Fertility Cares

A blog with advice, guidance and updates on fertility care

02.03.2012
Should You Get the Influenza Vaccine During Infertility Treatment?

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Many people being treated for infertility are unsure whether to get the “Flu Shot.”  During the 2012 influenza season both the Centers for Disease Control (CDC) and the National Health Department of Health and Human Services (NH DHHS), Division of Public Health Services continue to have a universal recommendation for influenza vaccination to anyone over six months of age in the absence of medical contraindications. Medical contraindications include: history of severe allergic reaction to a prior influenza vaccination; persons who developed Guillain Barre Syndrome (a rare disorder that causes your immune system to attack your peripheral nervous system) within 6 weeks of receiving a prior influenza vaccine; and people with a severe egg allergy.

The above agencies and the American College of Obstetrics and Gynecology and the American Society for Reproductive Medicine endorse that all pregnant women and those contemplating pregnancy be vaccinated against influenza. However, you should not take the version of the vaccine given in a nasal spray as it contains a live albeit attenuated form of the virus. You should only take the vaccine made from ‘killed’ virus because of the chance of catching the flu from an attenuated vaccine and the side effects and danger of a pregnant woman with the flu are more of a health risk than getting vaccinated. 

 

 

So, no matter how you get pregnant, the consensus from all governmental agencies and medical societies is that vaccination with ‘killed’ virus against influenza offers you and your baby the best chance of staying healthy during flu season.
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01.26.2012
Pregnant or Not Pregnant? That is the Question

Danielle Vitiello, Ph.D., M.D. Board-Eligible Reproductive Endocrinologist

Danielle Vitiello, Ph.D., M.D. Board-Eligible Reproductive Endocrinologist

Fertility treatments allow patients to be empowered and to regain hope.  Once the patient has engaged in treatment, the two-week wait prior to pregnancy confirmation can be unbearable.

Not surprisingly, patients search for both emotional and physical signs to affirm or deny the potential of pregnancy; all while watching the calendar turn at a turtle’s pace.  One becomes hyperaware of weight, the body’s reaction to elevating progesterone and the psychologic stress involved.  The amount of rent-free brain space afforded to becoming pregnancy often is greater than prior to presenting to the fertility center to initiate treatment.

This two-week time between anticipated fertilization and pregnancy test is related to biology.  Once the embryo is created from fertilization of the egg by the sperm, the embryo must develop.  As it develops, the implanting blastocyst (stage of embryo development) becomes more specialized forming both the fetus and the placenta.  This placental tissue much reach a critical mass as it is releasing pregnancy hormone into the maternal circulation.  Pregnancy hormone is hCG (human chorionic gonadotropin).  Patients return to the center on one of the first days that this level can be detected accurately.

We recommend that patients refrain from performing home pregnancy tests as they are not as sensitive as blood levels and can render both false-positive as well as false-negative results; thus, they can provide more angst than affirmation.

Pregnancy hormone, along with progesterone (natural and supplemented) causes very rapid transitions in the women’s body in preparation for providing the most accommodating environment for the pregnancy.   Some women perceive these changes and some do not.

They symptoms can include a perception in ability in changes in respiratory rate – pregnant women tend to breathe more rapidly with more shallow breathes; Bloating and constipation can be an issue – intestinal motility slows so maximal nutrition can be pulled from the gut.   Breast soreness and tenderness is a direct effect from progesterone exposure and it is exceedingly difficult to make it not noticeable.  Having more symptoms does not mean that pregnancy did not occur.  Ironically, many women are more hopeful the more uncomfortable they become.

One of the best ways to get through this time is to keep one occupied.  A calendar with daily projects and activities will help to pass the time.  Women should continue their healthful diets and ways as well continue to take their prenatal vitamins as discussed previously with their health care teams.  Remember, healthy mothers make healthy babies.

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01.19.2012
Male Fertility: The Other Half

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Approximately 40% of infertility is related to the male.  Key to understanding male fertility is analysis of the semen.  Semen samples can vary from month to month, or even day to day because it takes about 72 days for sperm to develop within the testicles. Unlike eggs, which are present since you were born, sperm are made all the time following puberty.  Since men are producing sperm all of the time and  since illnesses, injuries, medications, or illicit drug use a few months before could make one sample abnormal, a repeat semen analysis three weeks later should be done.

Sometimes a semen analysis shows a low number of sperm which is less than 20 million and is called oligospermia. If no sperm are found , it’s called azoospermia. When sperm do not swim very well, this condition is called asthenospermia. Sometimes there are a lot of moving sperm, but the sperm themselves look abnormal.  Abnormal sperm morphology (what the sperm look like) is the most sensitive indicator of whether a man will get their partner pregnant the old fashion way.  In spite of their small size, sperm have three distinct regions: the head, neck or mid-piece, and tail.  An abnormality in any of these sections can cause infertility. The head of the sperm contains the genetic material (DNA) needed to make a baby. If the head is abnormally  shaped, fertilization may be impaired and if fertilization is able to occur, an abnormal embryo may result not capable of implantation or making a baby.  The mid-piece of the sperm contains the energy producing organelles enabling the sperm to get to an egg and the tail of the sperm makes the sperm move rapidly through the maze of the female reproductive tract.

There are two ways of determining sperm morphology: an out-dated method using criteria established by the World Health Organization (WHO) in the 1970’s and is still used in most hospitals and path-labs; and Kruger morphology using ‘strict criteria’ which is used by the best fertility centers.  Studies using ‘strict criteria’ morphology assessment have been correlated with fertilization in IVF. Men with greater than 14% normal appearing sperm had normal fertilization rates, while men with intermediate morphology (between 4-14%) had intermediate fertilization.  Men with less than 4% normal looking sperm had only an 8% chance of achieving fertilization using standard insemination techniques (one egg per 10,000 sperm). Less than 4% normal morphology is called teratospermia. Successful pregnancies can  be achieved especially when using IVF together with Intracytoplasmic Sperm Injection or ICSI. This is when one sperm is injected per egg using a microscopic techniques.

The identification of sperm morphology using Kruger’s ‘strict criteria’ is an integral part of the semen analysis and hence the most important part of the evaluation of male fertility. So make sure that your physician uses this test when doing a semen analysis. In this way the most likely treatment to help you have a baby can be done.

 

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01.12.2012
Diet and Lifestyle Issues While Attempting to Conceive

Robert M. Weiss, M.D. Board-Certified Reproductive Endocrinologist

Robert M. Weiss, M.D. Board-Certified Reproductive Endocrinologist

Although a healthy lifestyle, including exercise and proper diet, is important for general health, it is not necessary to abstain completely from caffeine and alcohol while trying to conceive. On the other hand, extremes of weight and cigarette smoking have been shown to be detrimental to people trying to conceive.

Caffeine
Studies have shown that small amounts of caffeine are not necessarily detrimental to conceiving. Caffeine intake of up to one-to two cups of coffee per day has not been shown to decrease fertility. However, caffeine consumption greater than five cups of coffee per day has been associated with decreased fertility up to 50%. Also, consumption of 2-3 cups of coffee per day has been associated with an increased likelihood of miscarriage but does not affect risk of congenital anomalies. In summary, women who consume 1-1.5 cups of coffee per day, before and during pregnancy, should experience no adverse effects on fertility or pregnancy outcome.

Alcohol
Small amounts of alcohol prior to conception, up to 3-4 glasses per week, have also not been shown to decrease a woman’s fertility. Greater than two alcoholic drinks per day has been shown to decrease fertility in women. Certainly, once a woman believes she may be pregnant, she should, without question, abstain from all alcohol intake.

Patients who consume more than the above recommended amount of caffeine or alcohol should decrease their intake. However, it not necessary to bring intake of caffeine and alcohol down to zero.

Diet and Weight
Women who are significantly underweight (BMI<19) and women who are significantly overweight (BMI>35) will experience a 2-4 fold increase in time to conception. However, there is little evidence that specific dietary variations, such as low-fat diets, or vegetarianism, affect fertility. Women attempting to conceive should take 400 micrograms of folic acid. This is to reduce the risk of neural tube defects in the fetus. To calculate your own BMI, go to this link: http://www.nhlbisupport.com/bmi/.

Smoking
Smoking (even small amounts) has substantial negative effects on fertility. Women who smoke cigarettes have a 60% increased risk of infertility, as well as an increased risk of miscarriage. Additionally, women who smoke cigarettes go through menopause an average of 1-4 years earlier compared with women who do not smoke.  Smoking cigarettes appears to cause increased loss of healthy eggs. Smoking marijuana seems to have similar negative effects on fertility.

Men
When it comes to men attempting to conceive, small amounts of alcohol and caffeine use do not appear to adversely effect sperm parameters (density, motility, and abnormalities in morphology). However, cigarette smoking and marijuana use have been shown to decrease all sperm parameters. Severly overwight men also have decreased sperm parameters and decreased fertility.

In Sum
As Aristotle  wrote 2,500 years ago, “Everything in Moderation”: there is no need to be an ascetic while trying to conceive.

For more information, click here.

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01.05.2012
Cell Phones and Infertility: Is it Time to Hang Up the Phone?

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Cell phones are an everyday part of life. The advances in technology enabling not only voice communication but most recently high resolution pictures and internet access have been accompanied by increased intensity and frequency of electromagnetic waves being emitted. Our bodies receive these waves and convert them into both electric and magnetic fields.  Adverse biological interactions attributable to cell phone-emitted radiation have been made. Reproductive cells, sperm and eggs, are electrically active cells and their exposure to cell phone electromagnetic waves and currents have been postulated to affect reproductive function.  Evidence for the adverse effects of cell phones on fertility comes from both animal and in vitro (laboratory) studies.  While these studies may be different from in vivo human exposure, clinical correlations, especially with abnormal sperm parameters and function, have been made. Until further studies and performed and reported in humans, warnings regarding further increase in the power density of emitted cell phone radiation should be heeded. Simple measures one may incorporate to minimize the impact of exposure include: use a land line whenever possible; use a speaker phone when possible; hold the phone well away from your body when sending a text or viewing images; avoid sleeping with the phone close to you; avoid wearing the phone on your body; and purchase a low radiation model and network.

Cell phone technology will undoubtedly continue to advance with more innovative and expansive services and newer and better products. Consumers need to be aware of the potential for adverse biological effects of this ever expanding technology so that proper precautions can be taken.

 

 

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12.29.2011
The Role of Tubal Reconstructive Surgery in the Era of IVF

Danielle Vitiello, Ph.D., M.D. Board-Eligible Reproductive Endocrinologist

Danielle Vitiello, Ph.D., M.D. Board-Eligible Reproductive Endocrinologist

Over the last few years, the ease, accessibility and efficacy of IVF has increased dramatically.  The success of tubal reconstructive surgery has remained relatively stable although the invasiveness of the surgery decreases.  Such divergence between IVF success and need for surgical involvement calls for a reassessment of a cost/risk to benefit ratio whether it may be more efficacious to repair the fallopian tubes or to pursue IVF.

Regardless of age, prior to making the commitment to moving forward, one should undergo a complete infertility evaluation to eliminate the possibility of coexistent infertility factors.   Laparascopy is the gold standard to asses the candidacy for tubal repair.  Although hysterosalpingogram (HSG) is relatively simple, it  does not afford the same information as surgical assessment.

Furthermore, it is difficult to compare success rates achieved comparing IVF to tubal repair.  IVF success rates are measured  and evaluated according to embryo transfer per cycle.  In contrast, after surgical repair, there is no time-dependent modicum to assess pregnancy rates and often are tabulated on a yearly basis.

In general, repair for damage within the structure of the fallopian tubes affords modest pregnancy rates (10-60%) with ectopic rates as high at 20%.  However, in more favorable instances, such as reversal of  elective sterilization procedures (tubal ligation),  cumulative pregnancy rates can be as high as 80%.

Whether IVF is more cost-effective or not remains uncertain.  Because there are no randomized controlled trials, the best therapy is both difficult and individualized.   Factors to be discussed with patients contemplating reversal include maternal age, risk of multiple pregnancy, procedure and risk of ectopic pregnancy.  Micosurgical tubal anastomosis and IVF remain viable options.

Tubal anastomosis is appealing to those who desire reversal or are not comfortable with IVF.  The need for major surgery, potential complications and resultant, eventual need for contraception are distinct disadvantages.  In women under the age of 35, this reconstructive procedure is a legitimate choice.  However, and predictably, a lower success rate occurs in aging women and those women may glean a distinct advantage from assisted reproductive technologies.

 

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12.22.2011
Genetic Disease – Spinal Muscular Atrophy (SMA)

R. Ian Hardy, M.D., Ph.D. Board-Certified Reproductive Endocrinologist, Medical Director

R. Ian Hardy, M.D., Ph.D. Board-Certified Reproductive Endocrinologist, Medical Director

Spinal muscular atrophy (SMA) is an inherited disease that affects an infant’s muscular activity.  Voluntary muscles are driven by motor neurons.  Children with SMA are missing a gene that is required to produce certain proteins involved in motor neuron development.  Without this protein, the nerves shrink and ultimately atrophy.  Without motor neuron innervation, the muscles then degenerate or atrophy.  Infants with Type I SMA will have difficulty raising their head, kicking their legs and even smiling.  The child’s brain is unaffected and children with SMA are of normal intelligence.  They are aware of their difficulties.  Normal body functions like swallowing and breathing are also affected.  Without the ability to swallow, a feeding tube is required to prevent starvation.  With progressive atrophy, the muscles involved in breathing are affected and a parent must make the difficult decision to place the child on permanent ventilation for life support.  The average lifespan of a child with SMA Type I is only 8 months of age, with 80% dying by the age of one, and the majority thereafter dying by two years of age.

SMA is an autosomal recessive genetic disease.  One in 35 Caucasians carries the SMA gene; one in 53 Asians and one in 66 African Americans carry the SMA gene.  The disease can only be acquired if both parents carry the gene and then the risk of having a child with SMA is 1 in 4.  The 1 in 35 simply carrying the recessive gene alone will not have the disease or any associated symptoms.  The statistical odds that both parents carry SMA = 35 x 35 = 1 in 1225 couples.

Although the odds that both parents carry the gene is low at 1 in 1225, the Fertility Centers of New England strives to reduce this risk to zero.  The Centers’ goal is not just to achieve pregnancy but to achieve a healthy pregnancy and child.  To undergo the rigors of fertility treatment without awareness of the genetic risk can be stressful and does not take advantage of the current screening technologies.  From a simple saliva sample, patients can be pre-screened and be fully aware of their genetic risks.  Those couples shown to both be carriers of an autosomal recessive trait, including SMA and others, may proceed with preimplantation genetic diagnosis (PGD) of their embryos.  Healthy embryos diagnosed not to carry the gene are then transferred for pregnancy.

Physicians at the Fertility Centers of New England are available to further discuss pre-conception genetic screening.  Further information on SMA can also be found here.

 

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12.15.2011
Eat for Fertility

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

Joseph A. Hill, III, M.D. Board-Certified in Reproductive Endocrinology and Infertility

A traditional Western-type diet composed of a high consumption of trans unsaturated fats, animal proteins and carbohydrates with a high sugar content has been associated with a risk for cancer, cardiovascular disease, obesity, and diabetes. Insulin resistance is also increased and is implicated in ovulation dysfunction in women with PCOS and with infertility and recurrent pregnancy loss.  A recent study from Spain (Fertil Steril 2011:96:1149-53) reported a much lower chance of infertility in women eating a Mediterranean-type diet compared to those eating a more typical Western-type diet.  Investigators from the Netherlands have found that a preconception Mediterranean-type diet to be associated with a 40% increased probability of success in achieving pregnancy among couples having in vitro fertilization  (Fertil Steril 2010:94:2096-101).  These two studies provide evidence that the Mediterranean-type diet may be  an efficient and healthy alternative means of enhancing fertility.

The key component of a Mediterranean-type diet is replacing animal proteins, trans unsaturated fats, sugar, and refined foods with primarily plant based foods such as fruits, vegetables, whole grains, legumes, and nuts.  Simple measures you can do to potentially enhance your fertility include:

1)      Replacing butter with healthier fats like olive oil and canola oil;

2)      Using herbs and spices instead of salt to flavor foods;

3)      Limiting red meat to no more than a few times a month;

4)      Eating fish and poultry at least two times a week; and

5)      Drinking red wine in moderation.

Choosing a healthy diet is one component of living a healthier  life style that can minimize your risk for life threatening diseases and also enable you to eat for fertility.

 

 

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12.09.2011
What Are the Risks with IVF?

Danielle Vitiello, Ph.D., M.D. Board-Eligible Reproductive Endocrinologist

Danielle Vitiello, Ph.D., M.D. Board-Eligible Reproductive Endocrinologist

What are the true risks of in vitro fertilization?

Often thought as “the great equalizer”, the internet is information-laden. However, not all sources are equitable.  Deciphering amongst myth, opinion and truth, particularly in the field of Assisted Reproductive Technologies (ART) can be complicated and equally frustrating.

When one is contemplating whether IVF is suitable for their circumstance, it is important to understand true risks.  These data were by Sutcliffe et. Al.  Outcome of assisted reproduction. Lancet 2007; 370: 351-9.

The greatest risk is multiple births. Yes, there has most definitely been an increase in the number of twins and higher order multiples (triplets and quadruplets) over the initial years of instituting these technologies.  In 2007, our governing body , ASRM (American Society of Reproductive Medicine), published guidelines with regard to the number of embryos recommended for transfer.  However, prior to this publication, a move to reduce the number of embryos transferred had started.  As a result, the twin rate, and in particular, higher-order multiple-rate has decreased.

A second concern is that the miscarriage rate seems to be slightly increased when compared to spontaneously conceived pregnancy.  It is possible that this increase may be biased partially.  It may be that with IVF, exact timing is monitored; therefore, those women who have transient demonstrations of pregnancy hormone (biochemical pregnancies) may be registered whereas in naturally-conceived pregnancies, the woman may not even have realized that she was transiently-pregnant.  Or, perhaps, IVF made it possible to achieve a pregnancy that may not have occurred naturally.

Thirdly, there seems to be a slight increase in numeric sex-chromosome abnormalities with injecting of the sperm into the oocyte (ICSI) (0.6% vs 0.2%).

However, it must be noted that to be a medical candidate for ICSI, there is often an underlying issue regarding subfertility at the level of sperm function. Therefore, these same issues causing the infertility, may very well play a part in how the chromosomes come together to form the developing embryo.  It should be noted that there are other medical conditions that have much higher predispositions to such chromosomal rearrangements.  In particular, a women with Diabetes Mellitus demonstrates a greater of an offspring with such an issue in comparison to the minute risk of ICSI (<1%).

Risks of preeclampsia, slightly smaller infants and pre term delivery increase.  In part, these risk increases may be related directly to multiple gestation.  For instance, twins are more likely to deliver earlier and be slightly smaller than their singleton counterpart.

It is important also to look at the long term data regarding how ART babies fair.

Neurodevelopmentally mature-term babies born after ART progress equally as well as those children that are the result of a spontaneously conceived pregnancy.  To those couples who are candidates for IVF, the benefits of ART greatly outweigh the risks and may be the only chance to have a baby.


 

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12.01.2011
Chronic Endometritis

R. Ian Hardy, M.D., Ph.D. Board-Certified Reproductive Endocrinologist, Medical Director

R. Ian Hardy, M.D., Ph.D. Board-Certified Reproductive Endocrinologist, Medical Director

Chronic endometritis is chronic inflammation (“itis”) of the endometrium (the uterine lining).  Chronic inflammation may hinder normal implantation of an embryo and its subsequent development. A patient with good embryo morphologic quality with either a negative pregnancy or with an early miscarriage may be evaluated for chronic endometritis before proceeding with further treatment.

Evaluation of chronic endometritis is typically a microscopic or histologic diagnosis.  A sample of the endometrium is obtained either by an office biopsy or during a hysteroscopy procedure.  Under the microscope, the endometrial sample can be stained and analyzed for chronic inflammatory immune cells, known as plasma cells.  An endometrial sample full of plasma cells is consistent with chronic endometritis.  Vaginal or cervical cultures have shown not to be a reliable indicator of chronic endometritis.  In one study of 910 women (J Minim Invasive Gynecol 12(6):514-8), chronic endometritis was found in 30% of infertile women and 35% of cases related to abnormal uterine bleeding.

There are several causes for endometritis; most involve a low grade infection.  The cervix or opening to a woman’s uterus usually prevents bacteria from migrating to the endometrial cavity.  Intrauterine insemination or embryo transfer catheters bypass the cervical gatekeeper and may introduce infection.  If a patient is miscarrying, the cervix may dilate to permit evacuation of the miscarriage tissue but in so doing allow bacterial contamination.  Chronic retained products of pregnancy may also be associated with infection.

Treatment consists of removing the source of infection (commonly chronic retained placental tissue) followed by a short course of antibiotics.  In some cases, a “proof of cure” repeat endometrial biopsy will be performed after completing antibiotics to ensure a normal endometrium.  Empiric use of antibiotics is often used near the time of an embryo transfer to rule out any minimal endometritis during implantation.

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