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Archive for the ‘pregnancy’ tag

The Man’s Role in IVF

By David Kreiner MD

January 24th, 2015 at 8:13 am

 

credit: imagery majestic/ freedigitalphotos.net


Many husbands complain that they feel left out of the whole IVF process as all the attention and care is apparently directed towards the woman. If anything they may feel that at best they can show up for the retrieval at which time they are expected to donate their sperm on demand. If you should fail at this then all the money, time, hope and efforts were wasted all because you choked when you could not even perform this one “simple” step.

I have not witnessed the terror and horrors of war but I have seen the devastation resulting from an IVF cycle failed as a result of a husband’s inability to collect a specimen. Relationships often do not survive in the wake of such a disappointment. Talk about performing under pressure, there is more at stake in the collection room than pitching in the World Series.

Husbands and male partners view IVF from a different perspective than their wives. They are not the ones being injected with hormones; commuting to the physician’s office frequently over a two week span for blood tests and vaginal ultrasounds and undergoing a transvaginal needle aspiration procedure. At least women are involved in the entire process, speak with and see the IVF staff regularly and understand what they are doing and are deeply invested emotionally and physically in this experience. So what is a husband to do?

 

Get Involved

Those couples that appear to deal best with the stress of IVF are ones that do it together.

Many husbands learn to give their wives the injections. It helps involve them in the efforts and give them some degree of control over the process. They can relate better to what their wives are doing and take pride that they are contributing towards the common goal of achieving the baby.

When possible, husbands should accompany their wives to the doctor visits. They can interact with the staff, get questions answered and obtain a better understanding of what is going on. This not only makes women feel like their husbands are supportive but is helpful in getting accurate information and directions. Both of these things are so important that in a husband’s absence I would recommend that a surrogate such as a friend, sister, or mother be there if he cannot be. Support from him and others help diminish the level of stress and especially if it comes from the husband helps to solidify their relationship.

Husbands should accompany their wives to the embryo transfer. This can be a highly emotional procedure. Your embryo/s is being placed in the womb and at least in that moment many women feel as if they are pregnant. Life may be starting here and it is wonderful for a husband to share this moment with his wife. Perhaps he may keep the Petri dish as a keepsake as the “baby’s first crib”.  It is an experience a couple is not likely to forget as their first time together as a family.

With regards to the pressure of performing to provide the specimen at the time of the retrieval, I would recommend that a husband freeze a specimen collected on a previous day when he does not have the intense pressure of having to produce at that moment or else. Having the insurance of a back-up frozen specimen takes much of the pressure off at the time of retrieval making it that much easier to produce a fresh specimen. There are strategies that can be planned for special circumstances including arranging for assistance from your wife and using collection condoms so that the specimen can be collected during intercourse. Depending on the program these alternatives may be available.

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If you did IVF, was your partner involved? How did it go? Any funny or sweet stories to share?

If your partner wasn’t involved, are you happy about that decision, and if so, why was it the right decision for you?

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Infertility and TCM: Part 9: Tong Bing Yi Zhi.

By David Kreiner MD

June 29th, 2014 at 8:34 am

 

image courtesy of stuart miles/ freedigitalphotos.net

According to Western Medicine, a particular disease is caused by a specific pathogen and the Western Medicine treatment is directed at that pathogenic factor. However, Traditional Chinese Medicine (TCM) recognizes that two people may react differently to that same pathogen.  They refer to this as Tong Bing Yi Zhi.  For example, in one individual the symptoms may appear as Damp heat syndrome and in another as Yin deficiency with false heat syndrome. In TCM, despite the common pathogen, patients would be treated differently depending on the syndrome identified. Syndrome identification is based on 4 diagnostic methods: inquiring, palpation, inspection and listening/smelling. This information is gathered and analyzed to identify the syndrome that a patient is experiencing.

 

On the other hand, two people with two different Western diagnoses such as menopause and hyperthyroidism may experience the same TCM syndrome from their respective pathologic conditions, Yin deficiency with false heat. This is also referred to as Tong Bing Yi Zhi.  In this case it refers to treating different diseases the same because they result in the same TCM syndrome.  In the first case TCM treats the same disease differently because as a result of the varying natures and constitutions of patients the symptoms resulting from the same pathologic condition often varies. To clarify, we do not need to know in TCM what diseases the patients have. We treat them according to TCM by their syndrome diagnosis.

Syndromes are differentiated based on several different factors. There are eight principles of paired opposing conditions including; Exterior and Interior, Cold and Heat, Deficiency and Excess, and Yin and Yang. These general principles are the basis for categorizing all the syndromes. The other syndromes are differentiated according one of the following  theories such as; Qi, blood and body fluids, the theory of the Zang-Fu organs, the theory of the six channels or meridians of Qi, the four levels of heat invasion, and the three burners or sections of the body.

It is through the four diagnostic methods above that the practitioner identifies the syndrome affecting the patient. He/she will choose the particular treatment specific for the syndrome modified by the age and health of the patient. This can include Tui-Na massage, acupuncture, moxibustion, cupping, and herbal medicine all directed at specific points in the body depending on the syndrome.

To me, as a Western physician trained to direct treatment for a particular pathogen or disease, I am very attracted to differentiating treatment based on its specific effect on the individual patient. We know that the same disease can have different resulting effects on people and that different diseases can affect some individuals in the same way. Therefore, the concept of directing therapy based on the effect the pathogenic factor has on the individual appears to me to be an effective way to treat a patient. If a physician were to combine the Western pathogen-directed therapy with TCM treatment based on the syndrome affecting the individual then the East-West combination therapy I believe should be most ideal.

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Does the Western pathogen-based treatment plan seem sufficient or does the idea of blending it with Eastern principles of syndrome-based treatment seem like it’d be a complementary bonus?

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7 Tips to Help Your Guy Survive Father’s Day When You’re Infertile

By Tracey Minella

June 14th, 2014 at 7:18 am

 

Credit: david castillo dominici/freedigitalphotos.net

 

Just as Mother’s Day is the hardest day of the year for infertile women, Father’s Day is roughest on the infertile men.  And society’s expectations of men make it even harder.

Men are “supposed” to be so many things. Tough guys. Knights in shining armor. Passionate lovers. Good providers.

And daddies.

But the harsh reality of infertility flies in the face of all that. Real men cry. Timed sex is no fun. (Ditto for specimen cups.) Ten thousand dollar bills don’t grow on trees. You can’t “just look at her” and get her pregnant. And this Sunday is yet another day…and another year… without a crayon-colored card and painted rock paperweight present.

Our guys are there to pick us up each month as we face another disappointment and to hold us after yet another a failed cycle. Some hold back their tears so we can let ours flow freely while others join in.  (Either way, they hurt, too.) They lose sleep worrying about how to finance the next fertility treatment. And if the cause is male factor, they often shoulder unbearable guilt as well, no matter how much we reassure them.

Face it. Society isn’t even sympathetic to us on Mother’s Day even though the depth of the maternal instinct is universally accepted. So the support, empathy, and understanding our men need needs to come from somewhere else.

It needs to come from us. So what can we do to help our partners this Sunday?

Here are 7 tips to help get him through Father’s Day:

Cater to him: Get inside his head and go for the best diversion for him. Do whatever it is he likes…preferably where there won’t be children (if being around them is hard). In fact, set up a whole day of his favorite things, starting with breakfast in bed.

 

Surprise him: Has he been begging you to share a new experience with him, like fishing or hiking…or any other positively mortifying thing? Has he hinted about a concert or sporting event that you would rather die than attend? Well…surprise him with those tickets or grab the tackle box and go for it with a smile on your face. That simple gesture will speak volumes. (Tomorrow you can tell him it was a one-day only thing!)

 

Solo time with Dad: Instead of having to endure a barbeque with the whole family…including the wise-cracking fertile siblings and the 22 grandchildren they’ve already provided…plan to spend solo time with Dad. Consider breakfast on Sunday morning or dinner on Saturday night instead.

 

 

Daddy-in-Waiting card: He’s already a father in his heart. He’s just waiting. Don’t make him wait to get a card (or a gift for that matter). Write him a heartfelt note telling him how much he means to you and how he’s helped you on this journey. Tell him what wonderful traits he has that you hope your children will one day have and why he’d make a great dad. (Then get the tissues ready.)

 

Adopt a kid: If you can handle it emotionally and you’re close to someone with a child who no longer has a father in the picture, consider doing something with that child on Sunday. Toss a ball in a park, see a movie, get an ice-cream. It may be an awkward or difficult day for the child and his mom, but you could make a difference… and do your heart some good, too.

 

Get physical: Relieve some of the stress of infertility with physical activity. Take a walk or run on the beach. Take a trip to the gym. Have a roll in the hay. Or not.

 

Sow your seed: There’s something cathartic about getting your hands dirty with nature. About sowing seed or planting a tree that will live for generations. About fertility and making something grow. So while you are waiting for that baby, consider planting a Father’s Day tree or garden…something to watch grow over the coming years. A tree next to which you might take annual photos with your future child every Father’s Day as they both grow.

 

Remind him that this journey will end someday and that IVF success rates and technology continue to improve daily so there’s no better time to be trying to conceive.

Hopefully, the reality of that painted rock paperweight is only a stone’s throw away.

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What are you planning to do on Father’s Day this year?

 

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Infertile Women Never Forget

By Tracey Minella

June 4th, 2014 at 3:55 pm

 

credit: idea go/freedigitalphotos.net


When it comes to remembering, elephants have nothing on infertile women.

Date of last menstrual period? Pshhh! Without even a glance at a calendar or app, we can tell you the date… plus the time it started, where we were, what we were wearing, who we were with, and how many pee sticks we went through thinking we were pregnant in the 5 days before it began.

And that’s just getting warmed up.

We know how many vacation days we’ve used and how many precious few remain because they’ve been mentally earmarked for upcoming cycles. We can recite the months, years, series numbers, and assigned nurses’ names of all our IVF cycles. We know how many embryos we transferred back and what grades they were. And we can tell you the number and grade of any frozen embryos faster than we can give you the current time.

We know the number of follicles we had on each ovary from our last sonogram and the sizes of the dominant ones. We may not know how much gas is in the car, but we know how thick our uterine lining measured. We know our last Day 3 FSH level and how many vials of medication are still in the fridge. And we definitely know what vein still works.

We know the dates of our retrievals, our transfers, and our pregnancy test dates. Some of us carry the painful details of unspeakable losses as well. And we know what we wore to each and what music was playing on the radio. We can detail how we fell apart, how we pulled it back together, and how we recalculated when we’d be trying again…and what the new due date might be. We’re always aware of the date we need to conceive by in order for a baby to be born before the year ends, or before our next birthday.

These incredible memory skills build up gradually along the course of the infertility journey, starting with the innocent basal body temperature charts used for tracking ovulation patterns. As the journey progresses, more tests and procedures follow. Results come in and a treatment plan is made. The brain absorbs all this additional information… because there is simply nothing else on our minds as important as our goal of getting pregnant.

And in the end, all these dates…these often-frustrating dates…become your history. They make up the story of your journey to parenthood. And you will never forget them.

I know this because today I celebrate the 17th anniversary of the day of my first positive pregnancy test from my 6th fresh IVF cycle which resulted in the birth of my first IVF baby. It was also coincidentally the first day I started working at LIIVF as a medical assistant and I was wearing scrubs when Dr. Kreiner called me into his office to tell me the good news at the end of that nerve-wracking first day. After so many result calls that began with “I’m so sorry…” it was a moment that will live forever.

Your moment will, too.

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What has been your most memorable moment of the journey? What details do you remember that others would be impressed or amazed by?

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Mother’s Day: 5 Tips on Surviving The Hardest Day of the Year

By Tracey Minella

May 10th, 2014 at 8:00 pm

 

credit: david castillo/freedigitalphotos.net


Infertile women face plenty of rough days each year… Halloween, New Year’s Day, baby showers, and our birthdays. But, without question Mother’s Day is, well, the mother of them all.

It is the day the whole world dotes on moms…and assumes that any woman of a certain age is one. That assumption, when verbalized, can make you feel like crawling away and crying. And it is even worse for those who have lost babies along the journey. Everyone from store clerks to the whole congregation will unwittingly wish you a Happy Mother’s Day. So, what can you do?

Here are five tips for managing on Mother’s Day:

·         Focus on your own mom. It doesn’t help completely, but it can be a good distraction. You don’t have a child yet, but you do have a mom. If it’s too hard to be with her for a dinner that includes your pregnant siblings and their 37 kids, then make separate plans to see her for brunch instead. If she’s far away, schedule a nice, long call. If your mom is gone, consider visiting the cemetery with a note or flowers, or doing something that reminds you of good times with her. Yes, it may make you cry, but it’s a great place to vent. (Can you tell I’ve done this?) You will cry on this day anyway. Go for happier tears.

 

·         Call your church or temple in advance. If you’re dreading how all the mothers are asked to stand up and be recognized at your place of worship… something that would be particularly hard for those who have suffered miscarriages or lost babies or infants…why not call ahead and ask the priests or rabbis to recognize and include those who’ve lost children in that definition. Or ask when that moment of recognition will happen and plan to arrive before or after that point in the services.

 

 

·         Make yourself a Mother-in-Waiting’s Day Card. You are a mother. A mother-in-waiting. Believe your day will come. But why should your card wait? You should sit down and list all the reasons you are going to be a great mom. Things like, When I’m a mom, I’m going to let my kid have ice cream for dinner sometimes. While you’re at it, buy yourself a gift, too.

 

·         Make a garden. It’s a great way to connect with nature and spend some quiet, reflective time alone or with your partner on Mother’s Day and for many days to come. Plant pretty flowers or maybe some healthy, fertility-enhancing vegetables. Populate it with little gnomes, wind chimes, or cherub statues. It could become your sanctuary.

 

·         Get a dog. Or a cat. If you’ve been seriously thinking about getting a pet, this may be the time to act on it. “Furbabies” love unconditionally and fill a special spot in the infertile heart. Is there room in your life for one?

These are just a few tips to manage the day, not to enjoy it. The fact is that it won’t really be enjoyable until you are a mom. So, do whatever you want or need to do to get through this day. Treat yourself well. Spend time with your partner. Hiberate. And stay far, far away from Chuck E. Cheese.

As a mother-in-waiting, it’s your day, too. Take it one hour at a time.

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What are your Mother’s Day plans? Any tips to help others get through 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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TCM and Infertility Part 6: TCM Pathogens of Wind, Cold, Heat, Dampness, Dryness, Phlegm and Emotion

By David Kreiner MD

April 18th, 2014 at 10:27 pm

 

credit: stuart miles/freedigitalphotos.net


Welcome, to my new world where I often feel like Robert A. Heinlein’s “Stranger in a Strange Land”.  

UnIike Heinlein’s protagonist, I am not accustomed to eating the bodies of the dead (though some natural holistic purists may consider this act the ultimate in sustainability.)  But to the previously unexposed who’ve been brought up from a Traditional Chinese Medicine (TCM) perspective, perhaps some of the Western Medical physicians’ practices may appear a bit barbaric.

In our recent Western Medical history such practices as lobotomy for psychological disorders, certain hard core diet therapies including high risk bowel resection surgery, and nearly routine hysterectomies for perimenopausal women would be considered potentially dangerous malpractice today.  However, if we thought drastic high-risk unnecessary medicine were a thing of the past, then consider the fact that excessive plastic surgery and some other unnecessary current Western therapies are more common now and have resulted in occasional deaths and disfigurement. 

Greed is a strong motivator and is one of the ills pervading our society… and the health care field has not been immune to its seduction.  Greed too often factors into determining the direction of treatment for individuals today.  Corporate greed is the reason insurance companies fail to cover many in need of health care and force physicians to see more patients than they have time to care for.  It is also a reason some providers order and perform some expensive and potentially risky tests and procedures.  

Western Medicine has had its share of iatrogenic disasters, yet I have seen many ill or infertile patients reap the benefits as a result of modern Western Medicine.  Even so, I as well as other physicians am left without answers all too often to explain or cure some of the complaints we hear from our patients.  For this reason I study TCM to learn its explanations and its treatments for some of these common ailments and complaints that elude the expertise of the Western physician.

I have been involved in the health care field for 37 years and I am quite comfortable communicating about pathogens such as bacteria and viruses and parasites and about pathophysiologic processes such as atherosclerotic heart disease, hypertension, diabetes mellitus, pelvic inflammatory disease and endometriosis to name a few.   Today, as I study Traditional Chinese Medicine, I now read and speak an additional language.  

The pathogens of TCM are Wind, Cold, Heat, Summer Heat, Dryness and Dampness, Phlegm and an individual’s emotions.  They may attack from outside the body such as wind cold (the equivalent to the common viral cold) or internally as a result of a disharmony among one or more of the organ systems.  Emotions such as Grief and sadness, anger, fear, worry and even joy according to TCM can be pathogenic when carried to an excess and lead to a disharmony of an organ system or to a blockage of the flow of Qi which can result in dampness and other pathologic events or pathogens. 

These pathogens are the “root” cause of the individual’s disharmony resulting in the manifestations or symptoms.  For example, complaints such as fever, cough, sore throat, vomiting, diarrhea, constipation, bloating, etc. ., are the result of these pathogens.  Interestingly, ancient Chinese texts refer to insects or bugs as being carried by the wind as a cause of some syndromes such as the Wind Cold referred to earlier.

There are also multiple ways to categorize and classify pathologic syndromes. They may be classified as cold or hot, internal or external, excessive or deficient or yin or yang conditions.  They may be identified as affecting one of the organ systems which are defined more based on their physiologic role from a traditional Chinese perspective rather than by their Western anatomic and physiologic identity that we learn in medical school.  There are four different layers of pathogenic attack from the most superficial to the deepest and most internal. There are even other theories of disease which may be used to classify pathology usually described as a disharmony affecting one or more organ systems.

The treatment prescription is based on the identified syndrome(s) and may be geared towards eliminating the root cause of the disease as well as the clinical manifestations and associated symptoms.  One may use acupuncture to tonify a particular weakened organ or Qi, yin or yang.  Acupuncture can eliminate heat or cold from one or more of the channels of Qi.  Or there may be excess body fluids in the form of edema, dampness or phlegm that needs to be eliminated.  Chinese herbal prescriptions are often given as an adjunct to the acupuncture to improve the efficacy of an individual’s treatment.

It does sound bizarre to this Western-trained physician, but I am impressed that the science of TCM has lasted thousands of years.  I imagine there must be something to this needling patients to modify the Qi in the body that has some benefit to the patients’ health and well-being.

I look forward to new adventures and greater understanding as I become more familiar navigating this strange land.

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Do you believe that TCM pathogens could be impacting your fertility?

 

 

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Nutrition, BMI, and Infertility

By Tracey Minella

March 28th, 2014 at 5:38 am

 

credit: surachaifreedigitalphotos.net


The practice of eating well while you’re pregnant is pretty common.  Most women know that, in addition to taking prenatal vitamins, eating the right foods during pregnancy can have a positive impact on their baby’s development. Even women who didn’t have stellar eating habits before conceiving often make healthier choices once they learn they are eating for two.

But did you know that proper nutrition and reaching a healthy weight for your height (also known as having a healthy body mass index, or “BMI”) prior to conceiving may help boost your chances of conception, whether naturally or through assisted reproductive technologies like IVF?

According to the American Society for Reproductive Medicine*, a BMI outside the normal range of 19-24 can impact the fertility of men and women. Obesity can contribute to low sperm count and motility in men and can cause irregular ovulation and irregular cycles in women. Underweight women may also experience irregular cycles or stop having periods altogether. In addition, there are several conditions that can impact achieving or maintaining a pregnancy… including PCOS, thyroid disease, gestational diabetes, and preeclampsia… which are often obesity-related.

To help you get to your nutritional peak and optimum fertility BMI, Long Island IVF offers nutrition counseling and safe, effective weight loss planning. If you are overweight, we can help you reach a healthy weight in a quick but safe way through the Take Shape for Life/Medifast program. In addition to medically- supervised weight loss, clients in the program learn lifestyle and behavior changes that support maintaining their weight loss success and improved health. If you are underweight, we offer nutritional counseling and life style change suggestions as well. If interested in either of these programs, please contact Mary Ann Vuolo, RN in the Melville office.

If you’d like to learn how fun eating fertility-friendly foods can be, join Long Island IVF for “Fun in the Fertile Kitchen”, a live cooking demonstration and multi-course dinner event on April 24, 2014, in celebration of National Infertility Awareness Awareness Week. For more details on this exciting, limited seating event, please see our website, our Facebook, or the previous blog post. To RSVP, contact our patient advocate, Bina Benisch at binabenisch@gmail.com

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Do you struggle with maintaining a healthy BMI? What tips have you tried, or foods have you eaten, to improve your BMI or overall nutrition?

 

*https://www.asrm.org/Weight_and_Fertility_factsheet/

 

 

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My Stork Went South for the Winter

By Tracey Minella

March 13th, 2014 at 7:59 pm

 

credit: njaj/freedigitalphotos.net


I don’t know about you, but I am beyond done with this winter.

A normal, dreary winter is enough to send folks… especially those suffering from infertility… into a serious bout of the blues. And these back-to-back blizzards have been just another reason to climb into bed and hide under the covers. And sulk…justifiably.

Spring coaxes us out of hibernation with warmer air and the promise of new beginnings. Longer daylight hours brighten our moods and invite us back to nature through exercise or gardening. And even those who respectfully decline those invitations are generally less down as the weather warms up.

Now that the clocks have been changed and spring is supposedly on the way, it’s a good time to reassess and possibly recommit to your infertility treatment plan. To do some mental “spring cleaning”. To try to grasp hope if it has eluded you lately.

However, if you’re feeling really depressed, it may be more than the “winter blues”. According to the Mayo Clinic, Seasonal Affective Disorder (SAD), is a type of depression that occurs at the same time every year, usually in the fall through winter months.*

If your depression is persistent or is interfering significantly in your daily life, you might consider group or individual counseling. Long Island IVF offers several therapy options, available to both existing patients and those who are not yet patients. For more information, see the Mind-Body section of our website: http://www.longislandivf.com/mind_body.cfm

 So get outside and take a deep breath. Open the windows and let the stale winter blow away. The buds will be returning to the trees soon.

And maybe that stork will be coming over the horizon soon, too.

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Do you find the winter months to be more depressing? Can you share any tips for how you handle feeling blue? What works for you?

 

*http://mayocl.in/1eigxod

 

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March is Endometriosis Awareness Month

By David Kreiner MD

March 5th, 2014 at 6:35 am

 

credit: wikipedia

 

I don’t have to tell you that endometriosis can be a very painful illness and that it can cause infertility. It is often a reproductive lifelong struggle in which tissue that normally lines the uterus migrates or implants into other parts of the body, most often in the pelvic lining and ovaries. This leads to pain and swelling and often times difficulty conceiving.

If you have endometriosis, you are not alone. Five to ten percent of all women have it. Though many of these women are not infertile, among patients who have infertility, about 30 percent have endometriosis.

Endometriosis can grow like a weed in a garden, irritating the local lining of the pelvic cavity and attaching itself to the ovaries and bowels. Scar tissue often forms where it grows, which can exacerbate the pain and increase the likelihood of infertility. The only way to be sure a woman has endometriosis is to perform a surgical procedure called laparoscopy which allows your physician to look inside the abdominal cavity with a narrow tubular scope. He may be suspicious that you have endometriosis based on your history of very painful menstrual cycles, painful intercourse, etc., or based on your physical examination or ultrasound findings. On an ultrasound, a cyst of endometriosis has a characteristic homogenous appearance showing echoes in the cyst that distinguish it from a normal ovarian follicle. Unlike the corpus luteum (ovulated follicle), its edges are round as opposed to collapsed and irregular in the corpus luteum and the cyst persists after a menses where corpora lutea will resolve each month.

Women with any stage of endometriosis (mild, moderate, or severe) can have severe lower abdominal and pelvic pain – or they might have no pain or symptoms whatsoever. Patients with mild endometriosis will not have a cyst and will have no physical findings on exam or ultrasound. It is thought that infertility caused by mild disease may be chemical in nature perhaps affecting sperm motility, fertilization, embryo development or even implantation perhaps mediated through an autoimmune response.

Moderate and severe endometriosis are, on the other hand, associated with ovarian cysts of endometriosis which contain old blood which turns brown and has the appearance of chocolate. These endometriomata (so called “chocolate cysts”) cause pelvic scarring and distortion of pelvic anatomy. The tubes can become damaged or blocked and the ovaries may become adherent to the uterus, bowel or pelvic side wall. Any of these anatomic distortions can result in infertility. In some cases the tissue including the eggs in the ovaries can be damaged, resulting in diminished ovarian reserve and reduced egg quantity and quality.

The treatment for endometriosis associated with infertility needs to be individualized for each woman. Surgery often provides temporary relief and can improve fertility but rarely is successful in permanently eliminating the endometriosis which typically returns one to two years after resection.

There are no easy answers, and treatment decisions depend on factors such as the severity of the disease and its location in the pelvis, the woman’s age, length of infertility, and the presence of pain or other symptoms.

Treatment for Mild Endometriosis

Medical (drug) treatment can suppress endometriosis and relieve the associated pain in many women. Surgical removal of lesions by laparoscopy might also reduce the pain temporarily.
However, several well-controlled studies
 have shown that neither medical nor surgical treatment for mild endometriosis will improve pregnancy rates for infertile women as compared to expectant management (no treatment). For treatment of infertility associated with mild to moderate endometriosis, ovulation induction with intrauterine insemination (IUI) has a reasonable chance to result in pregnancy if no other infertility factors are present. If this is not effective after about three – six cycles (maximum), then I would recommend proceeding with in vitro fertilization (IVF).

Treatment for Severe Endometriosis

Several studies have shown that medical treatment for severe endometriosis does not improve pregnancy rates for infertile women. Some studies have shown that surgical treatment of severe endometriosis does improve the chances for pregnancy as compared to no treatment. However, the pregnancy rates remain low after surgery, perhaps no better than two percent per month.

Some physicians advocate medical suppression with a GnRH-agonist such as Lupron for up to six months after surgery for severe endometriosis before attempting conception. Although at least one published study found this to improve pregnancy rates as compared to surgery alone, other studies have shown it to be of no benefit. The older a patient is, the more problematic post surgical treatment with Lupron will be as it delays a woman’s attempt to conceive until she is even older and less fertile due to aging Unfortunately, the infertility in women with severe endometriosis is often resistant to treatment with ovarian stimulation plus IUI as the pelvic anatomy is very distorted. These women will often require IVF in order to conceive.

Recommendations

As endometriosis is a progressive destructive disorder that will lead to diminished ovarian reserve if left unchecked, it is vital to undergo a regular fertility screen annually and to consider moving up your plans to start a family before your ovaries become too egg depleted. When ready to conceive, I recommend that you proceed aggressively to the most effective and efficient therapy possible.

Women with endometriosis and infertility are unfortunately in a race to get pregnant before the endometriosis destroys too much ovarian tissue and achieving a pregnancy with their own eggs becomes impossible. However, if you are proactive and do not significantly delay in aggressively proceeding with your family building, then I have every expectation that you will be successful in your efforts to become a mom.

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Do you suffer from endometriosis?

 

Photo credit: http://en.wikipedia.org/wiki/File:Endometriosis,_abdominal_wall.jpg

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