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Archive for the ‘Fibroids’ tag

Infertility Care: Starting with the Basics

By Steven Brenner MD

October 18th, 2014 at 10:52 am

credit: wpclipart.com

“Thinking the worst” is a very common reaction for individuals experiencing adversity.

This is especially true for people experiencing infertility. Concerns regarding the question of establishing the family someone has dreamed of since they were young is daunting and can leave a person with significant anxiety and doubt regarding her/his future.

In this context it is important to go back to basics regarding fertility and understand that many people suffering from this disorder will be successfully treated with relatively simple techniques and therapies. For the more severe abnormalities, it is comforting to know current available therapies can address these issues with great success.

Establishing a pregnancy without infertility treatment requires a healthy egg, functioning sperm and an anatomic path that allows sperm to ascend the genital tract and an egg to travel into a fallopian tube where fertilization takes place. The anatomic path needs to allow the fertilized egg to travel into the uterine cavity. A receptive uterine lining is then required for the pregnancy to implant and grow. To make things more challenging, sperm and egg have a very small window of time to find each for fertilization to take place.

Many couples have experienced infertility as a result of improperly timed intercourse.  This often results from the couple not being aware of the timing of ovulation and the short duration of egg viability. The “fix” for something like this is very simple, requiring merely an understanding of the basic physiology.  Sexual dysfunction can plague a relationship, but it is often not until fertility is compromised that couples seek treatment. The simple fix for fertility may involve nothing more than inseminations timed to natural ovulation. Much more in depth therapies may be required to overcome the other, additional concerns associated with sexual dysfunction.

Ovulatory dysfunction, while a very complex issue, is often very easily addressed with simple treatments. Weight loss or gain may be all that is needed to establish regular ovulatory cycles. Correction of hormonal abnormalities leading to problems with ovulation can often be treated with medications that do not require the intense monitoring of injectable fertility medications associated with in vitro fertilization procedures.  Sluggish thyroid activity and elevations in a hormone named prolactin are such issues that readily respond to oral medications.

A receptive uterine lining to allow for implantation of an embryo that formed in the fallopian tube is needed to allow a pregnancy to be established in the uterus. Although a scarred endometrium or one that is distorted from fibroids may require surgical repair, other disorders of the lining can be treated with local hormonal supplementation. The endometrium, the uterine lining, may not develop appropriately after ovulation secondary to hormonal abnormalities. This may reflect an abnormality in egg production and the hormones associated with ovulation.

Therapies directed at improving ovulation or directly supporting the lining of the uterus with vaginal application of the hormone progesterone may be all that is needed to correct this problem.

Anatomic problems such as scarring of the fallopian tubes may require surgical correction. However, blocked tubes may be opened by minimally invasive procedures at the time of a hysterosalpingogram (HSG). In such procedures, a tube blocked where it inserts into the uterus is opened with a catheter in a setting that does not require general anesthesia.

Many patients will be successfully treated with simple techniques and procedures that are not associated with the expense and invasiveness of the therapies that most people think they will require.

For each infertile person a plan of evaluation and therapy needs to be developed, beginning with the basics. It does not necessarily lead to those treatments that are more detailed and invasive.

* * * * * * * * * * *

Did you put off an infertility evaluation out of fear of needing expensive, invasive fertility treatments?

 

Photo credit: http://www.wpclipart.com/phps.php?q=ostrich

 

 

 

 

 

 

 

 

 

 

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Fibroids and Fertility

By David Kreiner MD

December 13th, 2013 at 9:13 am

 

 

 

Fertility is dependent upon so many things!

We must have healthy gametes (eggs and sperm) capable of fertilizing and implanting in a uterus with a normal endometrial lining unimpeded by any uterine or endometrial pathology. The sperm need be in sufficient number and capable of swimming up through a cervix which is not inflamed and provides a mucous medium that promotes sperm motility. The eggs need to ovulate and be picked up by normal healthy fimbriated ends (finger like projections) of the fallopian tubes. The tubes need to be covered with normal micro hairs called cilia that help transport the egg one third of the way down the tube where one of the sperm will fertilize it.

The united egg and sperm (the “conceptus”) then needs to undergo cell division, growth and development as it traverses the tube and makes its way to the uterine cavity by the embryo’s fifth day of life at which point it is a blastocyst. The blastocyst hatches out of its shell (“zona pellucidum”) and implants into the endometrial lining requiring adequate blood flow.

And you wonder why getting pregnant is so hard?

All too often patients, in some groups as many as 30% of women, are told that they have fibroids that may be contributing to their infertility. Fibroids or leiomyomata are non malignant smooth muscle tumors of the uterus. They can vary in number, size and location in the uterus including; the outside facing the pelvic cavity (subserosal), the inside facing the uterine cavity (submucosal) and in between inside the uterine wall (intramural). Fortunately, most fibroids have minimal or no effect on fertility and may be ignored.

The subserosal myoma will rarely cause fertility issues. If it were distorting the tubo- ovarian anatomy so that eggs could not get picked up by the fimbria then it can cause infertility. Otherwise, the subserosal fibroid does not cause problems conceiving.

Occasionally, an intramural myoma may obstruct adequate blood flow to the endometrial lining. The likelihood of this being significant increases with the number and size of the fibroids. The more space occupied by the fibroids, the greater the likelihood of intruding on blood vessels traveling to the endometrium. Diminished blood flow to the uterine lining can prevent implantation or increase the risk of miscarriage. Surgery may be recommended when it is feared that the number and size of fibroids is great enough to have such an impact.
However, it is the submucosal myoma, inside the uterine cavity, that can irritate the endometrium and have the greatest effect on the implanting embryo.

To determine if your fertility is being hindered by these growths you may have a hydrosonogram. A hydrosonogram is a procedure where your doctor or a radiologist injects water through your cervix while performing a transvaginal ultrasound of your uterus. On the ultrasound, the water shows up as black against a white endometrial border. A defect in the smooth edges of the uterine cavity caused by an endometrial polyp or fibroid may be easily seen.

Submucosal as well as intramural myomata can also cause abnormal vaginal bleeding and occasionally cramping. Intramural myomata will usually cause heavy but regular menses that can create fairly severe anemias. Submucosal myomata can cause bleeding throughout the cycle.

Though these submucosal fibroids are almost always benign they need to be removed to allow implantation. A submucosal myoma may be removed by hysteroscopy through cutting, chopping or vaporizing the tissue. A hysteroscopy is performed vaginally, while a patient is asleep under anesthesia. A scope is placed through the cervix into the uterus in order to look inside the uterine cavity. This procedure can be performed as an outpatient in an ambulatory or office based surgery unit. The risk of bleeding, infection or injury to the uterus or pelvic organs is small.

Resection of the submucosal myoma can be difficult especially when the fibroid is large and can sometimes take longer than is safe to be performed in a single procedure. It is not uncommon that when the fibroid is large, it will take multiple procedures in order to remove the fibroid in its entirety. It will be necessary to repeat the hydrosonogram after the fibroid resection to make sure the cavity is satisfactory for implantation.

The good news is, when no other causes of infertility are found, removal of a submucosal fibroid is often successful in allowing conception to occur naturally or at least with assisted reproduction.

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

Anyone have a fibroid story to share?

Photo credit: public domain: http://en.wikipedia.org/wiki/File:Fibroids.jpg

 

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Infertility Care: Calm Down and Begin with the Basics

By Steven Brenner MD

January 7th, 2013 at 10:33 pm

credit: marcolm/freedigitalphotos.net

“Thinking the worst” is a very common reaction for individuals experiencing adversity.

This is especially true for people experiencing infertility. Concerns regarding the question of establishing the family someone has dreamed of since they were young is daunting and can leave a person with significant anxiety and doubt regarding her/his future.

In this context it is important to go back to basics regarding fertility and understand that many people suffering from this disorder will be successfully treated with relatively simple techniques and therapies. For the more severe abnormalities, it is comforting to know current available therapies can address these issues with great success.

Establishing a pregnancy without infertility treatment requires a healthy egg, functioning sperm and an anatomic path that allows sperm to ascend the genital tract and an egg to travel into a fallopian tube where fertilization takes place. The anatomic path needs to allow the fertilized egg to travel into the uterine cavity. A receptive uterine lining is then required for the pregnancy to implant and grow. To make things more challenging, sperm and egg have a very small window of time to find each for fertilization to take place.

Many couples have experienced infertility as a result of improperly timed intercourse.  This often results from the couple not being aware of the timing of ovulation and the short duration of egg viability. The “fix” for something like this is very simple, requiring merely an understanding of the basic physiology.  Sexual dysfunction can plague a relationship, but it is often not until fertility is compromised that couples seek treatment. The simple fix for fertility may involve nothing more than inseminations timed to natural ovulation. Much more in depth therapies may be required to overcome the other, additional concerns associated with sexual dysfunction.

Ovulatory dysfunction, while a very complex issue, is often very easily addressed with simple treatments. Weight loss or gain may be all that is needed to establish regular ovulatory cycles. Correction of hormonal abnormalities leading to problems with ovulation can often be treated with medications that do not require the intense monitoring of injectable fertility medications associated with in vitro fertilization procedures.  Sluggish thyroid activity and elevations in a hormone named prolactin are such issues that readily respond to oral medications.

A receptive uterine lining to allow for implantation of an embryo that formed in the fallopian tube is needed to allow a pregnancy to be established in the uterus. Although a scarred endometrium or one that is distorted from fibroids may require surgical repair, other disorders of the lining can be treated with local hormonal supplementation. The endometrium, the uterine lining, may not develop appropriately after ovulation secondary to hormonal abnormalities. This may reflect an abnormality in egg production and the hormones associated with ovulation.

Therapies directed at improving ovulation or directly supporting the lining of the uterus with vaginal application of the hormone progesterone may be all that is needed to correct this problem.

Anatomic problems such as scarring of the fallopian tubes may require surgical correction. However, blocked tubes may be opened by minimally invasive procedures at the time of a hysterosalpingogram (HSG). In such procedures, a tube blocked where it inserts into the uterus is opened with a catheter in a setting that does not require general anesthesia.

Many patients will be successfully treated with simple techniques and procedures that are not associated with the expense and invasiveness of the therapies that most people think they will require.

For each infertile person a plan of evaluation and therapy needs to be developed, beginning with the basics. It does not necessarily lead to those treatments that are more detailed and invasive.

* * * * * * * * * * *

Did you put off an infertility evaluation out of fear of needing expensive, invasive fertility treatments?

Photo credit: http://www.freedigitalphotos.net/images/search.php?search=worried&cat=&page=6&gid_search=&photogid=0

 

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Forget the Bikini! Are You in Reproductive Shape?

By David Kreiner MD, and Tracey Minella

July 10th, 2012 at 9:00 am

It’s that time of year when your unused gym membership begs for renewal. I used to fall for that. Now I just scope out someone who looks worse than me to sit near on the beach. So lame, I know.

Alas…the trim, fit body of my youth is but a memory. I remember summers on the beach sporting the darkest tan and the smallest bikini I could get away with wearing when sneaking out to the ocean. I had no body issues back then. Way back then.

Then came the “freshman 15” from eating dorm food and doing midnight pizza runs. A pre-wedding diet wiped them away, only to find the same fifteen pounds creeping back during law school. Add a few more the summer of the bar exam. And BINGO… I was not in the best physical shape when we started TTC. Then, throw some more junk in my trunk from fertility meds and depression bingeing as each cycle failed. Suffice it to say, I didn’t give myself the best chance for fertility success.

You can learn from my mistakes.

Sure, being reasonably physically fit is important, but there’s so much more to making your baby dreams come true than being able to fit into that itsy bitsy teeny weenie yellow polka dot bikini.

Dr. Kreiner of Long Island IVF shares his tips for getting in fighting reproductive shape below:

How do you get started building your family when it isn’t happening on its own?

First, if you are thinking about getting pregnant get a check up! Get your pap done – go to the dentist – have your blood pressure and lipids checked. I’m not an expert on the art of motorcycle maintenance, but our bodies, like machines, go through wear and tear and, as a result, occasionally are not operating at optimum capacity.

Here’s what needs to happen for a life to be created. Millions of sperm need to traverse the cervix (which needs to have adequate watery mucus for the sperm to swim through to get to the uterus) and, from there, to the fallopian tubes where, en masse, the sperm gang release digestive enzymes that help bore a hole through the egg membrane. Your egg needs to be healthy and mature, picked up by the fimbria, the fingerlike projections of the fallopian tube and swept along the length of the tube by microscopic hairs within the tube. The environment of the tube needs to allow for fertilization with penetration by only one of the sperm, followed by division of the fertilized egg into a multi-cellular embryo. While the embryo continues to grow and cleave and develop ultimately into a blastocyst containing the future fetus (inner cell mass) and placenta (trophoblast) the tubal micro-hairs continue to sweep the embryo ultimately into the uterine cavity.

The lining of the uterus, the endometrium, must be prepared with adequate glandular development to allow the now hatched embryo to implant. Yes, there is a shell surrounding the embryo that must break in order for the embryo to implant into the uterine lining. Inflammatory fluid, polyps, fibroids or scar tissue may all play a role in preventing implantation.

Oy, it’s amazing this ever works!

In fertile bodies of good working order, this all works an average of 20% of the time!

So . . . how do we get our bodies in optimal shape to maximize our chance of conception?

Check on medications that you may be on. Can you stay on them while trying to conceive? Guys need to do this too! Some medications may affect ovulation or implantation. Prostaglandin inhibitors found in common pain relievers can affect both ovulation and implantation. Calcium channel blockers commonly used to control high blood pressure may affect your partner’s sperm’s ability to penetrate and fertilize an egg.

How is your diet? Is your weight affecting ovulation and preparation of your uterine lining either because it is too high or too low? Do you have glucose intolerance that is leading to high levels of insulin in the blood that affects your hormones and ovarian follicular and egg development? Perhaps you would benefit from a regimen including a carbohydrate restricted diet, exercise and medication to improve glucose metabolism.

Make love. Sex is critical to reproduction, obviously but I am often asked how often and how to time as if it need be a schedule chore. This is a bit tricky as it is vital that while we reproductive endocrinologists are assisting our patients to conceive we want to preserve the relationship that provides the foundation on which we want to build their family. I try not to give patients a schedule until they are in an insemination cycle where we actually identify the precise day of ovulation. I recommend spontaneous lovemaking that in cases of normal sperm counts (which should be analyzed as part of that check up) should average at least every other day in the middle of a woman’s menstrual cycle. Ovulation typically occurs 14 days prior to the onset of her menses. Sperm survive anywhere from 1 day to 7 days in a woman’s cervical mucus varying both on the sperm and the quality of her mucus which for some women is optimal for only hours if at all. Eggs survive 6-8 hours. Therefore, when we perform insemination it is better if we inseminate prior to ovulation rather than after as the sperm have more time to sit around and wait for the egg than visa versa.

See an RE. When all else fails, it is recommended that you consult with a reproductive endocrinologist if you have not conceived after one year before age 35 and six months if you are 35 or older. The treatments available to the specialist are extraordinarily successful today and should ensure that for the great majority of you, you may happily retire that teeny weenie bikini for a maternity swimsuit.

* * * * * * * * ** *

So…are you in fighting reproductive shape? If not, what’s on your list to take care of next?

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=16221&picture=girl-in-swimsuit

 

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Infertility Podcast Series: Journey to the Crib: Chapter 7: Are Fibroids and Polyps Preventing You From Getting Pregnant?

By David Kreiner MD

May 3rd, 2012 at 11:05 am

Infertility Podcast Series: Journey to the Crib: Chapter 7 Are Fibroids and Polyps Preventing You From Getting Pregnant?

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Seven: Are Fibroids and Polyps Preventing You From Getting Pregnant? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.eastcoastfertility.com/?p=52

Are Fibroids And Polyps Preventing You From Getting Pregnant?
Fibroids, also known as myomata, are benign smooth muscle tumors of the uterus.   Most are located in the muscle wall and become clinically significant if they invade the uterine cavity or take up so much space in the uterine wall that they may distort the uterine cavity, obstruct the blood vessels serving the endometrial lining or even block the fallopian tubes.   Fibroids may also extend outside the uterine surface, subserosal or pedunculated when connected to the uterus by a stalk.  These tend to be clinically significant only when they affect the fallopian tubes from picking up the eggs.  Fibroids growing into the uterine cavity are called submucosal myomata and these have the greatest impact on implantation and fertility.
 The diagnosis of fibroids may be suspected at a bimanual examination of the uterus or a hysterosalpingogram but ultrasound and MRI are the best diagnostic modalities to evaluate the extent of the fibroids.  A hydrosonogram where water is injected into the uterine cavity allows delineation of the myoma or, for that matter, polyps (endometrial growths).  Further examination of the uterine cavity is performed at a hysteroscopy when the myoma or polyp may be excised.
 There remains controversy regarding the indication to surgically remove intramural fibroids or those that reside within the uterine wall and not significantly affecting the uterine cavity.   Some specialists believe that intramural fibroids greater than 3 cm are more likely to affect fertility and recommend surgery for these.  Others have a larger threshold or smaller if there are numerous myomata or they cause tubal obstruction.
 Polyps like submucosal fibroids are thought to effect implantation and it is therefore recommended they be removed when trying to conceive.  Patients with a history of anovulation and unopposed estrogen are more likely to have hyperplastic endometrium which can include polyps.  Rarely, in these cases they can be neoplastic and need to be removed and examined by a pathologist.
 Examination of the uterine cavity is essential prior to performing an IVF procedure to ensure the optimal result for patients.
* * * * * * **  * * * *
Was this helpful in answering your questions about the effects of fibroids an polyps on TTC?

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

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Infertility Care: Beginning with the Basics

By Steven Brenner MD

April 16th, 2012 at 12:01 am

 “Don’t Ignore Infertility” is this year’s theme for National Infertility Awareness Week, which runs from April 22-28, 2012. Sometimes people may suspect a fertility problem, but like an ostrich with its head in the sand, they ignore it out of fear.

 If you fit that profile, Long Island IVF’s Dr. Steven Brenner’s post may calm your fears:

 “Thinking the worst” is a very common reaction for individuals experiencing adversity.

 This is especially true for people experiencing infertility. Concerns regarding the question of establishing the family someone has dreamed of since they were young is daunting and can leave a person with significant anxiety and doubt regarding her/his future.

 In this context it is important to go back to basics regarding fertility and understand that many people suffering from this disorder will be successfully treated with relatively simple techniques and therapies. For the more severe abnormalities, it is comforting to know current available therapies can address these issues with great success.

Establishing a pregnancy without infertility treatment requires a healthy egg, functioning sperm and an anatomic path that allows sperm to ascend the genital tract and an egg to travel into a fallopian tube where fertilization takes place. The anatomic path needs to allow the fertilized egg to travel into the uterine cavity. A receptive uterine lining is then required for the pregnancy to implant and grow. To make things more challenging, sperm and egg have a very small window of time to find each for fertilization to take place.

Many couples have experienced infertility as a result of improperly timed intercourse.  This often results from the couple not being aware of the timing of ovulation and the short duration of egg viability. The “fix” for something like this is very simple, requiring merely an understanding of the basic physiology.  Sexual dysfunction can plague a relationship, but it is often not until fertility is compromised that couples seek treatment. The simple fix for fertility may involve nothing more than inseminations timed to natural ovulation. Much more in depth therapies may be required to overcome the other, additional concerns associated with sexual dysfunction.

Ovulatory dysfunction, while a very complex issue, is often very easily addressed with simple treatments. Weight loss or gain may be all that is needed to establish regular ovulatory cycles. Correction of hormonal abnormalities leading to problems with ovulation can often be treated with medications that do not require the intense monitoring of injectable fertility medications associated with in vitro fertilization procedures.  Sluggish thyroid activity and elevations in a hormone named prolactin are such issues that readily respond to oral medications.

A receptive uterine lining to allow for implantation of an embryo that formed in the fallopian tube is needed to allow a pregnancy to be established in the uterus. Although a scarred endometrium or one that is distorted from fibroids may require surgical repair, other disorders of the lining can be treated with local hormonal supplementation. The endometrium, the uterine lining, may not develop appropriately after ovulation secondary to hormonal abnormalities. This may reflect an abnormality in egg production and the hormones associated with ovulation.

Therapies directed at improving ovulation or directly supporting the lining of the uterus with vaginal application of the hormone progesterone may be all that is needed to correct this problem.

Anatomic problems such as scarring of the fallopian tubes may require surgical correction. However, blocked tubes may be opened by minimally invasive procedures at the time of a hysterosalpingogram (HSG). In such procedures, a tube blocked where it inserts into the uterus is opened with a catheter in a setting that does not require general anesthesia.

 Many patients will be successfully treated with simple techniques and procedures that are not associated with the expense and invasiveness of the therapies that most people think they will require.

 For each infertile person a plan of evaluation and therapy needs to be developed, beginning with the basics. It does not necessarily lead to those treatments that are more detailed and invasive.

 * * * * * * * * * * *

Did you put off an infertility evaluation out of fear of needing expensive, invasive fertility treatments?

 

Photo credit: http://www.wpclipart.com/phps.php?q=ostrich

 

 

 

 

 

 

 

 

 

no comments

ASRM 2011 and IVF’s “Magic Bullet”

By David Kreiner, MD

November 10th, 2011 at 1:52 am


This past October, reproductive endocrinologists from around the globe gathered for the annual scientific meeting of the American Society for Reproductive Medicine (“ASRM”).  It is an opportunity for us to share experiences and learn from each other.  

I had lunch with a colleague practicing IVF in Mumbai, India and was fascinated with how similar our practices felt despite the huge geographic and cultural differences.  The human interactions and emotional and social issues of infertility afflict our apparently disparate populations of patients in very similar ways.

There were a few presentations during the five day conference worth noting.  

Regarding ovulation induction for patients unable to ovulate on their own: Metformin, in combination with clomid appears to be slightly more effective than clomid alone or letrizole which may have a lower risk of multiples.  Ovarian drilling (a surgical procedure involving cauterizing small craters in the ovaries) is equally effective and was suggested for clomid/letrizole failures.

The best presentation according to many attendees was on surgery to enhance IVF success.  Data was presented documenting the huge benefit of eliminating hydrosalpinges (fluid filled fallopian tubes) prior to embryo transfer.  It is thought that the inflammatory fluid in these tubes bathes the uterine cavity… creating a hostile environment for the embryos.  It appears that salpingectomy (removal of the tubes), or tubal ligation laparoscopically or by one of the less invasive hysteroscopic procedures (such as Essure) appear to be equally effective.

Cysts of endometriosis do not affect the number or quality of a patient’s embryos. Because of the risk of removing normal ovarian tissue (and thereby reducing the ovarian reserve), it is not generally recommended that patients undergo endometriosis surgery to improve IVF outcome.

Routine hysteroscopy (visualization of interior of uterus through a scope) on asymptomatic patients found abnormalities in 11-12% of cases.  Removing polyps significantly improved pregnancy rates.  It was recommended that patients undergo a hysteroscopy after one failed IVF, if not done sooner.

Fibroids that were partially in the uterine cavity affected pregnancy rates and should be removed.  Likewise, fibroids that are intramural (in the muscle of the uterus) and distort or increase the size of the uterine cavity should be removed to increase the IVF pregnancy rate.  

It was also suggested that resection of the uterine septum increases the IVF pregnancy rate.

There were several interesting presentations about IVF over the course of the five day conference. But the one that stimulated the most conversation on the trip home was a study from Egypt.  

This program injected (through a catheter placed vaginally through the cervix) 500 units of HCG into the uterine cavity just before performing the embryo transfer.  They found higher pregnancy rates in women who were injected with this "magic bullet".  It inspired enough interest that I expect a year from now, we will learn if the intrauterine HCG is in fact the IVF magic bullet.

Certainly, we will endeavor to utilize the worthwhile studies presented at this year’s ASRM to continue to improve the outcomes for our patients.

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

Did you learn anything new from this post? What is the most interesting thing? If the “magic bullet” was available to you, do you think you’d be interested in it? How important is it to you that your RE attends the annual ASRM conference?

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TTC with Fibroids

By David Kreiner MD

October 27th, 2011 at 9:39 pm

As many as three out of ten women have fibroids, or uterine muscle tumors. Don’t get nervous about the word “tumor”. Often, they are not malignant. Sometimes they don’t need to be removed.

Everything you ever wanted to know about fibroids and your fertility is right here.

Dr. David Kreiner of East Coast Fertility gives you the facts about fibroids and how they may…or may not…be a factor in your fertility.

Fertility is dependent upon so many things!

We must have healthy gametes (eggs and sperm) capable of fertilizing and implanting in a uterus with a normal endometrial lining unimpeded by any uterine or endometrial pathology. The sperm need be in sufficient number and capable of swimming up through a cervix which is not inflamed and provides a mucous medium that promotes sperm motility. The eggs need to ovulate and be picked up by normal healthy fimbriated ends (finger like projections) of the fallopian tubes. The tubes need to be covered with normal micro hairs called cilia that help transport the egg one third of the way down the tube where one of the sperm will fertilize it.

The united egg and sperm (the “conceptus”) then needs to undergo cell division, growth and development as it traverses the tube and makes its way to the uterine cavity by the embryo’s fifth day of life at which point it is a blastocyst. The blastocyst hatches out of its shell (“zona pellucidum”) and implants into the endometrial lining requiring adequate blood flow.

And you wonder why getting pregnant is so hard?

All too often patients, in some groups as many as 30% of women, are told that they have fibroids that may be contributing to their infertility. Fibroids or leiomyomata are non malignant smooth muscle tumors of the uterus. They can vary in number, size and location in the uterus including; the outside facing the pelvic cavity (subserosal), the inside facing the uterine cavity (submucosal) and in between inside the uterine wall (intramural). Fortunately, most fibroids have minimal or no effect on fertility and may be ignored.

The subserosal myoma will rarely cause fertility issues. If it were distorting the tubo- ovarian anatomy so that eggs could not get picked up by the fimbria then it can cause infertility. Otherwise, the subserosal fibroid does not cause problems conceiving.

Occasionally, an intramural myoma may obstruct adequate blood flow to the endometrial lining. The likelihood of this being significant increases with the number and size of the fibroids. The more space occupied by the fibroids, the greater the likelihood of intruding on blood vessels traveling to the endometrium. Diminished blood flow to the uterine lining can prevent implantation or increase the risk of miscarriage. Surgery may be recommended when it is feared that the number and size of fibroids is great enough to have such an impact.

However, it is the submucosal myoma, inside the uterine cavity, that can irritate the endometrium and have the greatest effect on the implanting embryo.

To determine if your fertility is being hindered by these growths you may have a hydrosonogram. A hydrosonogram is a procedure where your doctor or a radiologist injects water through your cervix while performing a transvaginal ultrasound of your uterus. On the ultrasound, the water shows up as black against a white endometrial border. A defect in the smooth edges of the uterine cavity caused by an endometrial polyp or fibroid may be easily seen.

Submucosal as well as intramural myomata can also cause abnormal vaginal bleeding and occasionally cramping. Intramural myomata will usually cause heavy but regular menses that can create fairly severe anemias. Submucosal myomata can cause bleeding throughout the cycle.

Though these submucosal fibroids are almost always benign they need to be removed to allow implantation. A submucosal myoma may be removed by hysteroscopy through cutting, chopping or vaporizing the tissue. A hysteroscopy is performed vaginally, while a patient is asleep under anesthesia. A scope is placed through the cervix into the uterus in order to look inside the uterine cavity. This procedure can be performed as an outpatient in an ambulatory or office based surgery unit. The risk of bleeding, infection or injury to the uterus or pelvic organs is small.

Resection of the submucosal myoma can be difficult especially when the fibroid is large and can sometimes take longer than is safe to be performed in a single procedure. It is not uncommon that when the fibroid is large, it will take multiple procedures in order to remove the fibroid in its entirety. It will be necessary to repeat the hydrosonogram after the fibroid resection to make sure the cavity is satisfactory for implantation.

The good news is, when no other causes of infertility are found, removal of a submucosal fibroid is often successful in allowing conception to occur naturally or at least with assisted reproduction.

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

Anyone have a fibroid story to share?

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Father Time is an IVF Terrorist

By Tracey Minella

April 12th, 2011 at 12:57 am


Ever feel like Father Time has joined Mother Nature in mocking you?

Mother Nature’s arsenal of weapons of mass destruction is legend in the Fight for Fertility: fibroids, endometriosis, hydrosalpinx, recurrent miscarriage, male factor, and premature ovarian failure, just to name a few. And many of us are so focused on disarming Mother Nature that we fail to notice the emotional damage being done by her insidious cohort in the spider hole…Father Time.

Allow me to illustrate:

What do you do when the third IUI fails again? Or the first IVF cycle doesn’t work? Do you rush right into the next cycle of treatment? Or do you take a break?

How much of your decision to forge ahead, or move quickly on to the next most aggressive treatment option, has to do with TIME vs. other factors, like money? Are you ruled by the deafening sound of your biological clock ticking? Do you push forward even though you feel overwhelmed and could benefit from taking a break from treatment? (Would you bite off the head of anyone who suggested you do just that?)

And for those who do choose to take time off between treatment cycles, maybe even as long as six months (gasp!), are you comfortable in that decision? Or are you stressing over the TIME that is going by, as the next birthday is coming up faster?

Do you constantly and effortlessly calculate potential due dates in your head? And when certain months pass without a pregnancy, do you automatically think: Since I’m not pregnant this month, I won’t be a mom before this coming Christmas, or Mother’s Day, or New Year’s, or your birthday, or your anniversary.

Although you have the RE to battle the havoc Mother Nature wreaks on your reproductive system, only you can find the strength to outlast Father Time. Set the pace of your journey based on what you need today in order to get through this day. Take the time you need, or push forward if you need. But make an active choice either way and be comfortable with that decision.

I could tell you to stop the stressing and calculating…but that would be asinine. Of course you will continue to stress as time continues to pass without a baby. You never thought you’d even be in these shoes… fighting this hard and long for something that is supposed to just happen naturally in the privacy of our bedrooms… much less still be in them as months or years pass by.

So I will leave you with the only positive spin I can put on this nightmare.

Unfortunately, I feel the need to quote both a cliché about time and a song by the Byrds (one that I never liked and that will make me sound like I’m old enough to be Mrs. Time): To every thing, turn, turn, turn. There is a season, turn, turn, turn. And a time to every purpose under heaven.” The cliché is that time heals all wounds.

Your battle will end someday, and the odds are that it will end successfully, with a baby from one of possibly many available options. And you won’t be able to imagine how you lived before the moment someone handed you that perfect angel. It will be love at first sight. You’d never want a different baby.

And you will come to realize that the baby you ultimately get is the one you are meant to have and hold. Not one from an earlier cycle. This one.

And a time to every purpose under heaven.

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Are Fibroids a Factor in Your Fertility?

By David Kreiner MD, and Tracey Minella

March 29th, 2011 at 12:00 am


Picture a room full of ten women. As many as three of them will have fibroids, or uterine muscle tumors. Will that affect their fertility? Did your mind just go blank when I mentioned the word “tumors”. That’s totally understandable. You came here fearful about your fertility. I said "tumors"… and now you’re probably fearful for your life. Well, don’t be. Read on for fibroid facts from an expert in the field of fertility.

Dr. David Kreiner of East Coast Fertility gives you the facts about fibroids and how they may…or may not…be a factor in your fertility:

Fertility is dependent upon so many things!

We must have healthy gametes (eggs and sperm) capable of fertilizing and implanting in a uterus with a normal endometrial lining unimpeded by any uterine or endometrial pathology. The sperm need be in sufficient number and capable of swimming up through a cervix which is not inflamed and provides a mucous medium that promotes sperm motility. The eggs need to ovulate and be picked up by normal healthy fimbriated ends (finger like projections) of the fallopian tubes. The tubes need to be covered with normal micro hairs called cilia that help transport the egg one third of the way down the tube where one of the sperm will fertilize it.

The united egg and sperm (the “conceptus”) then needs to undergo cell division, growth and development as it traverses the tube and makes its way to the uterine cavity by the embryo’s fifth day of life at which point it is a blastocyst. The blastocyst hatches out of its shell (“zona pellucidum”) and implants into the endometrial lining requiring adequate blood flow.

And you wonder why getting pregnant is so hard?

All too often patients, in some groups as many as 30% of women, are told that they have fibroids that may be contributing to their infertility. Fibroids or leiomyomata are non malignant smooth muscle tumors of the uterus. They can vary in number, size and location in the uterus including; the outside facing the pelvic cavity (subserosal), the inside facing the uterine cavity (submucosal) and in between inside the uterine wall (intramural). Fortunately, most fibroids have minimal or no effect on fertility and may be ignored.

The subserosal myoma will rarely cause fertility issues. If it were distorting the tubo- ovarian anatomy so that eggs could not get picked up by the fimbria then it can cause infertility. Otherwise, the subserosal fibroid does not cause problems conceiving.

Occasionally, an intramural myoma may obstruct adequate blood flow to the endometrial lining. The likelihood of this being significant increases with the number and size of the fibroids. The more space occupied by the fibroids, the greater the likelihood of intruding on blood vessels traveling to the endometrium. Diminished blood flow to the uterine lining can prevent implantation or increase the risk of miscarriage. Surgery may be recommended when it is feared that the number and size of fibroids is great enough to have such an impact.

However, it is the submucosal myoma, inside the uterine cavity, that can irritate the endometrium and have the greatest effect on the implanting embryo.

To determine if your fertility is being hindered by these growths you may have a hydrosonogram. A hydrosonogram is a procedure where your doctor or a radiologist injects water through your cervix while performing a transvaginal ultrasound of your uterus. On the ultrasound, the water shows up as black against a white endometrial border. A defect in the smooth edges of the uterine cavity caused by an endometrial polyp or fibroid may be easily seen.

Submucosal as well as intramural myomata can also cause abnormal vaginal bleeding and occasionally cramping. Intramural myomata will usually cause heavy but regular menses that can create fairly severe anemias. Submucosal myomata can cause bleeding throughout the cycle.

Though these submucosal fibroids are almost always benign they need to be removed to allow implantation. A submucosal myoma may be removed by hysteroscopy through cutting, chopping or vaporizing the tissue. A hysteroscopy is performed vaginally, while a patient is asleep under anesthesia. A scope is placed through the cervix into the uterus in order to look inside the uterine cavity. This procedure can be performed as an outpatient in an ambulatory or office based surgery unit. The risk of bleeding, infection or injury to the uterus or pelvic organs is small.

Resection of the submucosal myoma can be difficult especially when the fibroid is large and can sometimes take longer than is safe to be performed in a single procedure. It is not uncommon that when the fibroid is large, it will take multiple procedures in order to remove the fibroid in its entirety. It will be necessary to repeat the hydrosonogram after the fibroid resection to make sure the cavity is satisfactory for implantation.

The good news is, when no other causes of infertility are found, removal of a submucosal fibroid is often successful in allowing conception to occur naturally or at least with assisted reproduction.

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