% of cases and rarely results in more than twins. 

The risk of cancer, which has been a concern raised by many over the years, is either minimal or nonexistent. 

Recently, the risk of ovarian hyperstimulation syndrome (OHSS) has been raised in the media with a sensationalized 10% incidence reported.  OHSS is a syndrome whereby a woman’s ovaries enlarge, fluid accumulates in the abdomen, sometimes in the soft tissues of the legs and occasionally around the lungs.  It rarely can cause clotting in the blood that increases the risk of a pulmonary embolus, a complication I have seen twice since 1985 (both women had babies and did fine afterwards). 

In fact most studies identify a 3% incidence of OHSS which due to recent prophylactic treatments is becoming less common with less severe symptoms.  At Long Island IVF, patients at increased risk identified by having an estradiol of greater than 3000 are prophylactically treated with a medication, cabergoline, which minimizes the OHSS.  Additionally, the final stage of maturation in these cases is triggered using lupron and a very low dose of hCG further minimizing the risk for OHSS.  In patients with the greatest risk for OHSS, all embryos are cryopreserved and the patient undergoes embryo transfer in a subsequent unstimulated cycle. 

As a result of these measures, OHSS has become a rare serious side effect of gonadotropin use in IVF at Long Island IVF while live baby rates have flourished. 

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Was this helpful in answering your questions about medications for IVF treatment? 

Are you aware that Long Island IVF is giving away a free basic Micro-IVF cycle, valued at $3,900.00? Check out the contest here: http://bit.ly/LHbmQR 

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

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The Hole

By Tracey Minella

June 18th, 2012 at 9:23 pm

 

I’m emotional today. I got to relive my personal IVF experience today during a video shoot for an upcoming LIIVF video. The highs and lows of several years.

Maybe you are emotional, too.

You may be emotional from medications, from opening a baby shower invitation, from an insensitive comment, or from yet another negative pregnancy test. I’ve been there. I spent years there.

I call those years “The Hole”.

I didn’t realize at the time… as I was living the day to day, minute to minute hell of infertility…that it was the hole that it in fact became. I was too busy surviving it all.

It’s a survivor’s thing, I guess. When a major life crisis like cancer or autism or infertility hits, it plucks you out of the regular world and dumps you into another place. A dark and scary place full of uncertainty and fear and broken dreams.

A hole.

I wish I could spare you. I wish I could guarantee that happy ending, that light at the end of the tunnel. But I can only hope that the hole is not too deep. That it doesn’t steal too much of your life, as it did mine. That another hole won’t follow.

Fortunately, we all will see an end to our infertility journeys. Some journeys are long, others short. But they all do end. You won’t be in treatment TTC for 20 years (though it may feel that way). It may end with a baby that’s genetically connected, or not, or, in some cases it may end without a baby. Happily, advances in assisted reproductive technology make the last scenario less likely.

My point is that there are things you are not doing, not enjoying right now because your happiness…or unhappiness…is controlled by your infertility. It’s understandable to tell yourself you’ll do those things soon… right after you get pregnant. And to protect your heart by thinking this will be the month it happens. But when it doesn’t (again), you can lose sight of the time that is actually passing. You’re putting the rest of your life on hold. And life is passing you by like the blur in your peripheral vision.

Reclaim it. It takes effort not to allow infertility to pull you into the hole. Herculean effort, at times. I didn’t have the insight. I didn’t have someone who’d walked in my shoes to tell me about the hole. But I’m telling you, though.

Because whenever… and however… it is that you do eventually get out of the hole, you will look back and wonder where those months or years went. And no matter how happy you are to have that miracle baby, and how worthwhile you feel the whole journey was, you can’t get that time back. Trust me… it’s no fun to admit I can’t remember anything fun between 1992- 1998.

It’s summer and social calendars are active. Please resist the urge to say “no” to all of the social outings and events. Skip those that are too difficult, of course, but don’t deny or isolate yourself so much that you slip away completely. Make memories you can share with your future children.

Defy the hole.

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Has your journey been a hole? When did you realize that?  If you were able to defy the hole, how did you do it?

 

Photo credit: http://www.publicdomainpictures.net/hledej.php?hleda=black+hole

 

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A Guide to Fertility Medications

By Dr. Jessica Mann

December 15th, 2010 at 7:17 am

Couples facing subfertility have many tasks at hand in order to begin treatment.  The emotional, financial, and psychological burden can be overwhelming.  Fortunately, the field of reproductive endocrinology has and continues to offer new modalities to help couples achieve their dreams.  New medications in today’s market promise to be “patient friendly” and indeed, efforts are made to make the process of medication administration easier on patients.  Hopefully, an understanding of these medications, how they work, and common side effects may lessen some the anxiety and “fear of the unknown” that couples may experience when beginning fertility treatment.  The goal of our caring, compassionate, and dedicated team at East Coast Fertility is to be there for patients every step of the way.  Below is a list of common medications used to treat various forms of subfertility and how they work.

Pills

Estrogen receptor blocker (aka Clomiphene citrate or Clomid)

This medication is used for patients who are not able to ovulate (or release the eggs) as it resets the hormonal imbalance typical of anovulation.  It can also be used to treat couples with unexplained infertility by increasing the number of eggs exposed to sperm, the latter is done by performing artificial insemination.  This drug is a pill which is ingested early in the menstrual cycle, commonly for 5 days.  It works by blocking estrogen in the brain.  This blockade tricks the brain into thinking that the ovaries need to be working harder and hence increases the amount of a hormone called FSH (follicle stimulating hormone).  Some of the most common side effects include hot flashes (up to 10%), mood changes, breast tenderness, bloating, ovarian enlargement, nausea, abdominal discomfort, multiple pregnancy (up to 8% chance of twins and 1% chance of triplets) and rarely visual changes.  Don’t be alarmed if you suddenly feel extremely emotional, it’s not you, it’s the medication.  If visual changes develop, you should talk to your doctor before taking any more pills.  In a small number of patients, clomid can make the endometrial lining too thin, which is not ideal for implantation.  If this was your case, your doctor may not continue with another cycle of clomid but rather switch to injectable medications.   

Injectable medications

Exogenous Gonadotropins (aka FSH/hMG combinations)

The goal of these hormonal injections is to provide the ovaries with a source of “fuel” to power ovarian activity.  These hormones are necessary for proper ovarian function and egg development.  The initial amount and combination of medication is carefully chosen by your Reproductive Endocrinologist based on your history.  Most of the injections are given subcutaneously (in the fatty part just below the skin).  Some are given in the muscle.  The latter may be a little more uncomfortable but in general, they are well tolerated.  Side effects include breast tenderness, dry skin, muscle aches, joint pains, generalized body discomfort, headaches, abdominal discomfort, ovarian hyperstimulation syndrome, and multiple pregnancy.  Allergic reactions are rare but can be severe but difficulty breathing, mouth, lip, face swelling, or chest pain need immediate attention.    

Human Chorionic Gonadotropin (hCG)

This hormone is normally produced by the placenta of pregnant women.  It is utilized to allow the eggs to complete maturation and to ovulate, in other words, to release the eggs from the ovaries.  This shot is administered subcutaneously.   It can be used during cycles of clomiphene citrate or injectable medications to adequately time an intrauterine insemination.  However, when hCG is given for the purpose of in vitro fertilization, one must adhere strictly to the specific administration time.  This is carefully coordinated by the physicians and nursing staff.  Retrieval of the eggs will follow about 35-36 hours later.   A mistake in the timing of administration and retrieval can lead to ovulation prior to egg retrieval (removal of the eggs) and a loss of all eggs.  Any concerns about mixing or administration of hCG should be addressed promptly.  Side effects include headache, water retention, sore breasts, fatigue, irritability, and ovarian hyperstimulation syndrome. 

Ovarian control

When patients are undergoing in vitro fertilization, the ovarian response needs to be controlled by the clinician so that patients do not ovulate before appropriate development has taken place.  In order to achieve a controlled stimulation two classes of drugs are commonly used.

GnRH Agonists (leuprolide acetate)

This medication is an injectable hormone used to keep the ovaries “quiet”.  Initially, it will make the brain secrete more FSH.  However, after a few days, the brain will shift into a “menopausal state”, characterized by lack of hormonal interchange between the ovaries and the brain.  This allows for control of a woman’s cycle by the Reproductive Endocrinologist.  In most cases, only a small amount of medication is needed to achieve ovarian control, as this is a very potent drug.    Hence, the injection is only minimally painful.  Side effects include hot flashes, headaches, generalized discomfort, joint pains, and rarely allergic reactions.  The symptoms will improve upon initiation of hormonal repletion in the form of FSH and/or LH. 

GnRH Antagonists (ganirelix, cetrorelix)

These drugs block GnRH (which stimulates production of FSH) and allow for controlled stimulation of the ovaries.   This medication is usually started after stimulation with injectable hormones has begun.  As this medication comes in a preloaded syringe, it is very patient friendly in terms of administration.  Side effects are usually minor and infrequent.  Allergic reactions may still occur although most are localized to the site of injection.

Luteal support

After the embryo(s) is(are) transferred into the patient’s uterus, it needs to be nourished for proper development.  In a woman’s regular cycle, after an egg is ovulated (released), the remaining cells in the ovary (corpus luteum) will begin secreting progesterone, a hormone that supports pregnancy throughout.  During ovarian stimulation the ovaries may fail to properly secrete progesterone hence the need to supplement.  This medication is usually begun before the embryo(s) transfer.  

Progesterone in oil

This medication is given intramuscularly and can be more painful than the other medications.  However, patients should keep in mind, this is the final stretch!  You’ve made it this far!  It is absorbed from the muscle, into the bloodstream, and brought to the uterus.  The most common side effect is pain at the injection site.  Allergic reactions can occur and there are various types of formulations available to patients.  The shots may be switched to vaginal supplementation at the discretion of your Reproductive Endocrinologist. 

Progesterone Vaginal inserts (crinone, endometrin)

Very patient friendly medications, the vaginal inserts claim they are the next generation luteal support.  This drug can be used in combination with any form of fertility treatment, from clomid to in vitro fertilization.  Benefits include local absorption into the uterine cavity and minimal side effects, the most common ones being vaginal itchiness, discomfort, and significant discharge. 

In summary, having an understanding of your medications may decrease the anxiety that can be associated with “opening the box of meds”.  Our goal is to help you through this new journey.  Rest assured that our staff is always there, ready and eager to help you every step of the way. 

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The Key to Treat Infertility

By Dr. Eli Rybak

November 18th, 2010 at 1:12 am

Patients and practitioners alike, when confronting the challenges of infertility, perceive the uniquely existential aspect of this ordeal.  Indeed, most individuals and couples contending with infertility are otherwise “healthy”.  Many have vibrant careers, close-knit family and friends, and various volunteer or community service obligations. Yet, they and their physicians understand that without successful resolution of their infertility, the patient remains with an unfulfilled void in their life-long mission, destiny and dreams. 

I have been pondering such thoughts over the past several weeks.  In Jewish tradition, the Five Books of Moses are divided throughout the year, and a portion is read aloud in the Synagogue every Sabbath.  The cycle begins and ends each year at Simchat Torah, the conclusion of the High Holiday Season in October.  And every year in November and December, the segments from the middle of Genesis are reviewed – and with that, comes the piercing drama and recurrent cry of the Matriarchs – most of whom struggled with infertility.

After decades of childlessness, Sarah encouraged Abraham to bear a child through, effectively, a surrogate – their maidservant, Hagar.  It was only through an explicitly recorded Divine promise and intervention that Sarah herself subsequently underwent a reversal of her menopause and gave birth at age 90 to Isaac. (Oh, and she lived to see Isaac reach age 37 – I digress, but 2 important points come to mind: First, I believe that our society must develop far more effective workplace policies to enable women to better balance family and career during their peak reproductive years.  I always feel pained when I counsel a 40+ year-old patient who is not prepared to consider egg donation, and I discuss the success rates of IVF in patients over 40, as well as the risks of miscarriage etc.  At good centers like East Coast Fertility, IVF has an over 60% success rate per retrieval for women under age 35; however, such success is age-related, and does not apply to “older” reproductive-age women using their own eggs. Second, for “older” women who do choose to use donor eggs, many face unfair societal skepticism – “will that woman be alive when that child graduates college?”  I feel that such speculation is unwarranted and unfair.  Women in their 40s and 50s are leading productive, happy, healthy, and increasingly long lives.  Let’s leave a person’s longevity in the Almighty’s hands.)

Back to ancient times, Rebecca and Isaac suffered for 20 years until their prayers were answered and Rebecca delivered twin boys, Esau and Jacob.  And, most famous, is Rachel’s anguished cry to Jacob (Genesis 30:1), “Give me children, if not, I am dead.”  Biblical commentators query as to the prevalence of infertility among the righteous matriarchs.  One famous answer suggests that G-d craves the prayers of the virtuous.  Indeed, infertility is a tremendous test of one’s inner strength, and regardless of a person’s spiritual beliefs, prayer never hurts.  And, ultimately, I personally believe in the Talmudic Dictum that the key to the womb remains (alongside the key to rain, for example) with the Almighty.  As much as we have learned – and continue to learn on a daily basis regarding egg and embryo quality, fertilization, and endometrial receptivity (my colleague Dr. Zapantis and I have, ourselves, performed and published laboratory research regarding the latter), there is still so much that science cannot answer.

Nevertheless, in the 30-plus years since the birth of the very first IVF baby in 1978, assisted reproductive technology has enabled amazing new treatments for couples and individuals enduring the age-old scourge of infertility.  Many vibrant centers like ours offer the full range of diagnostics, treatment and assisted reproduction including IUI, IVF, ICSI, PGD, egg donation, egg and/or embryo freezing – and the list, thankfully, goes on.  What many centers, however, do not offer, is a “key” to unlock the financial barriers to many of these expensive, often uninsured procedures.  It is a pity and a tragedy.  In 2010, G-d and science have enabled enormous strides in treating infertility.  At East Coast Fertility, I am proud of our efforts to help patients unlock some of the financial barriers.  I welcome you: please inquire about our IVF grants as well as our successful and unique Micro-IVF and elective Single Embryo Transfer (SET) programs. We take our pledge seriously, to make IVF safe and affordable

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“What can I expect to feel like on fertility drugs? What are the side effects?” Part 2 (Injectable Gonadotropins)

By Joseph Peña, Md, Facog

August 5th, 2010 at 12:00 am

Side effects, risk, and complications of gonadotropins may include the following:

·         Ovarian hyperstimulation syndrome (OHSS)

o   OHSS occurs when the ovaries respond too well to the medication and produce too many eggs.  The ovaries rapidly swell to several times their size and leak fluid into the abdominal cavity.

o   If present, usually mild (10-30% of IVF cycles, less likely in intrauterine insemination (IUI) cycles) resulting in some discomfort (abdominal and pelvic bloating and discomfort) but almost always resolves without complications

o   Severe OHSS occurs ~1% of IVF cycles, increased in younger women, women with PCOS, and women who conceive.  Potential complications include:

§  Abdominal and chest fluid collections, blood clots, kidney problems, ovarian twisting

§  May occasionally require draining of fluid from the abdomen (paracentesis) to help alleviate symptoms (e.g. difficulty breathing, abdominal pain due to distention, decreased urine output)

§  May require hospitalization for close monitoring, but the condition is usually transient lasting about 1-2 weeks

o   The key is prevention.  A couple of options that may be considered in patients deemed to be at significant risk for OHSS (increased number of ovarian follicles on ultrasound, increased serum estradiol levels, PCOS) to decrease risk of manifesting severe OHSS include:

§  Cancelling IVF cycle (withholding hCG) and prevent ovulation

§  Cancelling embryo transfer with cryopreservation of the embryos for frozen embryo transfer in a subsequent menstrual cycle, in order to prevent conception during current cycle

·         Multiple pregnancy

o   Up to 20% risk of multiple pregnancy with use of gonadotropins in IUI cycles (majority are twins, but up 5% risk of triplets or greater), compared to baseline of 1-2% in the general population

o   Associated with increased risk of pregnancy loss, premature delivery, handicap due to the consequences of very premature delivery, pregnancy-induced hypertension, hemorrhage, and other maternal complications

·         Ectopic (tubal) pregnancies

o   Slightly increased risk from the 1-2% rate in the general population

o   Important for close monitoring in the early part of pregnancy to confirm that the pregnancy is located in the uterus

·         Adnexal torsion (ovarian twisting)

o   The enlarged, stimulated ovary can twist on itself, cutting off its own blood supply in < 1% of cycles

o   May require surgery to untwist or remove the ovary

·         Ovarian cancer?

o   Link between use of gonadotropins and the development of ovarian cancer is unknown and is the subject of ongoing research

Thus, while the use of the injectable gonadotropins is generally safe and the benefits outweigh the risks/side effects for many women undergoing fertility treatment, it is important that while taking any of these medications, it should be done under the close supervision of a physician who specializes in managing such treatment cycles.  And if one has any questions or concerns while taking any of these medications, it is best to consult one’s physician.

References:
-Clinical Gynecologic Endocrinology & Infertility.  Speroff.

-ASRM Patient’s Fact Sheet: Side Effects of Gonadotropins

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“What can I expect to feel like on fertility drugs? What are the side effects?” Part 1 (Clomiphene Citrate)

By Joseph Peña, Md, Facog

August 4th, 2010 at 9:10 am

“Fertility drugs” can refer to any number of medications used for fertility treatment.  The two most common of these are the oral medication clomiphene citrate (Clomid) and the injectable gonadotropins (e.g. Gonal F, Follistim, Bravelle, Menopur, Repronex, etc.).  Some side effects and complications are common to both, while others may be unique to each group.  A review of the side effects, risks, and complications of both groups is listed below.

Side effects, risks, and complications of clomiphene citrate (CC) may include the following:

·         Menopausal symptoms are not uncommon such as:

o   Hot flashes (~10%)

o   Irritability

o   Headaches (1.3%)

·         Abdominal distension, bloating, pain, or soreness (5.5%)

·         Ovarian cyst formation – not uncommon and temporary, resolving within in 1-2 menstrual cycles

·         Thickened cervical mucus

o   If present, it can be treated by bypassing the cervix with use of intrauterine insemination (IUI)

·         Breast discomfort (2%)

·         Nausea and vomiting (2%)

·         Visual disturbances (1.5%), such as blurring, spots or flashes, double vision, intolerance to light, decreased visual sharpness, loss of peripheral vision, and distortion of space

o   If present, should be cautious about driving a car or operating dangerous machinery

o   Notify your doctor immediately who may modify your treatment and/or recommend a complete evaluation by an eye specialist

o   Symptoms usually disappear within a few days of discontinuing the medication

·         Multiple pregnancy

o   5-8% risk of multiple pregnancy with use of CC (mostly twins, 1% risk of triplets), compared to baseline of 1-2% in the general population

·         Ovarian hyperstimulation syndrome

o   If present, usually mild (enlarged ovaries and abdominal discomfort)

o   Rarely, may be severe.  Potential complications may include

§  Massive ovarian enlargement, progressive weight gain, severe abdominal pain, nausea and vomiting, fluid in abdominal cavity, decreased urine output

·         Miscarriage risk?

o   Some studies have noted a slightly higher miscarriage rate.  However, it is not clear if this is due to an effect of the medication or related to preexisting conditions such as age or polycystic ovary syndrome (PCOS), which are found more often in women who take CC.

o   Other studies have not shown an increased risk of miscarriage.

o   No evidence that CC treatment increases overall risk of birth defects

·         Ovarian cancer?

o   No causal relationship between ovulation inducing drugs and ovarian cancer has been established

Thus, while the use of clomiphene citrate is generally safe and the benefits far outweigh the risks/side effects for a majority of women undergoing fertility treatment, it is important that while taking any of these medications, it should be done under the close supervision of a physician who is experienced in managing such treatment cycles.  And if one has any questions or concerns while taking any of these medications, it is best to consult one’s physician.  You can learn more about clomiphene citrate at:  http://www.eastcoastfertility.com/index.php?id=blogsingle&tx_ttnews[tt_news]=41&cHash=f6fa864a75e9c0f6e8982478ab2256db

References:
-ASRM Practice Committee: Use of clomiphene citrate in women
-Clinical Gynecologic Endocrinology & Infertility.  Speroff.
-WebMD: Infertility & Reproduction Health Center

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