Here is a link to this free blog post:

http://cnyfertility.com/2013/01/17/intra-uterine-hcg-at-embryo-transfer-jump-starting-the-implantation-process

I so enjoy writing and having this venue to share emerging evidence-based research in the field of reproductive medicine. In order to more efficiently balance my responsibilities to my patients as well as my readers, I will continue to reach out in this fashion. Starting this month however, I will be posting a title and excerpt in this blog with a link to the full post. That link will take you to the remainder of the post (free service that we offer to our patients– http://cnyfertility.com/blogs ). I truly hope you don’t find this to be inconvenient and I look forward to sharing more useful and practical information with you.
Best thoughts,
~Robert

Robert Greene, MD, FACOG
CNY Fertility Center
e-mail me at rgreene@cnyfertility.com
Call our toll-free number at 800.539.9870 or request a consult here.

One of the greatest challenges in reproductive medicine is trying to figure out ways to improve pregnancy rates for women that produce a limited number of eggs. Other posts on this blog[u1]  address various steps to try to optimize/improve egg quality[u2] . But new data suggests that the use of intracytoplasmic sperm injection (ICSI) can improve embryo formation and more importantly increase a woman’s chance of becoming pregnant. Traditionally, ICSI has been used to overcome male factor infertility. Over the last several years, some centers have included it in all of their treatment cycles as a means of maximizing fertilization. Some experts criticized this practice since it was based upon a theory rather than clinical proof of an improved outcome. In fact, the American Society for Reproductive Medicine has a Patient Fact Sheet [u3] that describes the guidelines for the use of ICSI (last revised in 2008). Recently a large study attempted to settle this debate on whether or not ICSI should be used in women considered to be “poor responders” to fertility therapy.

One of the limitations of previous studies on “diminished ovarian reserve (DOR)” was the lack of an agreed upon definition of how to diagnose this condition. In 2011 an international meeting was held to form a consensus [u4] on the identification of “poor response to ovarian stimulation.” Their goal was to improve the design of future studies and provide practical guidelines as well as assist doctors in the diagnosis of this condition. To meet diagnostic criteria it was agreed that a woman must have at least two of the following:

  • 40+ years of age or any other risk factor for poor ovarian response
  • A previous cycle producing  3 (or fewer) eggs with a conventional protocol (excludes Mini IVF)
  • An abnormal ovarian reserve test (i.e., AMH [u5] below the age- related norms)

The recent study [u6] referred to in this blog post followed over 1000 IVF patients that had failed on a previous cycle and met the new criteria for “poor responders.” These patient/couples completed nearly 3000 total cycles of IVF with ICSI. They found that including ICSI—despite a normal sperm count—improved the ongoing pregnancy rate by 40%. Another noteworthy fact is that this study was performed in Israel where IVF is a fully covered health benefit for all citizens. This made it possible for patients to continue treatment without concern of cost thereby removing a “selection bias.” The potential benefit of ICSI—in the absence of a male factor—does make sense. Some studies show that women with DOR have a thicker coating on the egg making it more difficult for a healthy sperm to enter. Selecting a sperm for use in ICSI may also reduce the possibility of an abnormal sperm fertilizing an otherwise limited number of healthy eggs. Whatever the reason, most women with a poor response to fertilization are immediately directed to use donor eggs. However, this study found that ~35% of these “poor responders” achieved a successful pregnancy within 5 to 7 IVF attempts. The bottom line is that couples that would otherwise have been discouraged from completing a second attempt went on to have a baby at least 1/3 of the time.

So discuss with your doctor whether or not you may benefit from including ICSI in your next IVF cycle. In doing so, be careful to ask if there is an additional charge for this service. At CNY Fertility[r7]  Center, we are pleased to offer this augmented fertilization technique to all of our patients as part of the standard IVF cycle (included in the standard fee). Now we have more data supporting this recommendation.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.

Our society puts a priority on reproduction. That makes sense since it is hardwired into our brain. Unfortunately, that value often results in the assumption that women that choose to wait and begin their family later in life are somehow selfish or narcissistic for “wanting to have it all.” I am pleased to share that a recent report made great strides in dispelling this myth.

A British psychologist recently performed a thorough review [r1] of women’s motivations and situations resulting in “delayed motherhood.” In fact, she even took exception with the term “delayed” because it so strongly suggests that it is a choice that women are consciously making to wait until their late thirties or early forties to become pregnant. Instead, she found that it more often women are responding to their situation. Her research revealed that many women today are having babies later as a result of strategic decision making, extensive negotiations or response to their life’s circumstances. Better still women today have more options to preserve their fertility.

Techniques [r2] are available today to more efficiently freeze and store unfertilized eggs or viable embryos. Embryo freezing has been available for several decades but the efficiency of the process is much greater today. Egg freezing now makes it possible for women to preserve their unfertilized eggs when they are more plentiful and at their healthiest but actually delay fertilization and pregnancy until the time is right. Recently, the technique for freezing unfertilized eggs has been refined so much and the availability of the procedure [r3] has become so readily available that it is no longer considered experimental. So as more women speak out [r4] about their own choices and empower others to do so, it is rewarding to be able to meet their needs with more treatment options.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.

In medicine, well intended advice often proves wrong. Sometimes, such recommendations are repeated for years until we lose sight of the where/how the ideas originated. It then takes well documented research to retract the outdated ideas—even then correction is often resisted. An example is the frequently repeated advice that women allergic to seafood should not undergo a hysterosalpingogram (HSG). This rationalization is due to the fear that the iodine-containing contrast that is used to perform the test may provoke a reaction in sensitized patients[r1] .

Food allergies occur in about 4% of the population[r2] . Seafood is among the most common of the foods that people are allergic to. Shellfish and seaweed are the most common foods that contain high levels of iodine. That fact aside, it is difficult to establish how the concern between seafood allergy and iodine first originated. True allergies result when your immune cells react to a protein—not a mineral like iodine—by producing antibodies. These antibodies can then create a reaction upon repeat exposures to the allergen (protein that the person is allergic to). A true seafood allergy is typically a response to a protein called tropomyosin. There is no tropomyosin in the HSG contrast.  Therefore, a classical allergic effect isn’t possible.

A recent review [r3] of the medical literature confirmed that the actual risk of a reaction to the contrast is rare. In fact, the odds of a severe reaction were far less than 1% (0.02-0.5%). So given the importance of the information obtained by performing an HSG, most patients benefit from this part of the infertility evaluation.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.

 


One of the most challenging aspects of infertility care is helping couples understand why they have not yet become pregnant. About 20-30% of couples will have no definitive diagnosis after completing a standard infertility evaluation[r1] .  In today’s fast-paced treatment paradigm, some patients prefer to move forward with treatment without further clarification. Although oftentimes appropriate, this strategy should not be applied to every patient/couple. Laparoscopy and hysteroscopy are minimally invasive, out-patient surgeries [r2] that can provide a diagnosis and sometimes even offer improved pregnancy rates if scar tissue or endometriosis is found and treated at the time of surgery.

Women with infertility are about eight times more likely to have endometriosis than women that have been pregnant. Treatment of endometriosis can not only reduce pain but also improve pregnancy rates as well. In fact, a large, randomized meta-analysis[r3]  of the available research found that treating endometriosis was associated with about a 60% increase in the chance for a successful pregnancy. Additionally, if there is scar tissue preventing the egg from reaching the fallopian tubes this can also be identified and treated. So consideration of diagnostic surgical procedures can be beneficial. The challenge is in deciding which patients should pursue this option further.

A more recent study [r4] investigated the usefulness of these diagnostic surgical procedures from a financial perspective. They found that laparoscopy was cost-effective in improving pregnancy rates/outcomes based upon many factors including the potential impact of endometriosis. Finally, they also found that undergoing diagnostic surgery was associated with a lower rate of patients “dropping out” of fertility treatment before becoming pregnant. This suggests that having all of the information available prior to treatment is preferred by some couples experiencing infertility. In summary, if you are having trouble conceiving and want more information, minimally invasive surgery may be your best next step.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.

It’s never easy to reverse a long held opinion. But in order to keep improving what we do, we must be open-minded to change. I remind myself of this perspective whenever I encounter a new study that contradicts a long held belief. Recently, I started reconsidering my skepticism on “scratching” or taking an endometrial biopsy in order to better prepare a woman’s uterus for embryo implantation.

The way I was trained, it was imperative that we perform an embryo transfer without causing any trauma to the endometrial lining. Oftentimes we worked through difficult transfers in order to minimize the risk of getting a spot of blood on the catheter as it was felt to be an ominous sign. Blood on the catheter tip was believed to reduce the chance for successful implantation. Recent studies suggest that in some cases the opposite may be true. Let’s first consider the theory behind this potential benefit.

Following any damage to the endometrial lining, chemicals called cytokines are released which promote healing of the injury. This healing process promotes what is called decidualization which also encourages implantation. Decidualization can also help slow the changes that are occurring in the endometrium—another benefit since the hormone levels associated with IVF can accelerate endometrial growth and therefore make the uterine lining out of synch with the actual embryo development. Whether some or all of these changes are responsible there have been a few studies now that have looked at the impact that inducing an endometrial injury can have upon embryo implantation.

A recent review [r1] of the five published studies on the effects of performing an endometrial biopsy prior to or during and IVF cycle was even more revealing. They found that four of these studies demonstrated that endometrial biopsy significantly improved implantation—suggesting that in some patients it may even double success rates. They also found that the timing of the biopsy was critical. In the one study[r2]  that involved performing the biopsy on the day of the egg retrieval, they found a dramatic reduction in the implantation and on-going pregnancy rate; an observation that validates my previous doubts about “scratching” the endometrium. So before you request this treatment consider the following:

  • Discuss with your doctor whether you may have had an implantation problem or if your previous unsuccessful cycles were due to poor embryo quality.
  • Request this procedure be performed before the menstrual cycle of the month you wish to proceed with IVF (prior to starting ovarian stimulation meds)
  • Endometrial biopsy can be uncomfortable so consider the use of an anti-inflammatory about an hour or so before your procedure

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at rgreene@cnyfertility.com

Call our toll-free number at 800.539.9870 or request a consult here.

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