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Archive for the ‘ICSI’ tag

The IVF Transfer

By Tracey Minella

February 7th, 2015 at 9:24 am

 

photo credit: marin/freedigital photos.net


In vitro fertilization (IVF) is a long process. The transfer is at the end of the line.

When people do IVF, they endure weeks of daily hormone injections and blood work and ultrasounds designed to make the woman produce more than the one egg she would otherwise likely produce. When the time is right, an injection is given that leads to the final maturation of the eggs and the egg retrieval is scheduled for about 34 hours thereafter, so that the eggs will not be ovulated and the cycle lost.

Once the eggs are retrieved, they are placed in a petri dish with the partner’s sperm, and in some cases, Intra-Cytoplasmic Sperm Injection (ICSI) is performed. With ICSI, a single sperm is isolated and injected into a single egg to increase the odds of fertilization, usually in cases where sperm count or quality is an issue. Then, you wait a day for a fertilization report.

If there is fertilization, the resulting embryos are continually monitored and graded based on how they grow and develop. An agreed upon number of Day 3 embryos (or Day 5 blastocysts) get transferred back to the woman’s uterus via catheter. Each embryo or blastocyst has the potential to develop into a baby, or in rare cases, may even split into twins. Excess embryos are usually cryopreserved (frozen) for future use.

In order to make it to Transfer Day, a couple must survive all the prior phases: cycle suppression, ovarian/follicle stimulation with blood work that corresponds to the number and size of the follicles, a uterine lining that is thick enough for embryo implantation, retrieval of quality eggs, fertilization of eggs, development and growth of quality-grade embryos. Then, the transfer.

Optimists may relax more as each hurdle is cleared. Worry-warts hold their breath ‘til the end. And even then, they beg to lay there for the next two weeks with their hips elevated by pillows or they slam their partners’ driving with every bump on the ride home.

The transfer is a magical moment. It’s not only the end of the treatment cycle, but for many it’s the closest they may ever have been to getting pregnant.

The beauty of IVF comes in the knowledge that you did create embryos…they are real and you can literally see them. If you get pregnant you have breathtakingly beautiful photos of your child from the earliest moments of conception. You know the exact date of conception. You even see the glow of the embryos in the uterus after transfer.

There is nothing quite like the feeling of hope on transfer day. You can bask in the literal moment you may be becoming a mom. Visualize implantation happening. Will it to happen. Allow yourself to believe it because you never know what the effect of positive thinking could be.

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What was your transfer day like? What do you most remember about it?

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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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Did IVF on Live TV Help or Hurt the Cause?

By Tracey Minella

October 23rd, 2013 at 8:23 pm

 

credit: Dream designs/freedigitalphotos.net


In vitro fertilization, or IVF, went mainstream media recently with the ground-breaking, first ever televised account of human fertilization taking place on the Today show.

A young couple, who were undergoing IVF for the first time, agreed to show the world …on live TV… the moment her eggs were fertilized with his sperm using intracytoplasmic sperm injection, or ICSI, a technique whereby an embryologist isolates and injects a single sperm into a newly-retrieved egg. The resulting embryos were then left to develop for a few days in the embryology lab before being transferred back into the woman’s uterus or being cryopreserved (frozen and stored) for later use.

When I first saw the story, I thought it was both courageous and incredibly cool. I could have seen myself doing it. But it also struck me that the IVF newbies seemed more caught up in the probability of a positive outcome than I thought they should have been. Even their excited doctor stopped just short of guaranteeing success. The guards were down. But maybe that was just my IVF veteran heart worrying on their behalf that they’d suffer a devastating disappointment…also on national TV…if the result was negative. A result I and many, many couples have gotten even though today’s IVF success rates are better than ever.

Happily, they received positive pregnancy results… also live on the air. Like so many infertile couples watching their journey, I sent out a virtual fist-pump to the lucky couple, who are already speculating on whether they’re having twins. I didn’t sense in their reactions any visible worry about the potential risks or added costs of a multiple pregnancy or, dare I speak it, of a miscarriage or other complication. And many who haven’t seen or experienced what I have may rightly argue to let them have their moment. If things go awry, they will deal with it then. Fast forward to the assumption of a fairy tale happy ending with boy/girl twins.

Do we ignore the elephant in the room?

If things go wrong, will that be news, too? Should it be news? Or will we only be invited to the post-birth experience where they exit the hospital with their bundle(s) of joy? Is society really ready to see the ugly side of infertility if at any point it, God forbid, came to be? Were we ready to see them fail to get pregnant? Are we ready to see anything go wrong? To share in what would normally be complete and private devastation and heartbreak?

As much as this televised IVF cycle has given infertility awareness a major boost on a national scale, it has also on one level painted an unbalanced or unrealistic picture of IVF. Many couples do not get pregnant on the first try… as many infertile couples already know. They may be older, have greater obstacles, or may simply not have had first-round IVF success despite what all the factors seemed to indicate would be the case. Sadly, others get pregnant, but don’t end up with a baby, which is why it is important to inquire about birth rates, not just pregnancy rates when choosing an IVF center.

But now the public (or at least those who remember the story)…through this positive experience…may think IVF is always an easy fix. So, this experience may in fact result in increased awareness, but not necessarily increased sympathy for infertile couples. I can hear the public now: “Oh just do IVF. It always works, right?”

And then there’s the rest of the public…those who have already forgotten this couple as yesterday’s news. What a luxury to be them. I haven’t forgotten the couple. I can’t forget them. I’m worrying on their behalf and will keep worrying until I see them on the news holding a bundle of joy on those hospital steps in eight months.

Please, I don’t want to see them on the news a moment sooner.

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Do you think the story helped or hurt infertility awareness? Do you think their experience is typical?

 

Photo credit: dream designs / http://www.freedigitalphotos.net/images/agree-terms.php?id=100187846

 

 

 

 

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Dude Looks Like a Baby

By Tracey Minella

July 18th, 2013 at 4:49 pm

 

image courtesy of fotographic 1980/free digital photos.net

Music and In Vitro Fertilization (“IVF”) rates are in the news.

Whether you’re into Aerosmith or Beyonce, Rascal Flatts or Metallica, a new study found that playing music in the presence of eggs increased fertilization rates in patients undergoing IVF.

In the study*, conducted at Barcelona’s Marques Institute fertility clinic, 1,000 eggs were “injected with sperm”. Half were then placed in incubators where various genres of music…including Nirvana, Madonna, Michael Jackson, Mozart and Bach… were playing on iPods. The other half of the eggs was not exposed to music.

 The fertilization rates were five percent (5%) higher in the eggs exposed to music.

Study leaders speculated that the vibrations from the iPods… not the music itself… was likely responsible for the difference in the fertilization rates.

Oxford Fertility expert, Dr. Dagan Wells, offers this theory: In natural fertilization, egg and sperm meet in the Fallopian tube and, if fertilization occurs, the resulting embryo gently “rocks and rolls” its way down the tube and into the uterus where it hopefully implants and results in a pregnancy. But with in vitro fertilization, the egg and sperm just sit largely stagnant in the culture media of the petri dish and “stew in its own juice.” Specifically, the addition of music may provide good vibrations for increased fertilization by helping nutrients pass into the egg and by speeding up the removal of toxic waste.**

Study leaders also found that the style or type of music was not a clear factor… so anything from Sinatra to show tunes may suffice. However, there was some speculation that pounding, rhythmic “techno music” with bass may provide the most vibration.

Music is almost always playing in the Long Island IVF O.R. and embryology lab.

What kind?  I’m told it usually ranges from soft pop to classical. Does that make our doctors and embryologists “rock stars” in their field?

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Was there music playing during your retrieval or transfer? Do you remember the song?

* http://www.institutomarques.com/pdf/music-enhances-in-vitro-fertilisation.pdf

** http://dailym.ai/17oCorm

Photo credit: fotographic 1980 and http://www.freedigitalphotos.net/images/agree-terms.php?id=100138806

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Infertility Podcast Series: Journey to the Crib: Chapter 13 Sperm Meets Egg- Why Doesn’t It Work Every Time?

By David Kreiner, MD

May 20th, 2013 at 9:48 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Thirteen: Sperm Meets Egg-Why Doesn’t It Work Every Time? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=92

Sperm Meets Egg- Why Doesn’t It Work Every Time?

We live in a society where people grow up with certain entitlements.

We expect to complete a transatlantic flight within 6 hours without delay.  While 30,000 feet up in the air we get upset if our internet momentarily goes on the blink.  When normally menstruating women having regular intercourse cannot get pregnant it turns their lives upside down.  After all, we plan our lives, our careers and our families and there often is not time allowed for such difficulties.

When the source of the trouble is the Man, the impact on his ego, his mood and the couple’s relationship can be quite dramatic.  Men have a problem that contributes to the difficulty conceiving in 50-60% of cases.  Most of these cases can be picked up by a simple semen analysis. 

Unfortunately, even when the semen analysis screen is normal about 10% of the time when routine in vitro fertilization is attempted, the partner’s eggs fail to fertilize.  This is why we recommend that we perform ICSI, intracytoplasmic sperm injection, in cases of unexplained infertility, on half the eggs.  That allows us to test the fertilizability of the eggs and treat those with deficient fertilization in the same cycle.

There are numerous causes of male infertility discussed in the chapter.  Some are amenable to hormonal treatment, some could benefit from surgery, and nearly all may be overcome with IVF using ICSI. Other supplements, herbal medicine, and adjunctive therapy are mentioned.

Recently, it has been found that in cases of severe male infertility, though pregnancies may be achieved with ICSI, in those cases there appears to be a higher incidence of miscarriages and congenital anomalies and other problems in some babies born to such couples.

Still… for those couples who otherwise would never have previously been able to conceive without IVF… IVF with ICSI offers a significant possibility for them to build their own healthy families using their own eggs and sperm.

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Was this helpful in answering your questions about why it doesn’t work every time sperm meets egg?

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

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Spring Forward and Infertility

By Tracey Minella

March 10th, 2013 at 6:27 pm

image courtesy of digital art/free digital photos.net

After what feels like a whole year of lousy weather…starting with Hurricane Sandy and ending with a couple of Super snowstorms, including the blizzard named Nemo… it looks like we can finally breathe a sigh of relief. Sandy stole the fall and Nemo knocked us down, but it’s time to set the clocks ahead and look forward to spring.

Spring ahead.

Doesn’t that sound so cheery? So hopeful? The season of rebirth is on the way.

Or are you like me and only see it as an hour of lost sleep? And the start of the baby shower season?

Do you feel hopeful as spring comes in? Or will you miss the comforting, socially-acceptable isolation of a long, cold winter… as spring forces you back outside and into social situations again?

Well, here is a thought to brighten …or further brighten…your mood.

According to the Wall Street Journal, a study in Brazil involving ICSI (intra-cytoplasmic sperm injection) found that spring was the season with the highest fertilization rates. http://online.wsj.com/article/SB10001424052702303644004577524824251585782.html

“The rate of fertilization was 73.5% in spring, 68.7% in summer, 67.9% in winter and 69% in autumn.”

It should be noted however that the study found the season had no effect on pregnancy rates and it did not explore the role of sperm in seasonal fertilization rates.

It was also theorized that natural fertilization rates may be higher in springtime, possibly due to temperature changes and days of increased sunlight.

So whether you are going the natural fertilization route, or IVF with ICSI, spring certainly can’t be a bad thing. And maybe…just maybe…it’ll turn out to be your favorite season ever!

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How do you feel about spring? Renewed hope or kind of down?

 

Photo credit: http://www.freedigitalphotos.net/images/Spring_g102-Types_Of_Season_p61769.html

 

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IVF 101: Infertility Terms Defined

By David Kreiner MD, and Tracey Minella

March 8th, 2012 at 11:07 pm

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 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 20-25% 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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Did you find this helpful? What was the most important piece of info you got from this post?

 

Photo credit: http://www.publicdomainpictures.net/view-image.php?image=14704&picture=deer

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What the #@WI-FI&* Happened to Your Sperm?!

By Tracey Minella

December 30th, 2011 at 6:50 pm

Last post of the month… so it’s one for the guys as usual.

We all know the things the ladies are doing (or should be doing) to increase their chances of conceiving a healthy baby. Tests taken, prenatal vitamins, dental work, healthy diet and exercise, etc. And you both should be avoiding excessive caffeine, alcohol, and tobacco, of course.

But if you think sportin’ those loose boxers is all you need to do to maximize the potential of “your boys”, think again!

High tech breakthroughs have advanced the fields of assisted reproductive technologies, like IVF. But not all things “high-tech” are beneficial. Some things can potentially do harm.

Like Wi-Fi. (a/k/a wireless internet connections.)

We already know that a laptop on your lap for extended periods of time can cause scrotal hyperthermia, or increased testicular temperature. But great balls o’ fire, there’s another sperm quality killer to worry about!

It’s possible that laptop of yours, with its Wi-Fi could be messing with your sperm’s motility (ability to move) and quality. It could be fragmenting your sperm’s very DNA!

Now don’t try this at home…yes, I went there… but when semen samples were placed under a laptop for four hours, one group with the Wi-Fi on and the other with the Wi-Fi off, there were noticeable differences in the quality of the sperm.

The Wi-Fi sperm sample showed 25% lost motility and 9% suffered DNA fragmentation, compared to the non-Wi-Fi sperm sample which showed 14% lost motility and 3% suffered DNA fragmentation. Scientists theorized that the electromagnetic radiation emitted from the Wi-Fi may be the reason for the results. For more information, click here: http://www.medicalnewstoday.com/articles/238455.php

So fellas, be careful what you allow on your lap!

Which brings me to a potentially-related closing comment, depending on how wild your plans are tomorrow night: Have a safe and healthy New Year’s Eve. I hope all your dreams come true in 2012.

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How do you plan to spend New Year’s Eve? Do you put infertility aside and have fun out with a crowd or have a romantic dinner for two? Do you stay in with a small group or alone and watch the ball drop on TV? Or do you treat it like any other night and go to bed early?

 

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Is Micro-IVF the Answer?

By David Kreiner MD

December 19th, 2011 at 9:08 pm


You’ve already crossed the bridge from “We’re going to get pregnant!” to “We need help…” But this other side looks filled with more obstacles, including expensive and risky fertility medications.

How far do you have to go just to have a baby?

Micro IVF (sometimes called MiniIVF) may be your answer.

The primary point of MicroIVF: fewer fertility drugs, less cost.

Plus you get additional benefits: decreased chances of ovarian hyperstimulation syndrome and of multiple pregnancy.

Additionally, East Coast Fertility and Long Island IVF patients who choose MicroIVF can increase their savings if they also use our Single Embryo Transfer Program — embryo freezing, storage, and future frozen embryo transfers are free.

Why go Micro?

I learned long ago that pregnancies of twins, triplets, and more can bring heartache to what should be a joyous journey for fertility patients. So the ECF team has dedicated our practice to the achievement of safe, healthy pregnancies.

IUI or IVF?

Intrauterine insemination (IUI) is often considered the first order of business for many infertility patients.

Sometimes called “artificial insemination,” the usual protocol — oral and injectable fertility medications to induce superovulation (of more than one egg in a cycle), followed by insemination via exam room procedure — is believed to be simpler and, therefore, less costly than IVF.

That’s just not true any longer.

The facts now are that success rates can be far better for IVF than for IUI, depending on the individual’s or couple’s cause of infertility. Many women undergo several IUIs before achieving conception.

Some infertility causes — pelvic adhesions/scarring, blocked fallopian tubes, endometriosis, and severe male factor issues — will not respond to IUI but are treatable with IVF.

Even patients who would otherwise try IUI to get pregnant will find that choosing MicroIVF can result in cost savings and greater safety:

Micro IVF fee (current as of Dec 2011): $3900

ICSI (if required): $1000

Anesthesia (as requested): $550

IUI with hormone injections: $3500 to $4500

Is MicroIVF right for you?

Each patient’s case is considered carefully and individually. The following are conditions that might respond best to MicroIVF:

Young healthy women with PCOS or who otherwise produce many follicles

Women with pelvic adhesions or scarring, blocked fallopian tubes, or endometriosis

Couples with severe male factor infertility

MicroIVF really is a case of a little treatment going a long way! With it, you can access the world’s most successful assisted reproductive technology at far less cost.

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Has this blog post changed your mind about the course of treatment you are taking (or planned to take)? Did you know about Micro-IVF and Single Embryo transfers prior to this post?

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Cryopreservation: Peeking in the IVF Freezer

By Tracey Minella and David Kreiner MD

April 8th, 2011 at 12:00 am

Remember the Good Humor man? You’d hear that sound from blocks away and bolt out the door barefoot, shrieking “STAAAPPP!”, arms flailing like you were trying to get the bathroom pass from the teacher, and being joined by the rest of the block like rats to the Pied Piper. Remember the way the white square door with the chunky silver hinge on the back swung open and all that cold, smoky fog billowed out into the humid air?

Remember the frozen magic inside?

Well, East Coast Fertility has a magic freezer, too. Full of dreams. Full of potential. Full of embryos that may one day turn out to be rugrats running after the ice cream man. Below, Dr. Kreiner lets us take a peek inside ECF’s cryopreservation program:

In 1985, my mentors, Drs. Howard W. Jones Jr. and his wife Georgeanna Seegar Jones, the two pioneers of in-vitro fertilization in the USA and the entire western hemisphere, proposed the potential benefits of cryopreserving or freezing embryos following an IVF cycle. They predicted that cryopreserving embryos for future transfers would increase the overall success rate of IVF and make the procedure more efficient and cost effective. They also suggested that it would reduce the overall risks of IVF. For example, one fresh IVF cycle might yield many embryos which can be used in future frozen embryo transfer cycles, if necessary. This helps to limit the exposure to certain risks confronted only in a fresh IVF cycle such as the use of injectable stimulation hormones, the egg retrieval operation, and general anesthesia.

At East Coast Fertility, we are realizing the Jones’ dream of safer, more efficient and cost effective IVF. By utilizing the ability to cryopreserve embryos in 2007, 61.5% (118/192) of patients under 35 were successful in having a live birth as a result of only one egg stimulation and retrieval cycle! In addition, because of our outstanding Embryology Laboratory, we are usually able to transfer as few as 1 or 2 high quality embryos per cycle and avoid risky triplet pregnancies. In fact, since 2002, the only triplet pregnancies we have experienced have resulted from the successful implantation of two embryos, one of which goes on to split into identical twins (this is rare!). By cryopreserving embryos in certain high-risk circumstances, we are able to vastly reduce the risk of ovarian hyperstimulation syndrome requiring hospitalization. At East Coast Fertility, safety of our patients comes first. Fortunately, our success with frozen embryo transfers is equivalent to that of fresh embryo transfers, so that pregnancy rates are not compromised in the name of safety, nor are the babies.

Today, as reported in the Daily Science: “The results are good news as an increasing number of children, estimated to be 25% of assisted reproductive technology (ART) babies worldwide, are now born after freezing or vitrification” (a process similar to freezing that prevents the formation of ice crystals).

The study, led by Dr Ulla-Britt Wennerholm, an obstetrician at the Institute for Clinical Sciences, Sahlgrenska Academy (Goteborg, Sweden), reviewed the evidence from 21 controlled studies that reported on prenatal or child outcomes after freezing or vitrification.

She found that embryos that had been frozen shortly after they started to divide (early stage cleavage embryos) had a better, or at least as good, obstetric outcome (measured as preterm birth and low birth weight) as children born from fresh cycles of IVF (in vitro fertilization) or ICSI (intracytoplasmic sperm injection). There were comparable malformation rates between the fresh and frozen cycles. There were limited data available for freezing of blastocysts (embryos that have developed for about five days) and for vitrification of early cleavage stage embryos, blastocysts and eggs.

‘Slow freezing of embryos has been used for 25 years and data concerning infant outcome seem reassuring with even higher birthweights and lower rates of preterm and low birthweights than children born after fresh IVF/ICSI. For the newly introduced technique of vitrification of blastocysts and oocytes, very limited data have been reported on obstetric and neonatal outcomes. This emphasises the urgent need for properly controlled follow-up studies of neonatal outcomes and a careful assessment of evidence currently available before these techniques are added to daily routines. In addition, long-term follow-up studies are needed for all cryopreservation techniques,’ concluded Dr Wennerholm.

The use of frozen embryos has become a common standard of care in most IVF Programs. At East Coast Fertility we are able to keep multiple pregnancy rates down – by only transferring one or two embryos at a time – while allowing patients to hold on to the additional embryos that they may have created during the fresh cycle. It is like creating an insurance plan for patients. We developed a unique financial incentive program using the technology of cryopreservation to encourage patients to transfer only one healthy embryo at a time. In order to ensure the best outcome for mother and child – these special pricing plans take the burden off the patient to pay for the additional transfers and the cryopreservation process. We have eliminated the cost of cryopreservation, storage and embryo transfer for patients in the single embryo transfer program. Thus, patients no longer have that financial pressure to put all their eggs in one basket! We truly believe we are practicing the most successful, safe and cost effective IVF utilizing cryopreservation.

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