Thursday, November 6, 2008
The Infertility Diaries
I am now the on-call fertility expert for Redbook blog, The Infertility Diaries. View posts and answers to key infertility questions every Wednesday, at Wisdom from Wisot Wednesdays.
Tuesday, November 4, 2008
Fertility After Forty
More than 15 percent of couples in the reproductive age group in the U.S. have difficulty conceiving a child. The tendency to delay childbearing in order to pursue an education and career has meant that more women in their late 30s and early 40s are attempting conception for the first time. Studies have demonstrated that almost 50% of women over the age of 40 will experience infertility. Because fertility in women decreases with advancing age, prompt evaluation and aggressive treatment are critical in infertile women close to or over the age of 40.
Numerous demographic studies suggest a consistent decline in fecundity (the chance to conceive in any given month) with increasing age. The average 25 year old woman who is trying to conceive may have a 25% per month chance of conceiving if all fertility factors are optimal. Compare this with the 5% per month chance for conception of the average 40 year old woman. This age associated decline in live births is due largely to abnormalities in the egg. The meiotic spindle, which helps the chromosomes segregate for cell division, exhibits abnormalities in chromosome alignment. This high rate of abnormal chromosome distribution is the major factor that can explain a lower rate of successful pregnancies in older women. In addition to decreasing fecundity, older women experience an increasing incidence of miscarriage. Women over age 40 have approximately a one in three chance of having a miscarriage in any given pregnancy. In addition, at age 40 one in sixty live births is genetically abnormal.
With this in mind, it seems reasonable to promptly evaluate women over 40 who are concerned about fertility. Before starting an evaluation, however, it is important to discuss some of the special considerations for the woman over 40 trying to conceive. These include general health issues, since women over 40 are more likely to have medical problems including diabetes, hypertension, heart disease, all of which can complicate a pregnancy. Therefore, we recommend that an over 40-year-old woman contemplating a pregnancy have a thorough medical evaluation, including a mammogram. The increased incidence of genetic abnormalities in infants born to women over age 40 and the recommendation for prenatal genetic diagnosis should also be discussed.
Patient Evaluation
The usual trial period of one year of attempting conception prior to an infertility evaluation is not appropriate for women who are close to forty years old.
A basic infertility evaluation is indicated for any couple who have been attempting conception for six months if the woman is approaching 40. First, an infertility history should include how long the couple has been trying to conceive, method of timing and the frequency of intercourse, as well as questions regarding menstrual regularity, premenstrual symptoms, and any prior pregnancies. Factors suggesting problems with the patient’s fallopian tubes, such as a history of sexually transmitted diseases, IUD use, or pelvic infection, should be noted, as well as any previous cervical procedures such as cryotherapy or conization. In addition, the patient should be asked about early menopausal symptoms.
Laboratory and other tests should include:
• A semen analysis for the patient's partner.
• Evaluation of ovulation: basal body temperature charts, a midluteal serum progesterone level, a urine luteinizing hormone ( L H ) t e s t using an ovulation predictor kit, or ultrasound monitoring of follicular development.
• An evaluation of the patient’s fallopian tubes and uterine cavity with a hysterosalpingogram.
• Evaluation of ovarian reserve (see below) Ovarian Reserve
Studies suggest that a woman's chronologic age and her ovarian reserve are independent predictors of fertility. Ovarian reserve describes a woman’s reproductive potential with respect to egg quantity and quality.
Perhaps the best method we have readily available to measure ovarian reserve is a cycle day 2 or 3 blood FSH (Follicle Stimulating Hormone) level and an estradiol (estrogen) level. This measurement may be very important in evaluating how aggressively to treat women approaching the age of 40 and also to give that woman a realistic idea of her chance for a successful pregnancy. The levels of FSH that are considered in the normal range are dependent on the lab where the test is performed. With modern techniques for measuring FSH, generally, a level of less than 10 is good, 10-14 borderline, and 15+ suggests a very low chance for successful pregnancy with fertility treatment with a woman’s own eggs. A single elevated FSH level predicts a poor prognosis even when subsequent FSH levels are normal. In women with a normal FSH, a Clomiphene
Challenge Test may provide more information about a patient’s ovarian reserve than a day 3 FSH level. Blood testing is done on day 3 for FSH & estradiol, clomiphene 100 mg day is taken on days 5-9, and a blood test for FSH level is taken on day 10. Elevation of either FSH level (day 3 or day 10) is a poor prognostic sign. Also a cycle day 3 estradiol level above 70 may suggest a lower chance for success. In a general infertility population an abnormal clomiphene challenge test predicts that a successful pregnancy will be achieved only about five percent of the time. Risk factors for early loss of ovarian reserve include smoking, family history of early menopause, shortening menstrual cycle interval and previous ovarian surgery.
The basic evaluation can be performed over a period of one month in women approaching 40 years of age, rather than spreading it over a number of cycles. Any abnormalities that are uncovered in the basic evaluation should be corrected promptly. If the evaluation is normal, or if abnormalities have been corrected and the patient still does not conceive in a short period of time, aggressive therapy is indicated. It may be difficult to convince a couple that has been trying to conceive for only six months that a very aggressive approach such as IVF may be necessary. Similarly, use of controlled ovarian hyperstimulation (COH) with gonadotropins (injectable fertility drugs) combined with intrauterine insemination (IUI) may be unacceptable to some couples. Knowledge of the patient’s blood FSH level may help to convince the couple that an aggressive approach is needed.
Treatment
Treatment options for age-related infertility include controlled ovarian hyperstimulation with intrauterine insemination (COH-IUI), IVF, and ultimately in nothing else works, egg donation. COH-IUI and IVF help by increasing the chance to conceive in any given cycle. They cannot improve egg/embryo quality. COH-IUI involves taking gonadotropins to increase the number of mature eggs released in a given cycle and the placement of washed sperm into the uterine cavity at the time of ovulation. This treatment has fair success in women forty and older, with pregnancy rates of 10 percent per cycle in a 2004 study. For couples with tubal disease, endometriosis, or sperm abnormalities, as well as couples with unexplained infertility who want to accelerate their chance for pregnancy, IVF is an appropriate option. Per-cycle pregnancy rates with IVF are higher than from COH-IUI, but do decline significantly with increasing age.
Egg Donation
Egg donation has become an accepted and successful technique to achieve pregnancy in older women. Studies show that average delivery rate of over 50 % per cycle can be expected in recipients who are aged 40 and older. This treatment is the only treatment available to improve egg/embryo quality in older women. Egg donation involves preparing the recipient’s uterus with estrogen and progesterone to create an optimal bed for implantation. The egg donor undergoes hormonal stimulation to produce multiple eggs. The eggs are retrieved with a minor procedure and fertilized with sperm from the recipient’s partner. Fertilized embryos are then placed into the recipient’s uterus.
Egg donation offers couples a number of advantages over adoption. First, the sperm is obtained from the patient’s husband, and therefore the child is genetically related to him.
Second, since the pregnancy develops inside the patient herself, she has control over such factors as nutrition, smoking, drinking or taking recreational drugs during the pregnancy, control she would not have in the case of adoption.
Finally, the woman experiences the positive feelings of pregnancy and delivery and is able to breast-feed. These are all important experiences in establishing positive feelings toward the infant. For the present, egg donation is the best medical option for women over the age of 40 who have repeatedly failed other fertility therapies, as well as for women with elevated FSH levels. Adoption is a wonderful alternative for women who do not wish to use a biological ortion.
Recommendations
One approach to therapy for the infertile woman aged 40 and over who has a normal evaluation is to first consider one or two cycles of COH-IUI. This will give the patient a chance of conceiving and also allows the physician to evaluate ovarian response for a future IVF cycle. In addition, it helps the patient get used to the idea of a more aggressive, "higher-tech" approach. For the patient who desires the highest chance for pregnancy with her own eggs, IVF is a more successful treatment per cycle.
If the patient does not conceive with COH-IUI, IVF is a next possible step. If her ovarian response is suboptimal, her embryo quality is very poor, or she does not conceive with IVF cycles using her own eggs, egg donation or adoption may be considered. For a patient with an FSH level of 10 to 12, it may be best to direct her promptly to an IVF cycle with her understanding that the chance for a successful pregnancy is reduced. Patients with a day 3 FSH greater than 14 might best be offered egg donation as the first-line option.
Summary
Some women seeking to conceive after the age of 40 have little difficulty in achieving a pregnancy. For those who do not, however, prompt evaluation and aggressive treatment are critical. The serum FSH level, along with the patient’s comfort level with aggressive treatment can help to guide the treatment. Egg donation offers hope to women who can not achieve a pregnancy using other treatments with their own eggs.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Numerous demographic studies suggest a consistent decline in fecundity (the chance to conceive in any given month) with increasing age. The average 25 year old woman who is trying to conceive may have a 25% per month chance of conceiving if all fertility factors are optimal. Compare this with the 5% per month chance for conception of the average 40 year old woman. This age associated decline in live births is due largely to abnormalities in the egg. The meiotic spindle, which helps the chromosomes segregate for cell division, exhibits abnormalities in chromosome alignment. This high rate of abnormal chromosome distribution is the major factor that can explain a lower rate of successful pregnancies in older women. In addition to decreasing fecundity, older women experience an increasing incidence of miscarriage. Women over age 40 have approximately a one in three chance of having a miscarriage in any given pregnancy. In addition, at age 40 one in sixty live births is genetically abnormal.
With this in mind, it seems reasonable to promptly evaluate women over 40 who are concerned about fertility. Before starting an evaluation, however, it is important to discuss some of the special considerations for the woman over 40 trying to conceive. These include general health issues, since women over 40 are more likely to have medical problems including diabetes, hypertension, heart disease, all of which can complicate a pregnancy. Therefore, we recommend that an over 40-year-old woman contemplating a pregnancy have a thorough medical evaluation, including a mammogram. The increased incidence of genetic abnormalities in infants born to women over age 40 and the recommendation for prenatal genetic diagnosis should also be discussed.
Patient Evaluation
The usual trial period of one year of attempting conception prior to an infertility evaluation is not appropriate for women who are close to forty years old.
A basic infertility evaluation is indicated for any couple who have been attempting conception for six months if the woman is approaching 40. First, an infertility history should include how long the couple has been trying to conceive, method of timing and the frequency of intercourse, as well as questions regarding menstrual regularity, premenstrual symptoms, and any prior pregnancies. Factors suggesting problems with the patient’s fallopian tubes, such as a history of sexually transmitted diseases, IUD use, or pelvic infection, should be noted, as well as any previous cervical procedures such as cryotherapy or conization. In addition, the patient should be asked about early menopausal symptoms.
Laboratory and other tests should include:
• A semen analysis for the patient's partner.
• Evaluation of ovulation: basal body temperature charts, a midluteal serum progesterone level, a urine luteinizing hormone ( L H ) t e s t using an ovulation predictor kit, or ultrasound monitoring of follicular development.
• An evaluation of the patient’s fallopian tubes and uterine cavity with a hysterosalpingogram.
• Evaluation of ovarian reserve (see below) Ovarian Reserve
Studies suggest that a woman's chronologic age and her ovarian reserve are independent predictors of fertility. Ovarian reserve describes a woman’s reproductive potential with respect to egg quantity and quality.
Perhaps the best method we have readily available to measure ovarian reserve is a cycle day 2 or 3 blood FSH (Follicle Stimulating Hormone) level and an estradiol (estrogen) level. This measurement may be very important in evaluating how aggressively to treat women approaching the age of 40 and also to give that woman a realistic idea of her chance for a successful pregnancy. The levels of FSH that are considered in the normal range are dependent on the lab where the test is performed. With modern techniques for measuring FSH, generally, a level of less than 10 is good, 10-14 borderline, and 15+ suggests a very low chance for successful pregnancy with fertility treatment with a woman’s own eggs. A single elevated FSH level predicts a poor prognosis even when subsequent FSH levels are normal. In women with a normal FSH, a Clomiphene
Challenge Test may provide more information about a patient’s ovarian reserve than a day 3 FSH level. Blood testing is done on day 3 for FSH & estradiol, clomiphene 100 mg day is taken on days 5-9, and a blood test for FSH level is taken on day 10. Elevation of either FSH level (day 3 or day 10) is a poor prognostic sign. Also a cycle day 3 estradiol level above 70 may suggest a lower chance for success. In a general infertility population an abnormal clomiphene challenge test predicts that a successful pregnancy will be achieved only about five percent of the time. Risk factors for early loss of ovarian reserve include smoking, family history of early menopause, shortening menstrual cycle interval and previous ovarian surgery.
The basic evaluation can be performed over a period of one month in women approaching 40 years of age, rather than spreading it over a number of cycles. Any abnormalities that are uncovered in the basic evaluation should be corrected promptly. If the evaluation is normal, or if abnormalities have been corrected and the patient still does not conceive in a short period of time, aggressive therapy is indicated. It may be difficult to convince a couple that has been trying to conceive for only six months that a very aggressive approach such as IVF may be necessary. Similarly, use of controlled ovarian hyperstimulation (COH) with gonadotropins (injectable fertility drugs) combined with intrauterine insemination (IUI) may be unacceptable to some couples. Knowledge of the patient’s blood FSH level may help to convince the couple that an aggressive approach is needed.
Treatment
Treatment options for age-related infertility include controlled ovarian hyperstimulation with intrauterine insemination (COH-IUI), IVF, and ultimately in nothing else works, egg donation. COH-IUI and IVF help by increasing the chance to conceive in any given cycle. They cannot improve egg/embryo quality. COH-IUI involves taking gonadotropins to increase the number of mature eggs released in a given cycle and the placement of washed sperm into the uterine cavity at the time of ovulation. This treatment has fair success in women forty and older, with pregnancy rates of 10 percent per cycle in a 2004 study. For couples with tubal disease, endometriosis, or sperm abnormalities, as well as couples with unexplained infertility who want to accelerate their chance for pregnancy, IVF is an appropriate option. Per-cycle pregnancy rates with IVF are higher than from COH-IUI, but do decline significantly with increasing age.
Egg Donation
Egg donation has become an accepted and successful technique to achieve pregnancy in older women. Studies show that average delivery rate of over 50 % per cycle can be expected in recipients who are aged 40 and older. This treatment is the only treatment available to improve egg/embryo quality in older women. Egg donation involves preparing the recipient’s uterus with estrogen and progesterone to create an optimal bed for implantation. The egg donor undergoes hormonal stimulation to produce multiple eggs. The eggs are retrieved with a minor procedure and fertilized with sperm from the recipient’s partner. Fertilized embryos are then placed into the recipient’s uterus.
Egg donation offers couples a number of advantages over adoption. First, the sperm is obtained from the patient’s husband, and therefore the child is genetically related to him.
Second, since the pregnancy develops inside the patient herself, she has control over such factors as nutrition, smoking, drinking or taking recreational drugs during the pregnancy, control she would not have in the case of adoption.
Finally, the woman experiences the positive feelings of pregnancy and delivery and is able to breast-feed. These are all important experiences in establishing positive feelings toward the infant. For the present, egg donation is the best medical option for women over the age of 40 who have repeatedly failed other fertility therapies, as well as for women with elevated FSH levels. Adoption is a wonderful alternative for women who do not wish to use a biological ortion.
Recommendations
One approach to therapy for the infertile woman aged 40 and over who has a normal evaluation is to first consider one or two cycles of COH-IUI. This will give the patient a chance of conceiving and also allows the physician to evaluate ovarian response for a future IVF cycle. In addition, it helps the patient get used to the idea of a more aggressive, "higher-tech" approach. For the patient who desires the highest chance for pregnancy with her own eggs, IVF is a more successful treatment per cycle.
If the patient does not conceive with COH-IUI, IVF is a next possible step. If her ovarian response is suboptimal, her embryo quality is very poor, or she does not conceive with IVF cycles using her own eggs, egg donation or adoption may be considered. For a patient with an FSH level of 10 to 12, it may be best to direct her promptly to an IVF cycle with her understanding that the chance for a successful pregnancy is reduced. Patients with a day 3 FSH greater than 14 might best be offered egg donation as the first-line option.
Summary
Some women seeking to conceive after the age of 40 have little difficulty in achieving a pregnancy. For those who do not, however, prompt evaluation and aggressive treatment are critical. The serum FSH level, along with the patient’s comfort level with aggressive treatment can help to guide the treatment. Egg donation offers hope to women who can not achieve a pregnancy using other treatments with their own eggs.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Clomid—Moodiness and Multiples
Clomid is an anti-estrogen drug used to stimulate the ovaries to produce mature eggs, and it's often the first choice for women who don't ovulate regularly. "Lots of people feel lousy on Clomid. We get a lot of complaints about feeling moody and out of sorts," says Dr. Arthur Wisot, MD, F.A.C.O.G., executive director of Reproductive Partners Medical Group, which has offices throughout Southern California, and author of Conceptions & Misconceptions: The Informed Consumer's Guide Through the Maze of In Vitro Fertilization and Other Assisted Reproduction Techniques. Most women only take Clomid for a few weeks and weather the emotional storms. But one of Clomid's most notable side effects is permanent! "The biggest side effect is multiple births," says Wisot.
Read more ….
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Read more ….
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Wednesday, October 8, 2008
The Stress of Fertility Treatment
The stress, strain, and feelings connected with infertility and its treatment are universal and not to be taken lightly. Even before a couple visits a specialist, the worry often begins. For any couple, just making that first appointment with a specialist is stressful. To the couple, the fact that they need to see a specialist may mean they truly may have a problem and worse, may be incapable of having a biological child. It also means going to a new doctor and a new office. It may take a while to get the courage to make an appointment, which adds to the stress. They experience the feeling that time is passing and everyone else seems to be getting pregnant. People are asking when they will have children, and there is no easy answer for that painful question.
The first phase of infertility treatment consists of probing questions about their sexual practices, diagnostic tests including blood tests, ultrasound examinations, semen analyses, and sometimes even surgery or painful "procedures." None of this is pleasant. Appointments are disruptive to people's schedules, and because it's not often covered by insurance, may be a financial burden. It also means more time passing without a pregnancy while it seems there are pregnant women everywhere. The specialist cannot start treatment without the diagnostic testing, but all the couple wants is to start their family.
Normally the doctor will explain what the treatment choices are, and the chances of success with each one. He or she will explain side effects of drugs and possible risks, such as a multiple pregnancy. There are just so many decisions to be made. Many couples have to self-inject hormones to stimulate the woman's ovaries, which is very challenging to people who, like many, hate needles. Then there are more appointments, more stress and more financial burdens. If the couple has to go on to IVF, there will be some complicated decisions about how many embryos to transfer and what to do with the others.
When treatment cycles end in disappointing news (no pregnancy or a pregnancy that fails), the negative effect can be overwhelming. Couples search for ways to cope, and ask the question "why is this happening to us?" There may not be an answer, certainly not a satisfying one and many people unfairly blame themselves and their own stress. Although there is
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
The first phase of infertility treatment consists of probing questions about their sexual practices, diagnostic tests including blood tests, ultrasound examinations, semen analyses, and sometimes even surgery or painful "procedures." None of this is pleasant. Appointments are disruptive to people's schedules, and because it's not often covered by insurance, may be a financial burden. It also means more time passing without a pregnancy while it seems there are pregnant women everywhere. The specialist cannot start treatment without the diagnostic testing, but all the couple wants is to start their family.
Normally the doctor will explain what the treatment choices are, and the chances of success with each one. He or she will explain side effects of drugs and possible risks, such as a multiple pregnancy. There are just so many decisions to be made. Many couples have to self-inject hormones to stimulate the woman's ovaries, which is very challenging to people who, like many, hate needles. Then there are more appointments, more stress and more financial burdens. If the couple has to go on to IVF, there will be some complicated decisions about how many embryos to transfer and what to do with the others.
When treatment cycles end in disappointing news (no pregnancy or a pregnancy that fails), the negative effect can be overwhelming. Couples search for ways to cope, and ask the question "why is this happening to us?" There may not be an answer, certainly not a satisfying one and many people unfairly blame themselves and their own stress. Although there is
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Tuesday, September 23, 2008
Legal Considerations for Those Who Want to Conceive
That’s the gist of a recent talk I heard on “Legal and Ethical Dilemmas in ART Today.” The speaker was Susan L. Crockin, Esq., who is very experienced in reproductive law and authors the “Legally Speaking” column in the American Society of reproductive Medicine newsletter.
Using case illustrations, her main point was that unless one is in a legally binding relationship such as a marriage, it is advisable to have the relationship between the individuals involved in the procreation clearly defined. When people enter into these relationships to try to create a child they assume that things will go well and sometimes they do not. Situations which may raise a red flag include unmarried couples, those using surrogates or a known egg donor, single women using a known sperm donor, same-sex couples who have not been able to enter a legally-binding relationship, especially if one member of the couple is providing the eggs or sperm and the other is the carrier or has no biological relationship to the child.
Many situations have led Reproductive Partners to require a legal contract. It’s most commonly required when a surrogate or egg donor is used. But in other instances a fertility center may be unaware of the nature of the relationship between partners attempting to conceive. And this recommendation is valid regardless of the method used to conceive the child, whether it’s by natural conception or IVF with ICSI and PGD. One situation in which Ms. Crockin thought a contract was mandatory is when people of different states are involved (i.e. a couple in
To me this recommendation makes sense: After all one should not enter into an investment or buy real estate with an individual with whom one does not have a legal relationship without a contract. But sometimes we do not apply the same common sense principles to our personal lives that we do to business.
Reproducer, beware.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the
Wednesday, September 3, 2008
Embryo Donation Works
An email I recently received from a patient demonstrates how embryos created from successful IVF cycles that have been sitting in our facility for years can help create families for other unsuccessful patients.
The email was from a couple who had tried multiple IVF cycles without success and although she was relatively young we were never able to achieve success. Although we tested everything, we never found a reason for the repeated failures. This added to the frustration of the repeated failures.
On the other hand I had a couple who tried IVF because of secondary infertility and at the same time was struggling with the problem of what to do with a number of frozen embryos they had in storage. For ethical reasons they did not want to discard them and did not want more children. I brought up the concept of embryo donation and this option appealed to them especially since the recipient couple was planning to move out of the area.
Needless to say, the transfer was successful and all parties are thrilled. The previously unsuccessful couple has the child they had been longing for. The couple with the extra embryos are happy their disposition of their embryos resulted in them achieving their potential for life and that they got to give something back in return for their good fortune. And I am happy that I was able to help both couples.
Embryo donation works. I only wish more couples with unwanted frozen embryos sitting in freezers throughout the country would consider this option.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
The email was from a couple who had tried multiple IVF cycles without success and although she was relatively young we were never able to achieve success. Although we tested everything, we never found a reason for the repeated failures. This added to the frustration of the repeated failures.
On the other hand I had a couple who tried IVF because of secondary infertility and at the same time was struggling with the problem of what to do with a number of frozen embryos they had in storage. For ethical reasons they did not want to discard them and did not want more children. I brought up the concept of embryo donation and this option appealed to them especially since the recipient couple was planning to move out of the area.
Needless to say, the transfer was successful and all parties are thrilled. The previously unsuccessful couple has the child they had been longing for. The couple with the extra embryos are happy their disposition of their embryos resulted in them achieving their potential for life and that they got to give something back in return for their good fortune. And I am happy that I was able to help both couples.
Embryo donation works. I only wish more couples with unwanted frozen embryos sitting in freezers throughout the country would consider this option.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Wednesday, August 13, 2008
Court Backs Fertility Treatment Time Off
As though it were not difficult enough dealing with the shots and emotional ups-and-downs associated with fertility treatments, one aspect of fertility treatment might just be getting easier. Taking time off from work may be one of the most stressful aspects of fertility treatment. As reported in the August 13, 2008 issue of the Wall Street Journal, a Federal Appeals Court three-judge panel in
This ruling only currently applies in
“Conceptions & Misconceptions” a “book by two fertility specialists” is listed in the article as a resource. The two fertility specialists are Dr. Meldrum and me.
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the
Wednesday, July 30, 2008
Dr. Wisot Discusses Clomid
As a consultant on fertility issues for the Choice Mom community, choicemoms.org, I am frequently asked questions about treatment options for single women who are attempting to achieve pregnancy without a partner.
Q. What to do if my lining is thin on clomiphene (Clomid)?
One recent query sent to me by Choice Moms liaison Mikki Morrissette was about a woman whose RE clinic reported that her uterine lining was affected by taking Clomid, which had barely reached 6mm for her previous IUI. He recommended that she take injections [one option: Follistim]. She wasn't sure if the RE was erring on the side of too much intervention. She was concerned about the greater likelihood of having twins. And she was afraid that she would miss her next cycle while she waited to take the "training" required for the injections.
A. Success rates are not reported for this type of treatment so except for the doctor's pride this would not be recommended for the reason of increased success rates. I think most REs will actually try the most conservative treatments first. Of course there will always be someone who rushes patients into the highest level of treatment right away. But, as I point out in my book, Conceptions & Misconceptions," the treatment has to make sense and even a lay person can get a sense of what's appropriate. If there is a question, one can always get a second opinion.
The risk of multiples is increased over Clomid. That is true, but if the injectables are used judiciously the risk can be reduced, especially the risk of the higher order multiple pregnancies like triplets and above.
The injection training can be done in a few minutes and not really a reason for delaying a cycle.
But there is another alternative that you can ask for and do it in this cycle. If you use estrogen for five days after the last Clomid it may adequately thicken the endometrium and if it doesn't you can go to injectables next cycle.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Friday, July 25, 2008
Brad and Angelina: Meet Louise Brown
In an exclusive article just released in Us Weekly magazine it was disclosed that two of the world’s biggest celebrities and movie stars conceived their recently-delivered twins by in vitro fertilization (IVF). Coincidentally, this article was published 30 years to the week of the very first IVF birth (Louise Brown on July 25, 1978).
I am pleased that Us Weekly chose Reproductive Partners Medical Group, Inc. to be their source of background information on this important story. Here is an excerpt from the story as released on their website. For the full story, please see the August 4, 2008 issue of Us Weekly.
Forget Mother Nature – Us Weekly reports in its new issue, on newsstands now, that Angelina Jolie and Brad Pitt turned to fertility treatments to quickly conceive twins Knox and Vivienne. “They conceived through in vitro fertilization," a well-placed source within their camp tells Us. "They both desperately wanted more babies soon."
The chance of having fraternal twins at Angelina's age (33) naturally is under 1 percent; with in vitro, the chances are 25 percent. Says Dr. Arthur Wisot of
The actress chose the procedure (which can cost around $12,000 a pop) so "she wouldn't have to deal with the stress of trying to get pregnant," the source tells Us. "She could just knock it out."
Indeed, Jolie has spoken about her goal to do just that. "If we're going to have 10 kids, we'd like to raise them while we're young," she told Elle
A source adds: "They were too impatient."
Knox and Vivienne – born in Nice, France on July 12 – join the couple's adopted brood of Maddox, 6, Pax, 4, Zahara, 3.
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available fertility treatments please visit www.reproductivepartners.com.
Tuesday, July 15, 2008
Excerpts from the ReproductivePartners.com Infertility Bulletin Board
Ask Dr. Wisot -
When to perform an insemination?
Q. Could you please give your opinion on what is the best time to perform an insemination (IUI) without any drugs in relation to the detection of the LH surge? Is it before or after detection of surge and please be specific with hours. There seems to be a lot of differing info on best times.
A. I usually recommend that a single insemination be done in a natural cycle the day after an LH surge is detected by an ovulation predictor kit. That’s because the surge usually precedes ovulation by 36 or more hours. You are detecting the surge sometime after it happened. Most women test once a day in the afternoon or evening, so they should be close to ovulation by the next morning. The egg has about 12-24 hours to be fertilized and the most sperm specimens can maintain good motility for 48 hours in the wash media, so the IUI does not have to be done at the exact time of ovulation. All the averages coincide the morning after the surge is detected, making it the most logical time to perform the IUI. Alternatives to using the urinary ovulation predictor kit to time intercourse or insemination are ultrasound or a variety of fertility monitors. At the time of the insemination an ultrasound can be performed and if ovulation has not occurred, the insemination can be repeated, insuring that it will be done as close to ovulation as possible.
With eight previous miscarriages what tests should I DEMAND?
Q. I have just lost my 8th baby due to early pregnancy loss. All losses have been at 11wks or earlier. The hardest part was there was a great heartbeat and a perfect looking baby. My OB/GYN said I was having a textbook perfect pregnancy. Of course I let my guard down, got excited and lost the baby almost 2 weeks later. The
A. I am so sorry to hear about your repeated losses. You can be sure that your enthusiasm had nothing to do with the loss. The test the doctor wanted to do on the placental tissue was probably to examine the chromosomes to see if the baby was normal or abnormal. That could provide clues on what is causing the problem and how to deal with it.
Once you recover from this miscarriage you might want to see an Ob/Gyn who treats recurrent miscarriage or a reproductive endocrinologist to review your history and see what tests are appropriate. Yours does not sound like the typical case and I really can't tell specifically which tests should be done from this information. Generally the tests will check the following issues:
· The chromosomes of both partners
· The quality of the woman’s eggs with hormone tests
· Abnormalities of the uterus
· Infection with an organism-ureaplasma
· Progesterone levels/development of the uterine lining
· Abnormal antibodies in the woman’s blood
· Heredity blood clotting problems in the woman
By the way, when anyone approaches a doctor I would recommend that one not start the interaction by “demanding” that something be done. Start by listening to the doctor’s advice and then add any “request” you may have with the reason you want something done. The best doctor-patient relationship is one of mutual concern, cooperation and trust. If one does not feel that their doctor is concerned about their problem, not willing to reasonably cooperate or they do not trust the doctor, it is best to find another doctor.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Friday, June 20, 2008
Male Infertility: Intracytoplasmic Sperm Injection (ICSI)
Male infertility accounts for the reason for the problem in approximately 40% of the 2.3 million couples experiencing infertility in the
Treatment of male infertility often depends on the specific cause of the infertility and can include surgery, medical treatment and if those are not effective, microinsemination techniques. Microinsemination is laboratory assisted fertilization of an egg. Intracytoplasmic sperm injection (ICSI), a specialized form of microinsemination, was first developed by reproductive medical specialists in
The ART of Parenthood
There are several Assisted Reproductive Technologies (ART) that have been developed to assist couples in having children. Among them are: in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), egg donation, cryopreservation with subsequent thawing and transfer of embryos, and a growing number of microscopic techniques such as ICSI and most recently, preimplantation genetic diadnosis (PGD). These microscopic procedures are the most demanding and exacting part of ART.
Male Infertility & ICSI
Fertilization of the egg by ICSI, getting one sperm into one egg, is the starting point for embryo development. For many years the only approach available for fertilizing an egg in ART procedures was to imitate what occurs in fertile couples, incubating the egg with sperm. This approach is successful in fertilizing approximately 75% of eggs in men with normal sperm parameters. Microinsemination techniques were developed to improve the likelihood of fertilization in men whose sperm parameters are markedly abnormal. Male infertility can be associated with the production of low numbers of sperm, sperm that do not “swim” properly or do not swim at all, and sperm that are abnormal in shape. Abnormally shaped sperm have reduced ability to penetrate the egg.
Non-ICSI insemination can be a difficult process in men with abnormal sperm parameters for two reasons: the sperm must first reach the egg and then penetrate the egg. They may not have adequate numbers, motility or normal morphology to have a good chance of their sperm accomplishing these two tasks. ICSI overcomes these deficiencies by injecting a single sperm into an individual egg. ICSI makes a low number of sperm, “poor sperm motility” and “poor sperm morphology” no longer barriers to couples who seek to have their own biological children.
In some men, the tubes known as the vas deferens that transfer sperm from the testis are blocked or missing through a congenital abnormality, an accident, a disease or an irreversable vasectomy. In such situations, sperm may be obtained by a surgeon from the epididymis, the site where sperm are stored through a process called percutaneous epididymal sperm aspiration (PESA). In men with other severe problems, sperm can be obtained by testicular biopsy (TESE). ICSI makes it possible to use epididymal or testicular sperm to achieve a pregnancy. There is also the situation where, for unknown reasons, a man’s sperm does not penetrate the woman’s egg, even though the number, shape and motility of the sperm all appear normal. ICSI is also appropriate treatment in these situations.
ICSI - The Technique
ICSI requires only one sperm per egg to be effective. ICSI is a simple and elegant way to transfer that sperm directly into the egg. Using a microscope, the embryologist gently draws one sperm into a pipette. The tip of the pipette is then guided into the waiting egg. The egg is held steady at the end of another glass pipette. Then with a steady and measured forward motion, the sharpened tip of the sperm-containing pipette is inserted into the egg. Reversing the process that pulled the sperm into the pipette, the embryologist now ejects the sperm into the egg. And finally, the sharpened tip of the empty pipette is removed from the egg. After picking up the sperm, the entire ICSI technique takes the embryologist less than ten minutes.
ICSI - Does it damage the egg?
ICSI procedures are routinely done successfully without damaging the egg in most cases.
This is not surprising to embryologists for several reasons. First, the egg is many times larger than the pipette that is used to penetrate its surface. Second, the human egg is encased in a tough, elastic membrane that usually doesn’t crack, shatter or crumble.
Finally and most important, Mother Nature lends a hand: the egg has the ability to rapidly repair the small hole in its membrane made by the pipette.
ICSI - Are there any side effects?
Despite widespread use and acceptance, ICSI is still a relatively new procedure. Children born as the result of ICSI are still very young and have not yet reached an age to reproduce. Genetic reproductive abnormalities in the father can be passed on to male offspring. Currently there are reports of a small increase in minor birth defects and congenital abnormalities in babies born through ICSI. This is not surprising since it is usually being performed in couples in which the man has very abnormal sperm. In addition ICSI bypasses an important natural process of sperm penetration.
Theoretically, this could permit the transfer of certain conditions that have a genetic basis. Where a genetic basis for male infertility is suspected or known, the couple may also find it helpful to speak with a genetic counselor before choosing to use ICSI, as well as have genetic testing for abnormal chromosomes or microdeletion in the male (Y) chromsome.
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available fertility treatments please visit www.reproductivepartners.com.
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