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Archive for the ‘“Journey to The Crib”’ tag

To Qi or not to Qi? That is the Question

By David Kreiner MD

February 1st, 2014 at 5:27 pm

 

credit: StuartMiles/freedigital photos.net

It has been a month since I started my studies in Traditional Chinese Medicine and Acupuncture at the New York College of Health Professions in Syosset, NY. 

Why does this 58 year old Reproductive Endocrinologist want to go back to school for an additional career after practicing for 27 years you may ask?  Is it because I am jealous of my younger daughter starting the University of Michigan this past fall and I want to enjoy the Greek life?  Eh…I cannot deny the coincidence is suspicious.

However, my interest in Traditional Chinese Medicine (TCM) dates back to my own college days. While I bought a copy of the “Barefoot Doctor’s Manual”, the thick red book sat on a shelf for years.  I never got past a few lines about “dampness in the lower burner” and treating “excess phlegm”.  After all, my goal was to become a physician and I liked wearing my clogs back then anyway.

TCM appears quite strange to a Western-trained physician.  The language is unique to TCM and bears little resemblance to the medical physiology that we are familiar with.  As I become more knowledgeable about the fundamentals of TCM, I am fascinated by the elaborate construct of ideas on which TCM is based. 

Unlike modern Western Medicine which is based on scientific study and experimentation, the wisdom of TCM was built upon hundreds of generations of experience by the wise healers of China.  Observations of thousands of cases led to the development of theories regarding disease, illness and healing.  To my physician friends who question the concept of treating pain and illness by impacting channels of Qi, a form of life energy, I ask them: Who are we to question the collective wisdom and experience of hundreds of generations of the wisest healers of China when Modern Medicine has been helping more people than it has been hurting only for the past 80 years or so?  I personally have seen many examples of accepted “Medical Truths” rejected and disproved since graduating medical school in 1981.

My goal is to help my patients any way I can.  Yes, I am a Western-trained physician but more than that I am my patients’ healer who is helping them in their journeys to build their families.  We have great tools in Western Medicine including gonadotropin medications, intrauterine insemination (IUI) and in particular In Vitro Fertilization.  But sometimes they may not be enough. 

I am reminded of the book and movie “Life of Pi”.  The protagonist, Piscine or Pi,tells his story about how he survived 227 days after a shipwreck while stranded on a lifeboat in the Pacific Ocean with a Bengal tiger named Richard Parker.  The official representatives investigating the incident reject his story as unbelievable and insist on hearing the “truth”.  Pi then offers them a second story in which he is adrift on a lifeboat not with zoo animals, but with the ship’s cook, a Taiwanese sailor with a broken leg, and his own mother. The cook amputates the sailor’s leg for use as fishing bait, then kills the sailor and Pi’s mother for food. Pi then kills the cook and dines on him. 

Pi points out that neither story can be proven and neither explains the cause of the shipwreck and in the end of each story the outcome is the same… that he still lost his family.  We are left without an answer as to which story is real. Why does it matter which story was true?  We are asked which story we preferred.

Similarly, with TCM, if we can achieve the desired outcome…in my specialty, the much sought after pregnancy and healthy baby, why does it matter if we do not fully understand the science or principles behind the therapy? The story we choose for that much desired baby…for our “journey to the crib”… can include TCM if it could help us to attain our goal. 

PLEASE FOLLOW MY TCM AND FERTILITY SERIES OF BLOGS AS I CONTINUE THIS JOURNEY.

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Do you think the blending of TCM and Western medicine principles could benefit infertility patients? Have you ever used or considered using TCM in your own fertility journey?

Photo credit: Stuart Miles http://www.freedigitalphotos.net/images/agree-terms.php?id=10055066

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Infertility Podcast Series: Journey to the Crib: Chapter 30: The Gift of Life and Its Price

By David Kreiner MD

November 9th, 2013 at 11:56 am

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Thirty: The Gift of Life and Its Price. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=141

The Gift of Life and Its Price

 

IVF has been responsible for over 1 million babies born worldwide who otherwise without the benefit of IVF may never have been.  This gift of life comes with a steep price tag that according to a newspaper article in the New York Times in 2009 was $1 Billion per year for the cost of premature IVF babies.

 

According to the CDC reported in the same NY Times issue, thousands of premature babies would be prevented resulting in a $1.1 Billion savings if elective single embryo transfer (SET) was performed on good prognosis patients. 

 

The argument often given by a patient who wants to transfer multiple embryos is that to do SET would lessen their chances and to go for additional frozen embryo transfers is costly.

 

In fact, if one considers the combined success rate of the fresh and frozen embryo transfers that are available from a single stimulation and retrieval, the success rate is at least as high if not higher in the cases of fresh single embryo transfers. 

 

At Long Island IVF, in an effort to eliminate the financial motivation for multiple embryo transfers, we offer free cryopreservation and embryo storage for a year to our single embryo transfer patients.  In addition, we offer them three (3) frozen embryo transfers for the price of one for up to a year after their retrieval.

 

IVF offered with single embryo transfer is safer, less costly and probably the most effective fertility treatment available for good prognosis patients.                     

 

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Was this helpful in answering your questions about single embryo transfers?

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

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Infertility Podcast Series: Journey to the Crib: Chapter 29: Why the Wyden Bill Does Not Support Fertility Patients

By David Kreiner MD

November 3rd, 2013 at 11:20 am

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Nine: Why the Wyden Bill Does Not Support Fertility Patients. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=138

Why “The Wyden Bill” Does Not Support Infertility Patients

 

IVF results subjected to government audit were mandated to be reported with the passage of the “Wyden bill”.   The intent of the CDC and national reproductive society (SART) was to assist infertility patients by informing them of the relative success of all IVF programs in the country. 

 

Unfortunately, what sometimes creates the best statistical results is not always in the best interest of the mother, child, family and society.  Now that prospective parents are comparing pregnancy rates between programs there is a competitive pressure on these programs to reports the best possible rates.   Sounds good…unfortunately it doesn’t always work out that way for the following reasons.

 

Patients with diminished ovarian reserve, who are older or for any number of reasons have a reduced chance for success, have a hard time convincing some programs to let them go for a retrieval.  In 2008, we reported our success, 15% with patients who stimulated with three or fewer follicles.  Sounds low and in fact many of these patients were turned away by other IVF programs in our area.  However, for those families created as a result of their IVF, these “miracle” babies are a treasure that they otherwise… if not for our program giving them their chance… would never have been born.

 

Another unfortunate circumstance of featuring live birth rate per transfer as the gold standard for comparison is that it pressures programs to transfer multiple embryos thereby increasing the number of high risk multiple pregnancies created.  This is not just a burden placed on the patient for their own medical and social reasons but these multiple pregnancies add additional financial costs that are covered by society by increasing costs of health insurance as well as the cost of raising an increased number of handicapped children.

 

William Petok, the Chair of the American Fertility Association’s Education Committee reported on the alternative Single-Embryo Transfer (SET) “Single Embryo Transfer:  Why Not Put All of Your Eggs in One Basket?”.  He stated in November 2008, that although multiple rather than single-embryo transfer for IVF is less expensive in the short run, the risk of costly complications is much greater.  Universal adaptation of SET cost patients an extra $100 million to achieve the same pregnancy rates as multiple transfers, but this approach would save a total of $1 billion in healthcare costs.

 

We have offered SET since 2006 with the incentive of free cryopreservation, storage for a year and now a three for one deal for the frozen embryo transfers within the year in an effort to drive patients to the safer SET alternative. 

 

If we are going to report pregnancy rates with IVF as is required by the Wyden Bill, let us put all programs on the same playing field by enforcing the number of embryos to be transferred and even promoting minimal stimulation IVF for good prognosis patients.  The Wyden Bill without the teeth to regulate such things as the number of embryos transferred and reporting success per embryo transfer does more harm than good.  Let us promote safer alternatives and report in terms of live birth rate per stimulation and retrieval, including frozen embryo transfers, so that there is a better understanding of the success of a cycle without increasing risks and costs from multiples.

 

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Was this helpful in answering your questions about the Wyden Bill, IVF success rates and reporting requirements, and SET?

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

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Infertility Podcast Series: Journey to the Crib: Chapter 28: No More “Jon and Kate” Casualties

By David Kreiner, MD

August 23rd, 2013 at 5:12 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Eight: No More “Jon and Kate” Casualties. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=136

No More “Jon and Kate” Casualties

 

A few years ago when I wrote this chapter, the Jon and Kate makes eight story was still hot in the press.  It brought to the national limelight the potentially tragic risk of the high order multiple pregnancy for women undergoing fertility therapy.  It is one I was all too familiar with from my early days in the field, during the mid-1980′s when the success with IVF was poor and we consequently ran into occasional high order multiple pregnancies with transfer of four or more embryos or with the alternative gonadotropin injection treatment with intrauterine insemination (IUI).

 

Today, IVF is an efficient process that, combined with the ability to cryopreserve excess embryos, allows us to avoid almost all high order multiple pregnancies.  In fact the IVF triplet pregnancy rate for Long Island IVF docs has been under 1% for several years now.  There has not been a quadruplet pregnancy in over 20 years.  Such a claim cannot be made for gonadotropin injection/IUI therapy where as many eggs that ovulate may implant.

 

You may ask then why would we provide a service that is both less successful and more risky and was the reason Jon and Kate made eight.

 

Not surprisingly, the impetus for this unfortunate treatment choice is financial.  Insurance companies, looking to minimize their cost, refuse to cover fertility treatment unless they are forced to do so.  In New York State, there is a law that requires insurance companies based in NY State that cover companies with over 50 employees that is not an HMO to cover IUI.  The insurance companies battled in Albany to prevent a mandate to cover IVF as has been passed in New Jersey, Massachusetts and Illinois among a few others.  As a result, many patients are covered for IUI but not IVF.  This short-sighted policy ignores the costs that the insurance companies, and ultimately society, incurs as a result of high order multiple pregnancies, hospital and long-term care for the babies.

 

The answer is simple.  Encourage patients to practice safer, more effective fertility.  This can be accomplished with insurance coverage for IVF, wider use of minimal stimulation IVF especially the younger patients who have had great success with it and minimizing the number of embryos transferred. 

 

At Long Island IVF we encourage single embryo transfer by eliminating the cost of cryopreservation and embryo storage for one year for patients who transfer one fresh embryo.  In addition, we offer those patients up to three frozen embryo transfers for the price of one within a year of their retrieval or until they have a live birth.

 

It is my sincere wish that the government can step in to enforce a policy that will never again allow for the possibility of another Jon and Kate debacle.

 

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Was this helpful in answering your questions about multiple pregnancies, IVF, IUI, and Micro-IVF?

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

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Infertility Podcast Series: Journey to the Crib: Chapter 27: A Dozen Embryos, Who Will Stop This Madness?

By David Kreiner MD

August 12th, 2013 at 9:44 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Seven: A Dozen Embryos, Who Will Stop This Madness? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=133

A Dozen Embryos, Who Will Stop This Madness?

When I wrote this chapter, the news of the day was that an IVF clinic had transferred 12 embryos.  In fact, it was learned weeks later that this was a hoax.  However, in the wake of Octomom, where 8 embryos were transferred, I felt there was still an important lesson to be learned especially since insurance companies often insist that a patient try multiple cycles of intrauterine insemination (IUI) before covering IVF… if they cover it at all. 

 

In fact, gonadotropin hormones in conjunction with IUI offers a 35% risk of multiple pregnancy including a 5% risk of triplets or more.  After obtaining six fetuses after one such cycle, I became very wary of offering gonadotropin IUI cycles to my patients.

 

Yet, this is what our insurance companies are covering rather than the safer IVF where only 1 or 2 embryos can be transferred at a time.

 

When we do an IUI, as many eggs that ovulate can implant resulting in a high risk multiple pregnancy.  I believe that it is not until we discourage the use of gonadotropins without IVF by offering a regulated covered alternative will we eliminate these risky multiples.

 

Until then, all of us including society, the government, insurance companies and employers are to blame for letting these dangerous multiple pregnancies occur.

 

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Was this helpful in answering your questions about multiple pregnancy risks in IUIs and IVF?

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

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Infertility Podcast Series: Journey to the Crib: Chapter 21: Things You Should Know About Your Embryo Transfer

By David Kreiner MD

July 1st, 2013 at 9:43 pm

 

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-One: Things You Should Know About Your Embryo Transfer. You, the listener, are invited to ask questions and make comments.  Dr. Kreiner will answer himself. You can access the podcast here: http://podcast.longislandivf.com/?p=116

Things You Should Know About  Your Embryo Transfer

As many embryos as you transfer may implant.  There is also about a one per cent chance an embryo can spontaneously split resulting in identical twins.  For young patients with high quality embryos, the implantation rate is high enough that transfer of one embryo offers a 50% pregnancy rate or better and transfers of two a slightly higher pregnancy rate but a twin rate of 40%.  For this reason it is recommended that patients under 35 with a high quality embryo transfer one embryo to minimize their chance of having a higher risk multiple pregnancy.

At Long Island IVF, we offer the Single Embryo Transfer (SET) Program to minimize the cost implications of freezing the excess embryos by eliminating the fee to cryopreserve and store these embryos for up to a year.  We also offer for SET participating patients, three frozen embryo transfers for the price of one.

Embryos are typically transferred three to five days after retrieval. The longer duration allows the embryos to develop further giving embryologists an opportunity to judge better which embryos have the best pregnancy potential.  Otherwise, a day five transfer does not improve an embryo’s chance to implant.  Many embryos fail to develop further after the third day and therefore are not ideal for transfer on day five.  The embryologist will decide whether delaying transfer improves a woman’s pregnancy potential based on the number and grade of the embryos, the woman’s age, and her history.

The embryo transfer procedure, which we studied in the late 1990′s and presented at the ASRM in 2000 includes first passing a thin very pliable tube (trial catheter) through the cervix under ultrasound guidance.  Occasionally, a suture has been placed in the cervix during retrieval so as to not cause any uterine contractions at the time of transfer.  This suture can then be used to manipulate the cervix to straighten the cervical canal for easier atraumatic passage of the trial catheter.  The inner part of the trial catheter is removed leaving the trial open at its distal end.  The embryologist loads the embryo/s in the transfer catheter which is fed through the trial catheter noting on ultrasound when the transfer catheter has reached the center of the uterine cavity.  The embryo/s contained in a microdroplet are then gently expressed with visualization of an air bubble usually adjacent to the microdroplet noted on the ultrasound.  The catheter is then examined by the embryologist to insure that the embryo/s did not stick to the wall of the catheter.

If it does we repeat the procedure.

Results of our study of this transfer procedure, I called the two-step transfer method, showed shockingly higher implantation rates compared to transfers with different catheters, with a one-step approach, without ultrasound, and with a tenaculum at the time of transfer instead of the suture. 

In the 27+ years I am performing IVF, this advance in the embryo transfer stands out as one of the top three most significant advances in IVF along with the radical improvement in media preparation and the ultrasound-guided transvaginal follicular aspiration.

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Was this helpful in answering your questions about embryo transfers? Please share your thoughts about this podcast here. And ask any questions, which Dr. Kreiner will answer.

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Infertility Podcast Series: Journey to the Crib: Chapter 4

By David Kreiner MD

March 4th, 2013 at 9:59 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Four: Where Do You Go? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=34

 

Where Do You Go?

 

I try to help the reader understand the published statistics offered online by SART, the national organization of IVF programs that provides a registry of IVF programs who submit their data for audit by SART.  Rates are offered with a numerator and a denominator with the critical goal of a live baby per retrieval or transfer being the most crucial statistic.

 

The benefits and disadvantages of large programs are discussed basically offering that larger programs tend to have more experienced and often skilled personnel albeit with more waiting time for monitoring.  Some programs may provide more personalized care, some more psychological or emotional support and some offer adjunctive therapies such as acupuncture and mind body programs.

 

I emphasize the importance of the embryology lab as well as the skill of the physician performing the embryo transfer.  The technique of the transfer is described including factors that I believe may affect success rates.

 

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Please share your thoughts about this podcast here.

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Infertility Podcast Series: Journey to the Crib: Chapter 3: What Are My Odds?

By David Kreiner MD

February 26th, 2013 at 4:59 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Three: What Are My Odds? You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=24

 

What are my odds?

 

This chapter is dedicated to informing patients regarding the potential for success with fertility therapy.  Success, in particular with IVF has been increasing significantly over the years as physicians and embryologists became more experienced.   The tools we use are more accurate and effective today and the protocols, media and laboratory conditions are all far superior to that which was standard not so many years ago.

 

This improved efficiency of the process has allowed physicians to transfer fewer embryos thereby avoiding the higher risk multiple pregnancies that IVF was known for in the 1990’s.  Still pressure exists to transfer multiple embryos to minimize expenses for the patient and maximize success rates for the IVF programs.  I have instituted a single embryo transfer incentive (SET) program at Long Island IVF eliminating the cost of cryopreservation and storage for a year for patients transferring a single embryo.  These patients are also offered three frozen embryo transfers within a year of their retrieval for the cost of one in an effort to eliminate the financial motivation some patients express to put “all their eggs in one basket”.  Experience tells us that the take home baby rate for patients transferring a single embryo at the fresh transfer is equal to that for patients transferring multiple embryos when including the frozen embryo transfers. For information on the SET program, go to: http://bit.ly/WpzCvv

 

Since the merger of East Coast Fertility and Long Island IVF, we have seen clinical IVF pregnancy rates at 66% (35/53) for women <35, 60% (18/30) for women 35-37, 54.1% (20/37) for women 38-40 and 8/28 (28.6%) for women 41-42 from Oct 1- Dec 31, 2011.  MicroIVF has been running better than 40% for women <35.

 

Different factors are discussed that can affect pregnancy rates at different programs.  The use of Embryo Glue and co-culture at Long Island IVF are discussed as laboratory adjunctive treatments that appear to improve our success rates.

 

For the most recent success rates, speak to your Long Island IVF physician or visit our website at http://bit.ly/XYZrSC

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Please share your thoughts about this podcast or ask any questions of Dr. Kreiner here.

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Long Island IVF Podcast: Journey to the Crib Ch.1: Welcome

By David Kreiner MD

February 11th, 2013 at 10:24 pm

Welcome to the Journey To the Crib Podcast.  We will have a blog discussion each week with each chapter.  You, the viewer, are invited to ask questions and make comments. You can access the podcast for this Chapter 1 here: http://podcast.longislandivf.com/?p=16

The first chapter introduces the reader to the writer, me, and my early experiences in the field of reproductive endocrinology, infertility and IVF.  This was during the early years of IVF and I was a new doctor driven by a passion for fertility; the science, the surgery and the new technology of in vitro fertilization.

I dedicated the book to my parents who were still alive when it was published.  They taught me the importance of family as it was the most precious commodity they owned.  My father recently passed but he was excited and proud of the work his son did even if he suggested making more revisions to my original drafts than I wanted to hear.  My mother, who suffered a ruptured cerebral aneurysm twenty five years ago and as a result has significant cognitive issues, remains my biggest fan.

It was with great anticipation that I sent to my mentor, Dr. Howard W. Jones Jr., this first chapter as much of it describes my impressions of him and his wife, Georgeanna Seegar Jones, the American pioneers in In vitro fertilization.  Today, he is 101 years old and remains the sharpest individual I have ever met.  I am proud to say that he was touched and impressed with my memories as I recorded them.

If you have not had the opportunity to hear him speak, please do yourself a favor and listen to any one of many videos recorded of him.  “Dr. Howard” describes how he initiated his efforts to develop the first IVF program in the U.S. on http://vimeo.com/asrm/howardjones .

I have a YouTube video discussing this pioneering couple at: http://www.youtube.com/watch?v=b790aiFLzJI&feature=related

If you have time, Dr. Howard gives an exceptional speech on the future of fertility on http://vimeo.com/17418251 .  He starts speaking about 19 minutes into the video.

The reproductive endocrinologist who had the greatest impact on my career was Dr. Zev Rosenwaks.  I unfortunately did not sufficiently credit him with the huge influence he had on my career and in shaping the physician that I have become.  As Zev was a fellow of both Joneses at Johns Hopkins and I was a fellow of his, it is this family of Reproductive Endocrinology from which my career was born.  There is not a thing that I do in practice today that cannot be traced back to Zev or Drs. Howard and Georgeanna or to any of the other fertility giants that were in Norfolk in those days including Suheil Muasher, Mason Andrews, Annibal Acosta, Gary Hodgen, Sergio Oehninger and Richard Scott.

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Do you have any questions about this podcast? Dr. Kreiner would be happy to answer them. Please tune in weekly as we continue to cover Dr. Kreiner’s  book, Journey to the Crib, chapter by chapter. Back by popular demand.

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Infertility Podcast Series: Journey to the Crib: Chapter 26: Alternative Therapies and Holistic Medicine

By David Kreiner MD

September 7th, 2012 at 2:28 pm

Welcome to the Journey to the CribPodcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Six: Alternative Therapies and Holistic Medicine. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.longislandivf.com/?p=130

Alternative Therapies and Holistic Medicine

This chapter was written by our in house Mind-Body specialist, Bina Benisch.  She follows the popular Mind-Body program at Boston IVF that was shown in studies to improve pregnancy rates. 

The Mind-Body program at Long Island IVF focuses on symptom reduction and developing a sense of control over one’s life by utilizing Mind-Body strategies and interventions which elicit the relaxation response.   This counteracts the stress of a fertility cycle.  As a result, the body’s stress response is halted and hormones diminish.  Stress responses such as heart rate, blood pressure and breathing rate decrease.  The way in which you are taught to elicit the relaxation response is through methods such as: breath focus, guided vision, imagery, muscle relaxation and learned mindfulness and meditation. 

We work with “cognitive restructuring” which is examining our negative thoughts.  We learn to understand where there is distortion and reframe our thoughts positively and realistically.  In so doing we can change those negative thoughts and alleviate the anxiety attached to them. 

Awareness of the Mind-Body connection allows us to use our mind to make changes in our physiology.  This holistic treatment combining medical science with Mind-Body medicine deals with the treatment of the whole individual rather than looking only at the physical aspect. 

Used as an adjunct, not only do we expect Mind-Body treatment help you cope with the stress of the fertility process but improve your chances of success as well. 

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Was this helpful in answering your questions about alternative therapies and holistic medicine like the Mind-Body connection? Do you have an experience with the Mind-Body program you’d like to share? 

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

 

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