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Archive for the ‘fertility testing’ tag

Start the New Year with an Annual Fertility Screening

By David Kreiner MD

December 13th, 2015 at 12:31 pm

Photo Credit: George Hodan/ publicdomainphotos.net


As the year winds down and you reflect on the past, and make resolution for the future, it pays to consider an annual fertility screening.

Some of you may be well into treatment already, but others may just be starting out with their family-building plans…or may be putting off starting a family or adding to their family.

It may be wise to have a baseline or annual fertility screening done, just to help rule out identifiable and underlying fertility problems you may already have and are unaware of. Armed with the knowledge a screening gives you, you can make a more informed decision about how long you may want to wait before beginning or resuming your family building plan.

Dr. Kreiner explains what a fertility screening usually means:

Fertility screening starts with a blood test to check the levels of FSH (follicle stimulating hormone), estradiol and AMH (antimullerian hormone). The FSH and estradiol must be measured on the second or third day of your period. The granulosa cells of the ovarian follicles produce estradiol and AMH. The fewer the follicles there are in the ovaries the lower the AMH level. It will also mean that less estradiol is produced as well as a protein called inhibin. Both inhibin and estradiol decrease FSH production. The lower the inhibin and estradiol the higher the FSH as is seen in diminished ovarian reserve. The higher the estradiol or inhibin levels are then the lower the FSH. Estradiol may be elevated especially in the presence of an ovarian cyst even with failing ovaries that are only able to produce minimal inhibin. However, the high estradiol reduces the FSH to deceptively normal appearing levels. If not for the cyst generating excess estradiol, the FSH would be high in failing ovaries due to low inhibin production. This is why it is important to get an estradiol level at the same time as the FSH and early in the cycle when it is likely that the estradiol level is low in order to get an accurate reading of FSH.

The next step is a vaginal ultrasound to count the number of antral follicles in both ovaries. Antral follicles are a good indicator of the reserve of eggs remaining in the ovary. In general, fertility specialists like to see at least a total of eight antral follicles for the two ovaries. Between nine and twelve might be considered a borderline antral follicle count.
As you start to screen annually for your fertility, what you and your doctor are looking for is a dramatic shift in values from one year to the next.

What Does the Screen Indicate?

A positive screen showing evidence of potentially diminishing fertility is an alarm that should produce a call to action. When a woman is aware that she may be running out of time to reproduce she can take the family-planning reins and make informed decisions. The goal of fertility screening is to help you and every woman of childbearing years make the choices that can help protect and optimize your fertility.

Due to advancements in assisted reproductive technologies, younger women who may not be ready to start their families yet for social, financial or other reasons, can now freeze their eggs for future use if needed. This technology is available at Long Island IVF. If you are interested in egg-freezing for your own use or for donating to another woman, please contact our Program Coordinator, Vicky Loveland, RN in the Melville office.

Although none of these tests is in and of themselves an absolute predictor of your ability to get pregnant, when one or more come back in the abnormal range, it is highly suggestive of ovarian compromise. It deserves further scrutiny. That’s when it makes sense to have a discussion with your gynecologist or fertility specialist. Bear in mind, the “normal” range is quite broad. But when an “abnormal” flare goes off, you want to check it out.

It’s important to remember that fertility is more than your ovaries. If you have risk factors for blocked fallopian tubes such as a history of previous pelvic infection, or if your partner has potentially abnormal sperm, then other tests are in order.

Regardless of the nature or severity of the problems, today, with Assisted Reproductive Technology there is a highly effective treatment available for you.

 

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Did you put off a fertility screening… and end up regretting it? If so, what advice do you have for other women who may be doing the same thing?

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Femvue: The HSG Alternative Test

By David Kreiner MD

May 6th, 2013 at 8:40 pm

 

image courtesy of OhMega 1982/free digital photos.net

Fear can be an awesome motivator. 

Unfortunately, when it leads to avoiding a vital medical test such as investigating the patency of fallopian tubes it can prevent a physician from discovering the cause of a couple’s infertility. 

The hysterosalpingogram (HSG) is an x-ray of the fallopian tubes after radio-opaque contrast is injected transvaginally through the cervix.  Contrast can be visualized filling the fallopian tubes and spilling through patent fallopian tubes into the pelvis.

The HSG is performed using a metal instrument clamped on the lip of the cervix while a tube is placed through the cervix and contrast injected into the uterine cavity under pressure.  Patients have complained that this procedure is too painful for them to endure and either refuse to undergo the procedure or go for a surgical laparoscopy under general anesthesia.

Today, a new procedure, known as the Femvue, is available whereby a physician inserts a catheter similar to that used at insemination into the cervix.  The physician observes by transvaginal ultrasound the flow of air bubbles through the tubes and into the pelvis.  This can be accomplished in the office with typically minimal discomfort to the patient. 

Sometimes, it may be difficult to get reliable results with Femvue in obese patients. In cases where the results of Femvue are abnormal, a traditional HSG may be done to confirm results.

With the Femvue, the fear of pain experienced by some patients from the HSG is no longer an obstacle to the infertility workup.

Femvue is currently being performed at Long Island IVF by Doctors Kreiner, Pena, and Zinger.

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If you have had an HSG, was it painful? If you’ve had Femvue, how did it go?

Have you avoided an HSG because of fear?

 

Photo credit: http://www.freedigitalphotos.net/images/Diseases_and_Other_M_g287-Woman_With_Abdominal_Pain_p76296.html

 

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To Do List: Annual Fertility Screening

By Tracey Minella and David Kreiner MD

December 8th, 2011 at 8:06 pm


As the year winds down and you reflect on the past, and make resolution for the future, it pays to consider an annual fertility screening. Some of you may be well into treatment already, but others may just be starting out with their family-building plans…or may be putting off starting a family or adding to their family. It may be wise to have a baseline or annual fertility screening done, just to help rule out identifiable and underlying fertility problems you may already have and are unaware of. Armed with the knowledge a screening gives you, you can make a more informed decision about how long you may want to wait before beginning or resuming your family building plan.

Dr. Kreiner explains what a fertility screening means:

Fertility screening starts with a blood test to check the levels of FSH (follicle stimulating hormone), estradiol and AMH (antimullerian hormone). The FSH and estradiol must be measured on the second or third day of your period. The granulosa cells of the ovarian follicles produce estradiol and AMH. The fewer the follicles there are in the ovaries the lower the AMH level. It will also mean that less estradiol is produced as well as a protein called inhibin. Both inhibin and estradiol decrease FSH production. The lower the inhibin and estradiol the higher the FSH as is seen in diminished ovarian reserve. The higher the estradiol or inhibin levels are then the lower the FSH. Estradiol may be elevated especially in the presence of an ovarian cyst even with failing ovaries that are only able to produce minimal inhibin. However, the high estradiol reduces the FSH to deceptively normal appearing levels. If not for the cyst generating excess estradiol, the FSH would be high in failing ovaries due to low inhibin production. This is why it is important to get an estradiol level at the same time as the FSH and early in the cycle when it is likely that the estradiol level is low in order to get an accurate reading of FSH.

The next step is a vaginal ultrasound to count the number of antral follicles in both ovaries. Antral follicles are a good indicator of the reserve of eggs remaining in the ovary. In general, fertility specialists like to see at least a total of eight antral follicles for the two ovaries. Between nine and twelve might be considered a borderline antral follicle count.

As you start to screen annually for your fertility, what you and your doctor are looking for is a dramatic shift in values from one year to the next.

What Does the Screen Indicate?

A positive screen showing evidence of potentially diminishing fertility is an alarm that should produce a call to action. When a woman is aware that she may be running out of time to reproduce she can take the family-planning reins and make informed decisions. The goal of fertility screening is to help you and every woman of childbearing years make the choices that can help protect and optimize your fertility.

Although none of these tests is in and of themselves an absolute predictor of your ability to get pregnant, when one or more come back in the abnormal range, it is highly suggestive of ovarian compromise. It deserves further scrutiny. That’s when it makes sense to have a discussion with your gynecologist or fertility specialist. Bear in mind, the “normal” range is quite broad. But when an “abnormal” flare goes off, you want to check it out.

It’s important to remember that fertility is more than your ovaries. If you have risk factors for blocked fallopian tubes such as a history of previous pelvic infection, or if your partner has potentially abnormal sperm, then other tests are in order.

Regardless of the nature or severity of the problems, today, with Assisted Reproductive Technology there is a highly effective treatment available for you.

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

Did you put off a fertility screening… and end up regretting it? If so, what advice do you have for other women who may be doing the same thing?

no comments

Time for Your Fertility Workup!

By Tracey Minella and David Kreiner MD

September 13th, 2011 at 6:41 pm


Well, summer’s over and we’re all settling into the new routine.

Second only to January’s New Year’s resolutions, September has always been a time to reorganize life and  reassess goals.

That means fall cleaning. Garage sales. Preparing for winter. Maybe that pre-holiday diet or renewed gym membership?

Well, fall is also a good time to get your “fertility business” in order. What have you been putting off?

Have you been delaying seeing a reproductive endocrinologist, despite TTC for quite awhile? Or have you had an exam, but put off the follow-up testing?

Dr. Kreiner of East Coast Fertility discusses the fertility workup:

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.

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So, what test are you putting off and why?

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The ABCs of IVF

By David Kreiner MD, and Tracey Minella

April 5th, 2011 at 12:00 am

Don’t be a deer in the headlights when it comes to infertility diagnoses and treatments. Yes, there’s a lot to learn. Yes, it can be overwhelming, leaving you a bit glassy-eyed. 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 East Coast Fertility 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 20-25% 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. Some believe that a woman’s uterus may be more receptive to an embryo implanted at 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.

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.

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.

HMG – Human Menopausal Gonadotropins are purified from the urine of menopausal women since they have high levels of FSH and LH. Menopur and Repronex are brands 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. LH 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 is salt content like V 8 and Campbell’s chicken soup. We give patients baby aspirin to prevent clot formation. 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.

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.

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.

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.

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