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Archive for the ‘PCOS’ tag

PCOS: The Unwanted Pearl Necklace

By David Kreiner MD, and Tracey Minella

September 6th, 2012 at 7:49 pm

credit: maggiesmith/freedigitalphotos.net

There’s nothing at all sexy about PCOS, or Polycystic Ovarian Syndrome. In fact, some women who suffer from PCOS are not only fertility-challenged (by tiny ovarian cysts appearing like a string of pearls on an ovarian sonogram), but may be cursed with any number of other annoyances, including facial hair and acne and extra poundage. How lovely.

Dr. Kreiner, of Long Island IVF explains PCOS, its affect on your ability to conceive, and the way it can be managed:

PCOS is the most common hormonal disorder of reproductive age women, occurring in over 7% of women at some point in their lifetime.  It usually develops during the teen years.  Treatment can assist women attempting to conceive, help control the symptoms and prevent long term health problems.

The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels.  If a woman does not respond normally to insulin her blood sugar levels rise, triggering the body to produce more insulin.  The insulin stimulates your ovaries to produce male sex hormones called androgens.  Testosterone is a common androgen and is often elevated in women with PCOS.  These androgens block the development and maturation of a woman’s ovarian follicles, preventing ovulation resulting in irregular menses and infertility.  Androgens may also trigger development of acne and extra facial and body hair.  It will increase lipids in the blood.  The elevated blood sugar from insulin resistance can develop into diabetes.

Symptoms may vary but the most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.

Ovaries develop numerous small follicles that look like cysts hence the name polycystic ovary syndrome.  These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as  Ovarian Hyperstimulation syndrome, or OHSS.

Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs.  A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots.  Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation.  They may also prescribe aspirin to prevent clot formation.

These cysts may lead to many eggs maturing in response to fertility treatment also placing patients at a high risk of developing a high order multiple pregnancy.  Due to this unique risk it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.

A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries.  A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes.  Hormone assays will also be helpful in making a differential diagnosis.

Treatment starts with regular exercise and a diet including healthy foods with a controlled carbohydrate intake.  This can help lower blood pressure and cholesterol and reduce the risk of diabetes.  It can also help you lose weight if you need to.

Quitting smoking will help reduce androgen levels and reduce the risk for heart disease.  Birth control pills help regulate periods and reduce excess facial hair and acne.  Laser hair removal has also been used successfully to reduce excess hair.

A diabetes medicine called metformin can help control insulin and blood sugar levels.  This can help lower androgen levels, regulate menstrual cycles and improve fertility.  Fertility medications, in particular clomiphene are often needed in addition to metformin to get a woman to ovulate and will assist many women to conceive.

The use of gonadotropin hormone injections without egg removal as performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use.  In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer.   Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

It can be hard to deal with having PCOS.  If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition.  Ask your doctor about support groups and for treatment that can help you with your symptoms.  Remember, PCOS can be annoying, aggravating even depressing but it is fortunately a very treatable disorder.

* * * * * * ** *

Do you suffer from PCOS?

 

 

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Micro-IVF May Be Your Answer—and You Could Win a Free Cycle!!!

By David Kreiner MD, and Tracey Minella

August 21st, 2012 at 9:22 pm

credit:duron123/ freedigitalphotos.net

What better time than now to have Dr. Kreiner explain what Micro-IVF is all about!

Why? Because there are 5 days left to enter to win a FREE MICRO-IVF CYCLE FROM LIIVF! After you read all about the many benefits of Micro-IVF, I’m sure you’ll be excited enough to want to enter to win our annual contest.

Here’s the link for the contest: http://bit.ly/LHbmQR

Dr. Kreiner of Long Island IVF explains the process and who can benefit from it:

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 mini-IVF) 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 pregnancies.

Additionally, 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 LIIVF 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 IUI’s 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 Micro-IVF can result in cost savings and greater safety:

Micro-IVF fee (current as of August 2012): $3900

ICSI (if required): $2000

Anesthesia (as requested): $550

IUI with hormone injections: $3500 to $4500

Is Micro-IVF right for you? Each patient’s case is considered carefully and individually.

The following are conditions that might respond best to Micro-IVF:

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

Micro-IVF 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.

* * * * * * * * * **

So, are you excited or interested in learning if you are a good candidate? Why not enter our contest before it ends this Sunday?

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Infertility Podcast Series: Journey to the Crib: Chapter 9 Polycystic Ovarian Disease

By David Kreiner MD

May 17th, 2012 at 4:13 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Nine: Polycystic Ovarian Disease. You, the listener, are invited to ask questions and make comments.  You can access the podcast here: http://podcast.eastcoastfertility.com/?p=59

Polycystic Ovarian Disease

Polycystic Ovarian Disease (PCOS) is a syndrome, not truly a disease, in which a woman’s hormones are out of balance associated with a failure to ovulate regularly, irregular cycles and sometimes elevated male sex hormones resulting in hair growth on the face, chest or abdomen as well as acne. It can also be part of a “metabolic syndrome” which may include diabetes, hyperlipidemia and hypertension.

PCOS occurs in over 7% of women and usually develops during the teen years.  It may be caused by a variety of factors, is often hereditary, the most common being glucose intolerance resulting in abnormally high insulin levels.  Insulin stimulates male sex hormone production in the ovaries which blocks the development and maturation of ovarian follicles preventing ovulation which leads to irregular menses and infertility.  The ovaries develop numerous small follicles that look like cysts hence the name Polycystic Ovaries.

A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries.  A glucose tolerance test is useful to determine the presence of glucose intolerance and diabetes.  Typically patients have an elevated LH/FSH ratio.

Treatment starts with regular exercise and a diet including a controlled carbohydrate intake to reduce insulin production.  A diabetes medicine, metformin, can help reduce insulin levels as well.  Fertility medications are often needed to get a woman to ovulate and will successfully get 50% of women with PCOS to conceive.  The use of gonadotropin hormones without follicular aspiration and egg removal as is performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies.  However, IVF has been quite successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy as she can limit the number of embryos transferred with a single embryo transfer (SET). 

Though PCOS can be annoying, aggravating and even depressing it is fortunately a very treatable condition that, with the help of a reproductive endocrinologist, patients can have their families and prevent the health problems often seen with the “metabolic syndrome”.

* * * * * * **  * * * *
Was this helpful in answering your questions about PCOS and its effects on a woman’s fertility?

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

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“Yo Mama’s So Fat…” and Other Reasons Infertile, Overweight Women Kill

By Tracey Minella and David Kreiner MD

January 5th, 2012 at 6:21 pm

Didn’t these jeans fit me three weeks ago?

#@#*&%!!

Raise your hand if you made a resolution to lose weight this year…again. Or were you like me and just thought it but didn’t say it out loud… to avoid the snickering? C’mon, get that hand up, sister.

Tell me I’m not the only one out there who chomped down too many Christmas cookies, finished off too many fried latkes and zeppoles, and got hammered on gallons of eggnog. Really, I’m not the only one pulling out the “fat” clothes again, am I?

To a woman TTC, nothing is worse than being told you can’t have a baby without medical intervention…unless you’re then told you’re too overweight to have the treatments. That can hurt even more than those terrible fat jokes.

For me, depression and overeating Oreos went hand in…well… mouth. And the longer my infertility journey took… with the sorrows of miscarriage, failed IVFs, and an ovarian torsion to drown… the bigger the gap got in the back of my hospital gowns.

In a perfect world, we’d all be a healthy weight. None of us would be infertile, or have thyroid issues or diabetes, or PCOS, or just plain-old, depression-induced obesity to fill the void where our baby is supposed to be.

But the world is not perfect.

Fortunately, there are compassionate RE’s out there who are willing to give overweight patients the respect and the treatment they deserve. They’re just not easy to find. Maybe they even felt the sting of the public’s disdain for the obese on a personal level. Whatever their motivation, it’s worth the extra effort to find this kind of support on your infertility journey.

You need a doctor who is willing to potentially sacrifice his program’s IVF stats to make you a mom, because he believes he can do it…today…not after sending you home to lose those 20-30 pounds of extra weight first. Today.

Even if you are morbidly obese or have other health issues related to morbid obesity… and your treatment needs to be deferred for safety reasons until some of that weight is taken off…  there’s no reason to have to scale down to Cover Girl stickness in order to be treated. You can get a bun in your oven… and have some junk in your trunk!

Dr. Kreiner brings this prejudice and injustice to the forefront in his thoughtful, compassionate post:

The most shocking thing I’ve experienced in my 30 year career in Reproductive Endocrinology has been the consistent “resistance” among specialists to treat women with obesity. This “resistance” has felt at times to both me and many patients to be more like a prejudice. I have heard other REI specialists say that it is harder for women to conceive until they shed their excess weight. “Come back to my office when you have lost 20, 30 or more pounds,” is a typical remark heard by many at their REI’s office. “It’s not healthy to be pregnant at your weight and you risk your health and the health of the baby.” Closing the door to fertility treatment is what most women in this condition experience.

An article in Medical News Today, “Obese Women Undergoing Infertility Treatment Advised Not To Attempt Rapid Weight Loss”, suggested that weight loss just prior to conception may have adverse effects on the pregnancy, either by disrupting normal physiology or by releasing environmental pollutants stored in the fat. The article points out what is obvious to many who share the lifelong struggle to maintain a reasonable Body Mass Index (BMI): Weight loss is difficult to achieve. Few people adhere to lifestyle intervention and diets which may have no benefit in improving pregnancy in subfertile obese women.

The bias in the field is so strong that when I submitted a research paper demonstrating equivalent IVF pregnancy rates for women with excessive BMIs greater than 35 to the ASRM for presentation, it was rejected based on the notion that there was clear evidence to the contrary. Here’s the point I was trying to prove: IVF care must be customized to optimize the potential for this group.

Women with high BMI need a higher dose of medication. Those with PCOS benefit from treatment with Metformin. Their ultrasounds and retrievals need to be performed by the most experienced personnel. Often their follicles will be larger than in women of lower weight. Strategies to retrieve follicles in high BMI women include using a suture in the cervix to manipulate the uterus and an abdominal hand to push the ovaries into view.

Most importantly, a two-stage embryo transfer with the cervical suture can insure in utero placement of the transfer catheter and embryos without contamination caused by inadvertent touching of the catheter to the vaginal wall before insertion through the cervical canal. Visualization of the cervix is facilitated by pulling on the cervical suture, straightening the canal and allowing for easier passage of the catheter. The technique calls for placement of one catheter into the cervix through which a separate catheter, loaded with the patient’s embryo, is inserted.

Using this strategy, IVF with high BMI patients is extremely successful. With regard to the health of the high BMI woman and her fetus, it’s critical to counsel patients just as it is when dealing with women who live with diabetes or any other chronic situation that adds risk.

We refuse to share in the prejudice that is nearly universal in this field. It’s horrible and hypocritical to refuse these patients treatment. Clearly, with close attention to the needs of this population, their success is like any others.

Women who have time and motivation to lose significant weight prior to fertility therapy are encouraged to do so and I try to support their efforts. Unfortunately, many have tried and are unable to significantly reduce prior to conception.

What right do we have to deny these women the right to build their families?

It can be hard to deal with obesity and even more so when combined with infertility. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. I advise you to ask your doctor about support groups and for treatment that can help you including fertility treatment.

Remember, though this condition can be annoying, aggravating and even depressing, seek an REI who is interested in supporting you and helping you build your family and reject those who simply tell you to return after you have lost sufficient weight.

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

Have you been turned away from an RE because you’re overweight or obese? Do you think that’s fair?

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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.

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

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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Pixie Dust…and Baby Dust…From Heaven

By C. Tolliver

July 26th, 2011 at 12:00 am

The following essay was one of the winning entries from our first contest in April. The writer has given us permission to reprint it here. In the interim, she has conceived and is currently pregnant in her first trimester. We all wish her the best for a healthy, happy, and uneventful pregnancy!

I always had a very special mother/daughter relationship with my mom. She wasn’t just my mom, but my best friend. She was a very unique and special woman to a lot of people. Imagine everything a mother should be and that was her. She was everybody’s favorite aunt and she babysat for everybody’s kids in the family and the neighborhood. All my friends wanted to hang out at my house because she was so much fun.

She loved all things Disney, insanely decorated the entire house for every holiday, planned the most amazing parties, and always had a smile for everyone and a twinkle in her eye. She was the kind of woman who stayed up all night in the hospital when anyone she knew had their babies and then went into their homes before they were released and cleaned their house, set up the bassinet and baby supplies, and left them a meal for their first night home. She loved her life. As I got older, I started to look at her not just as a mom or a friend but also as a role model of the type of wife and mother I wanted to be.

One of her many dreams was for me to get married and have children so she could be a grandma. As a little girl, I always wanted to be a bride and mommy. It always amazed me that my mother had that same kind of passion and that she wished that for me. I guess wishing those amazing dreams for your children is something you can’t really understand until you’re a mom.

I was only nineteen when my mother was diagnosed with multiple myeloma, a blood/bone cancer, and had just begun my freshmen year of college. I decided to drop out of school and move back so that I could be home to take care of my mother. I couldn’t bear the thought of not being there for her every need. She always put my needs before hers. She was always there for me. It was my turn to help her now.

As I watched my mom slowly lose her 4 year battle, I made the wrong decision to marry, as planning my wedding seemed to give her something to live for. Unfortunately, she never made it to the wedding and passed away seven weeks earlier. In my grief, I kept going through with everything knowing that this wedding was something my mother always wanted for me and I knew she would be there in spirit making sure every detail was just the way she always dreamed it would be.

It wasn’t until months later when trying to conceive unsuccessfully with an unsupportive man that I realized I made a mistake. I later learned that he fathered a child with someone else, and right then the seed was planted that maybe there was something wrong with me… and it has haunted me ever since.

A few years later I was lucky to find and marry my soul mate, a man with a son of his own who is now five. I love and care for him as if he were my own and wish he lived with us full time. Nine months into our marriage we decided to start trying to have a baby. Still in the back of my mind was the idea that something may be wrong, but I went into baby-making with him hopeful… since he too had already fathered a child easily.

Of course I was looking for all of those signs like every woman does when they’re trying to conceive and I had none but I still thought maybe it was just too early and then… I got my period. What a bummer, but there was always next month. Right? So we kept trying month after month with negative results and wacky cycles and we finally decided to meet with my OBGYN.

After several tests it came up that I have PCOS. After talking with each other and the doctor we decide to start on our first cycle of Clomid. Again, I get psyched because now at this point I am thinking this has to work, my husband already has a kid so he has to be fertile and now I know I have PCOS which causes me not to ovulate and this medicine is going to help that so we are in.

So, we’re getting excited, everything is going smoothly I was having some early pregnancy signs and then…once again I get my period and learn what I thought were early pregnancy signs were just symptoms from the medicine. We currently are in our second month of Clomid and as it turns out my results this month are negative and the medicine didn’t even work. At this point we are bummed, we thought the medicine was supposed to help me ovulate and its not even working and who knows, maybe I will get it next week or the week after but without going bankrupt from ovulating strips how else am I supposed to figure out when I am ovulating?

At what point do we decide to move on to a fertility doctor? What kind of expenses is this going to become? We are already struggling with money; we live in a two bedroom apartment and pay a mortgage payment in child support. How we can afford infertility treatments?

My stepson asks when he is going to have a sister or a brother. He prays to God every night to send him a baby sister or brother and he thinks I can’t have a baby because I am not a mommy. This kills me. I cannot wait until the day comes when I can give him the exciting news that he is going to be a big brother and I will be the mommy.

It is hard for me every day of my life not having my mom, but it is especially hard now going through the ups and downs of infertility. So many times I want to pick up a phone and just call knowing she would support whatever it was that I had to say or just hug me and tell me everything will be okay. There’s something about a mother’s hug that just gives you that much more support. I just want that mother/child bond back in my life and the only way it can happen for me is having my own child to love and care for the way my mother taught me to.

Winning a free IVF cycle would make both my …and my mom’s… dream come true. And if it’s divinely possible to do so, I have no doubt that my mom will be looking over that Petri dish and guiding the doctor’s hand when the time comes.

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PCOS: The Other Pearl Necklace

By Tracey Minella and David Kreiner MD

June 28th, 2011 at 12:00 am

There’s nothing at all sexy about PCOS, except perhaps its naughty nickname. In fact, some women who suffer from Polycystic Ovarian Syndrome are not only fertility-challenged (by tiny ovarian cysts appearing like a string of pearls on an ovarian sonogram), but may be cursed with any number of other annoyances, including facial hair and acne and extra poundage. Guh-reat.

Dr. Kreiner explains PCOS, its affect on your ability to conceive, and the way its fertility roadblocks can be overcome at East Coast Fertility:

PCOS is the most common hormonal disorder of reproductive age women, occurring in over 7% of women at some point in their lifetime.  It usually develops during the teen years.  Treatment can assist women attempting to conceive, help control the symptoms and prevent long term health problems.

The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels.  If a woman does not respond normally to insulin, her blood sugar levels rise triggering the body to produce more insulin.  The insulin stimulates your ovaries to produce male sex hormones called androgens.  Testosterone is a common androgen and is often elevated in women with PCOS.  These androgens block the development and maturation of a woman’s ovarian follicles preventing ovulation resulting in irregular menses and infertility.  Androgens may also trigger development of acne and extra facial and body hair.  It will increase lipids in the blood.  The elevated blood sugar from insulin resistance can develop into diabetes.

Symptoms may vary but the most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.

Ovaries develop numerous small follicles that look like cysts hence the name polycystic ovary syndrome.  These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as Hyperstimulation syndrome. 

Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs.  A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots.  Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation.  They may also prescribe aspirin to prevent clot formation.

These cysts may lead to many eggs maturing in response to fertility treatment also placing patients at a high risk of developing a high order multiple pregnancy.  Due to this unique risk it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.

A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries.  A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes.  Hormone assays will also be helpful in making a differential diagnosis.

Treatment starts with regular exercise and a diet including healthy foods with a controlled carbohydrate intake.  This can help lower blood pressure and cholesterol and reduce the risk of diabetes.  It can also help you lose weight if you need to.

Quitting smoking will help reduce androgen levels and reduce the risk for heart disease.  Birth control pills help regulate periods and reduce excess facial hair and acne.  Laser hair removal has also been used successfully to reduce excess hair.

A diabetes medicine called metformin can help control insulin and blood sugar levels.  This can help lower androgen levels, regulate menstrual cycles and improve fertility.  Fertility medications, in particular clomiphene are often needed in addition to metformin to get a woman to ovulate and will assist many women to conceive. 

The use of gonadotropin hormone injections without egg removal as performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use.  In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer.   Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

It can be hard to deal with having PCOS.  If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition.  Ask your doctor about support groups and for treatment that can help you with your symptoms.  Remember, PCOS can be annoying, aggravating even depressing but it is fortunately a very treatable disorder.

no comments

“Yo Mama’s So Fat…” and Other Reasons Infertile, Overweight Women Kill

By Tracey Minella and David Kreiner MD

April 21st, 2011 at 12:00 am

Maybe murder is a bit extreme, but then again…

To a woman TTC, nothing is worse than being told you can’t have a baby without medical intervention…unless you’re then told you’re too overweight to have the treatments. That can hurt even more than those terrible fat jokes.

For me, depression and overeating Oreos went hand in…well… mouth. And the longer my infertility journey took… with the sorrows of miscarriage, failed IVFs, and an ovarian torsion to drown… the bigger the gap got in the back of my hospital gowns.

In a perfect world, we’d all be a healthy weight. None of us would be infertile, or have thyroid issues or diabetes, or PCOS, or just plain-old, depression-induced obesity to fill the void where our baby is supposed to be.

But the world is not perfect.

Fortunately, there are compassionate RE’s out there who are willing to give overweight patients the respect and the treatment they deserve. They’re just not easy to find. Maybe they even felt the sting of the public’s distain for the obese on a personal level. Whatever their motivation, it’s worth the extra effort to find this kind of support on your infertility journey.

You need a doctor who is willing to potentially sacrifice the program’s IVF stats to make you a mom, because he does believe he can do it…today…not after sending you home to lose loads of weight first. Today.

Dr. Kreiner of East Coast Fertility brings this prejudice and injustice to the forefront in his thoughtful, compassionate post:

The most shocking thing I’ve experienced in my 30 year career in Reproductive Endocrinology has been the consistent “resistance” among specialists to treat women with obesity. This “resistance” has felt at times to both me and many patients to be more like a prejudice. I have heard other REI specialists say that it is harder for women to conceive until they shed their excess weight. “Come back to my office when you have lost 20, 30 or more pounds,” is a typical remark heard by many at their REI’s office. “It’s not healthy to be pregnant at your weight and you risk your health and the health of the baby.” Closing the door to fertility treatment is what most women in this condition experience.

An article in Medical News Today, “Obese Women Undergoing Infertility Treatment Advised Not To Attempt Rapid Weight Loss”, suggested that weight loss just prior to conception may have adverse effects on the pregnancy, either by disrupting normal physiology or by releasing environmental pollutants stored in the fat. The article points out what is obvious to many who share the lifelong struggle to maintain a reasonable Body Mass Index (BMI): Weight loss is difficult to achieve. Few people adhere to lifestyle intervention and diets which may have no benefit in improving pregnancy in subfertile obese women.

The bias in the field is so strong that when I submitted a research paper demonstrating equivalent IVF pregnancy rates for women with excessive BMIs greater than 35 to the ASRM for presentation, it was rejected based on the notion that there was clear evidence to the contrary. Here’s the point I was trying to prove: IVF care must be customized to optimize the potential for this group.

Women with high BMI need a higher dose of medication. Those with PCOS benefit from treatment with Metformin. Their ultrasounds and retrievals need to be performed by the most experienced personnel. Often their follicles will be larger than in women of lower weight. Strategies to retrieve follicles in high BMI women include using a suture in the cervix to manipulate the uterus and an abdominal hand to push the ovaries into view.

Most importantly, a two-stage embryo transfer with the cervical suture can insure in utero placement of the transfer catheter and embryos without contamination caused by inadvertent touching of the catheter to the vaginal wall before insertion through the cervical canal. Visualization of the cervix is facilitated by pulling on the cervical suture, straightening the canal and allowing for easier passage of the catheter. The technique calls for placement of one catheter into the cervix through which a separate catheter, loaded with the patient’s embryo, is inserted.

Using this strategy, IVF with high BMI patients is extremely successful. With regard to the health of the high BMI woman and her fetus, it’s critical to counsel patients just as it is when dealing with women who live with diabetes or any other chronic situation that adds risk.

We refuse to share in the prejudice that is nearly universal in this field. It’s horrible and hypocritical to refuse these patients treatment. Clearly, with close attention to the needs of this population, their success is like any others.

Women who have time and motivation to lose significant weight prior to fertility therapy are encouraged to do so and I try to support their efforts. Unfortunately, many have tried and are unable to significantly reduce prior to conception.

What right do we have to deny these women the right to build their families?

It can be hard to deal with obesity and even more so when combined with infertility. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. I advise you to ask your doctor about support groups and for treatment that can help you including fertility treatment.

Remember, though this condition can be annoying, aggravating and even depressing, seek an REI who is interested in supporting you and helping you build your family and reject those who simply tell you to return after you have lost sufficient weight.

* * * * * *

Have you felt prejudiced along your journey because of your weight? Do you feel that obese women should have to lose weight before TTC with IVF?

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Stopping ‘Aunt Flo’ From Ruining Your Big Day

By Dr. Eli Rybak and Tracey Minella

March 10th, 2011 at 1:12 am

She’s about as welcome as the plague. Yet, despite your best efforts that freakin witch shows up each month. And sometimes the timing of her visit couldn’t be worse. What to do? Well, you can’t murder her in the conservatory with the candlestick. But, there is a handy weapon in your RE’s arsenal…OCPs.

You might be surprised to know that oral contraceptives (‘the pill’) have a place in the treatment of certain causes of infertility, like PCOS. And they also offer something patients rarely experience when battling infertility…some control.

So until the time Aunt Flo takes that long-awaited nine month vacation, remember that with careful planning and a little help from your RE, you may at least celebrate big days…like your wedding… without her crashing the party.

Dr. Eli Rybak, of East Coast Fertility, explains how strategic planning works:

A patient of mine with PCOS recently came to the office for a follow-up appointment.  The most rewarding aspect of the visit occurred when she asked me to help her calculate where she would be in terms of her OCP (oral contraceptive) pill-pack when her wedding day came around in a half-year from now. 

That encounter sparked a few thoughts in my mind:  Several situations may arise when patients might want to manipulate their menstrual timing a bit:  A vacation, a big event at work, or a wedding.  Observant Jewish women who observe the Laws of Ritual Purity (Mikvah) usually aim to have their wedding day occur shortly prior to the onset of a menses.  The good news is that such hormonal manipulation is relatively easy – and effective.  With sufficient lead-time, a woman should make an appointment to see a gynecologist or REI.  Unless contraindicated, an OCP can be prescribed. 

Most 28-day pill packs come as 21-days of active pills and 7-days of placebo (sugar pills) during which a withdrawal bleed (“period”) commences.  Of course, a patient may take more than 21 days of active pills in a row.  Many women, however, do have some spotting or breakthrough bleeding after a certain number of consecutive active pills.  Ideally, a woman can take, say, 28 or 35 days of active pills in a row, early on – as soon as she has a target date (so any irregular spotting is long gone, well before the target date) – and then she can take the standard 21 day regimens once she is “on schedule” to have a period avoid that target date. 

For last minute patients who find themselves 2-3 weeks or less prior to a target date (i.e. wedding) and realize their period will come before or on that target date, Norethindrone Acetate (“NETA”,  Aygestin) can be used to delay menses for several days.  A competent GYN or REI can prescribe this drug.  I have received good feedback from women who have used NETA for this purpose.  And if it works for you, maybe you’ll send us a happy wedding pic or two!

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Don’t Fear the Fertility Consultation

By Eli Rybak, Md and Tracey Minella

February 18th, 2011 at 12:38 am

Afraid you’re infertile? Afraid to see a specialist?

I know what you’re thinking. Something is wrong and that’s why you haven’t gotten pregnant. Well, that’s what your gut, your best friend, and the internet all say. Yet, going to a specialist means turning that suspicion into confirmation, right? And then, within like, ten minutes… while you’re head is still spinning… that specialist will have whisked you to an operating table to suck out your eggs. Ahhhhhhhhhhhhhh!

Was I close?

To our grandparents’ generation, IVF seriously would have been something out of a sci-fi thriller. And we are not so far removed from that generation that we aren’t spooked by it, too.

Yet, a visit to a fertility specialist need not be a fast-track to IVF, or to any other form of medically-assisted reproductive technology. A consultation can be just that… a visit to get clarification of what, if any, issues you should be concerned about in order to maximize your fertility.

Read on as East Coast Fertility’s Dr. Eli Rybak (“the fertility orthodoc”) reassures you that no reputable doctor is going to pressure you to commit to anything you are not ready for simply because you came in for a consultation:

MAXIMIZING FERTILITY AND KEEPING IT SIMPLE:

 Many women experience difficulty conceiving – or anticipate a challenge conceiving (they were diagnosed with “PCOS” perhaps based upon irregular cycles and excess hair growth on different parts of the body = hirsutism), but are not emotionally, logistically or even financially prepared to seek a formal fertility evaluation and management plan.  Sometimes, a patient tells me at the first visit: “Dr. Rybak – I’m just not ready for clomid etc.  But I really want to optimize things on my own for a few months.”  Sometimes I surprise the patient when I respond enthusiastically in the affirmative.  Especially for young patients trying to conceive for less than a year with no suspected cause for their subfertility / lack of successful conception thus far, I think some minimal intervention, common sense, and a positive attitude can go a long way.  Here are some suggestions and ideas that I wish to share:

1- Women with irregular cycles should not just assume they have “PCOS”.  And they should NOT freak themselves out by googling articles and images regarding what they might look like in the near future.  PCOS is an endocrine disorder with a wide range of clinical manifestations and physical appearances.  Some patients have excess facial and body hair, others don’t.  Some are obese, others might be thin.  My suggestion is that if a woman in her 20s or beyond has experienced bouts of irregular periods, she should see a reproductive endocrinologist or qualified gynecologist to perform a history and physical, pelvic ultrasound, and appropriate blood tests.  This can be done in one visit.  Then, there is no suspense, no agonizing.  The clinician can explain the findings, and address them accordingly.  I explain to my patients that PCOS requires attention to 5 aspects:

a- irregular periods = anovulation –> infertility

b- excessive hair growth = hirsutism

c- Lifelong risk for Diabetes even if patient is not obese

d- Lifelong risk for Elevated Lipids (high cholesterol, triglycerides) even if patient is not obese

e- Risk for developing hypertension and coronary heart disease (“Metabolic Syndrome”)

There is a tremendous amount more to say; and I derive much satisfaction from teaching my patients that although PCOS cannot be “cured”, it can be managed highly successfully.  Just because someone’s genetic lottery yielded them PCOS does NOT relegate them to a life of  infertility and medical disease.  And part of my education – AND THE POINT OF ALL THIS – is that I emphasize how, for most patients with PCOS, the oral contraceptive pill (combined estrogen/progesterone birth control pill) WILL BE THEIR BEST FRIEND (assuming no contraindications!).

Indeed, for a PCOS patient contemplating attempted conception in several months from now, in addition to the standard preconceptual counseling (Folic Acid, ensuring immunity to Rubella and Varicella / chicken pox etc etc), I would consider recommending she take the oral contraceptive pill for several months.  For many PCOS patients, this pill will – over a period of several months (not overnight) decrease the androgenic (male-hormone) environment in their body contributing to the syndrome.  And when PCOS patients stop the pill, some, indeed, have ovulatory cycles.

Readers who have done their homework – or who are unfortunately not new to infertility – may be wondering when I will mention another friend, METFORMIN.  Yes, Metformin too is a friend – but a separate and full discussion is needed to do “met” justice.

For women who do need assistance with ovulation induction, the 2007 Reproductive Medicine Network Multicenter Study published in the New England Journal Of Medicine established that clomid yields a live-birth rate superior to that of metformin.  A question persists, however, whether combining metformin with clomid affords even greater success.

2- PCOS or not, anovulatory or not, ALL women improve their fecundability (probability of conceiving in a given month) by optimizing their body weight.  Both obesity and being excessively thin can render a woman anovulatory. 

3- Patients who are not sure whether they are ovulatory or not can consider a variety of commercial fertility tests – for most women, the ovulation predictor kit may be easiest (the “LH” kit – sold at most supermarkets / drug stores).  As a GENERAL (not absolute) rule, if a woman’s menstrual cycle occurs monthly, between 25-35 days apart, she is PROBABLY OVULATORY.  The most definitive – and quick – confirmation is to have a midluteal blood test (7 days prior to the anticipated start of the next period) to check the Progesterone level.  In most labs, a value above 3 ng/mL confirms that ovulation occurred.

4- Vices:  Smoking is bad – surprise!  Smoking is associated with a higher likelihood of infertility, earlier menopause, and a higher risk of miscarriage.  Enough said.  If you do smoke, the best thing you could do for your overall health (and pocketbook) is to see your primary provider.  Cold turkey, as the signs on NYC buses say, is good for a lunch sandwich, NOT for quitting smoking.  And the therapies available (including nicotine gum, Zyban / Wellbutrin etc) are more effective than ever!

Now, the picture with alcohol is more interesting.  But before one is complacent, remember than once pregnant there is NO known safe level of alcohol consumption.  Thus, if conception is possible, complete abstinence is advised.   There is data that time-to-conception is shorter among women consuming <2 drinks of wine daily.  The mechanism is unclear.  Stress reduction ?

Finally, caffeine:   Bottom line – LESS IS MORE.  But if a patient must consume this stimulant, I am satisfied if she keeps it to a maximum of 2 cups of coffee per day (or the equivalent in soda).

5- Timing.  Yes, timing is everything.  Nature is flexible on some points, very unforgiving on others.  The fertile window each month when timed intercourse is likeliest to succeed – based on several landmark epidemiological studies – spans from 3 days prior to ovulation until the day of ovulation.  Simply put, an unfertilized egg loses its ability to be fertilized very rapidly once it is ovulated.  Successful conception requires the presence of sperm prior to ovulation.

Daily intercourse during this “fertile window” does not cause a decrease in sperm parameters (sperm concentration and motility).  Timed intercourse should occur at a 1-2 day interval during the fertile window.

A subsequent post will address techniques to lengthen the follicular phase for women with short cycles who ovulate prior to their husband’s availability – commonly referred to as “religious infertility”.

6- Finally, stress reduction is ESSENTIAL.  And if acupuncture or exercise or yoga reduces a person’s stress – go for it!

At East Coast Fertility, we celebrate every miracle, every baby, with our patients – from those with the most minimal intervention to those with the latest assisted reproductive technology.

A trial of keeping it simple is justified for young patients with no known risk factors who have been trying to conceive for relatively short durations.  Unsure?  A consultation is not a commitment – but can provide critical clarification.

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