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The American Fertility Association Blog

Minimal Stimulation

July 28, 2009 - Tuesday
Posted by admin

By:  Dr. Fred Licciardi

I have been practicing infertility at NYU for 16 years. Basic infertility, reproductive surgery, ovulation induction, IVF, and egg donation are all areas of my expertise. Most of my patients are from New York , but people come to see me from other states and other countries.

Reprinted From Monday, January 21, 2008

Does taking a lower dose of fertility drugs improve your chances of becoming pregnant with IVF? I think not, but I can tell you of some exceptions. Mostly I have had some very good experiences with patients confirming that lower is not better.

How do I know?

Well, as it turns out over the past few years I have been seeing more patients from Europe. There are a few things that have contributed to this. One is the blog. It’s been fun getting e-mails and seeing patients from around the world. The second is the exchange rate: for some, New York is now a “reproductive tourism” destination. The third has to do with laws in Italy, Germany and other countries that restrict IVF and donor egg.

Anyway, the European doctors give their patients a much lower dose of drug that we do in the US. Part of this is due to the fact that they may not be allowed to fertilize more than a few eggs, so they don’t bother trying to get more. Another reason may just be due to a general philosophy that less drug is better.

So the typical European woman that sees me has done IVF many times, usually making just a few eggs on a lower dose of drug. Unless she has had a fantastic response, I increase the dose for her IVF cycle with me. In most cases, the egg yield is much higher (still in a safe range) and the pregnancy rate in these women is very high. So the point is that in these women, a higher dose is better because it increases the number of eggs, and therefore there are more embryos available for selection.

Do some women make more eggs with a lower dose? I have seen a few cases of this. This is typically the woman who was given a lower dose for IUI and develops more follicles than she did with her higher dose IVF cycle. Should we go back to the lower dose for the next IVF cycle? It’s a gamble and it takes a little courage. It is really hard emotionally to go into an “experimental” IVF cycle.

Many patients considering this have had many attempts and may not be ready to give up a couple months for a “let’s see” cycle. If you and your doctor can stomach it, you can give it a try. I can tell you I have one woman, who had been through many cycles, who wanted to give it a go, and she did better with less. Was that her month to make more, regardless of drug dose? Who knows, but let’s give her the credit.

But I do think starting on a minimal dose, just because your doctor thinks it’s more homeopathic and will result in better quality embryos, is not correct. To return to our common theme, if one of the self proclaimed experts in minimal stimulation wants to take 100 women and give them minimal stimulation, and take another 100 and give them regular stimulation, and then show us that minimal is better, great. But until this happens we have to say that it’s not better, and may be worse for most people. I know some of you can tell me that you did minimal and got pregnant. I just feel that my experience has shown that overall, regular may be better.

Categories
Donor Egg • Egg Donation • Fertility • Fertility Drugs • IUI • IVF • Pregnancy

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Justice Sotomayor - How Will Her Confirmation Affect Those Suffering from Infertility?

July 22, 2009 - Wednesday
Posted by Lisa

By:  Theresa Erickson, Esq.

While watching the confirmation hearings last week (yes, I am one of those dorky lawyers), I was listening for any cues regarding how she may address a case that involved fertility treatments, fertility coverage, pregnancy discrimination (including pre-pregnancy for IVF treatments) and, of course, a woman’s right to chose, including the right to privacy involving medical treatments.  Now, mind you, I understand regulation may be needed in some areas of this industry, but I also do not want to see the government restricting our ability to create a family, regardless of marital status, age, or sexual orientation.  Again, these are issues that must be determined between a physician and their patient when he or she is accessing the health risks for the woman carrying the children, as well as any harm that may come to the future children in terms of prenatal health. 

I did discover, despite her attempts otherwise, that she appeared to hold a liberal point of view in many ways, which despite my own leanings, is important when it comes to autonomy for those patients and those involved in this industry.  However, regardless of her political stance, what is important is that she applies the law neutrally with a perspective of her life experience.  I know that many do not agree with that statement, but we all must agree that it is not humanly possible to take one’s own life experiences out of the picture when making decisions.  What we do want is for judges to use that experience, while simultaneously utilizing an objective vision when making decisions that will affect us all, as well as future generations.

Of course, much of what we do and what our clients/patients deal with is family law.  Judge Sotomayor has little experience in that area due to her previous posts as a federal judge, as most Supreme Court judges.  Even the Supreme Court itself has little experience in that area.  The most notable family law case is the case of Troxel v. Granville in which the Supreme Court did strike down a trial court judge’s decision to allow grandparent visitation involving a completely fit mother.  They were concerned that the judge had used his personal experience in making the decision since he stated he truly enjoyed his time with his grandparents as a child.  But, as I stated above, personal experiences do shape our lives and how we shape our decisions; however, in this case, the Court did not state that the judge did anything wrong in doing so, it was merely that it was a case with a backdrop of a fit mother.  Different set of facts could have created a different ruling. 

Now, with that in mind, Justice Sotomayor is a woman - she has no children, and she has been battling diabetes since the age of 8.  Does that make her more sympathetic to our plight or not?  I am not certain, as we do not know why she does not have children or if it was a path she chose.  But, we do know that she knows what it is like to battle a disease that controls your life, which should be good for those of us in the community. 

Remarkably, after reviewing her previous decisions, I was unable to locate much information on how she would rule if any such case comes before her.  In fact, she has not dealt with stem cell research regulation of Assisted Reproductive Technologies, healthcare choices, or on-point abortion cases; however, there are a few notable cases that she has dealt with as a judge:

1.  Saks v. Franklin Covey Co (316 F.3d 337 (2d Cir. 2003)) - This is a bioethical issues case in which she joined a Second Circuit opinion rejecting a claim that exclusion from coverage of surgical impregnation procedures, including in vitro fertilization, violated Title VII and the “Pregnancy Discrimination” Act.  Note that this does not assume that she is against IVF, only that she did not judge that that particular case was within the parameters of the Pregnancy Discrimination Act, which is her duty as a judge - to interpret law, not make laws.  For changes like this to be made, we need to address our Congress to have them amend these laws as they currently stand. 

      2.  Center for Reproductive Law and Policy v. Bush (304 F.3d 183 (2d Cir. 2002)) - Judge Sotomayor found that a “reproductive rights” group had standing to challenge the Mexico City Policy.  She concluded that the group had “competitive advocate standing,” on the grounds that the government’s allocation of a benefit “creates an unequal playing field” for organizations advocating their views in the public arena.  She agreed that the government had a rational basis for favoring “the anti-abortion position over the pro-choice position” with public funds.  Again, as the above case, since this case is not on point, we truly do not know how she would rule regarding the right to life, the right to abortion, status of embryos, etc.

Ultimately, based on her performance at the hearings and her record, and despite a few bumps in the road involving the case of the firefighters, it does appear that she will be confirmed prior to the start of the next Supreme Court session.  And, of course, I am truly excited, as a woman, as a lawyer, and as a member of the US Supreme Court Bar, that there is another woman on the bench.  Call me sexist, call me whatever you want, but we need diversity on the bench so that those who have never “walked in our shoes” can see the perspective, albeit objectively, when our cases come before them. 

 

 

Categories
Fertility • Infertility • IVF • Pregnancy • Reproductive Freedom

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Dear Toronto Sun Editor

July 14, 2009 - Tuesday
Posted by admin

A columnist with The Toronto Sun provided some very concerning and damaging advice to one of the publication’s readers, basically saying there’s no need to worry about having a baby now and that 40 is the new 30.  Her remarks could mean the difference between having a baby and not being able to conceive.  Please read the article and then the response below written to The Sun by AFA’s Communications Director, Brian Armentrout.

+++

Dear Toronto Sun Editor,

As a former journalist of nine years, I was a bit surprised to see journalist Robin Anderson so presumptuously jump to conclusions regarding one’s fertility in the recent column entitled Biological Clock Tick-Tockin’ Away.

While the title is accurate her statements within the piece are completely and entirely contradictory and go against the point made in the article’s title.  As a journalist, I constantly upheld my honesty, integrity, and credibility by thoroughly investigating and researching everything I wrote and took the ten o’clock news.  It’s clear Ms. Anderson’s standards are much lower.  Let me explain.

“These days, 40 seriously is the new 30. Many women are waiting until they are more “mature” to marry and have children.”

This statement is inaccurate.  A woman’s fertility begins to decline substantially at age 27.  Ms. Anderson has fallen into the mindset for which we can thank Hollywood.  All of these 40 something actresses are getting pregnant; what they fail to tell you is they probably spent thousands of dollars on infertility treatments and medicine, not to mention to emotional agony experienced by someone dealing with such a horrible problem.  The truth is 40 may already be too late.
 
“I would, however, caution you to examine why you want to have a baby before you do anything. If it is because you think a woman needs to be a mom to be whole, or because you want something to nurture and love, please reconsider.”

If a woman wants to have a child to be whole, or want something to nurture or love, what’s so wrong with that?  A woman’s decision to become a mom is her business and her business only.  It’s not up to a columnist to tell her to not have a child because she wants something to love.

“Give yourself six months to think about things.”

Seriously?  That’s like telling a smoker to keep smoking for twelve more months before you decide to quit, not to mention the possibility of getting cancer in the meantime.  Or telling an alcoholic: go ahead keep drinking, give yourself a half a year to think about quitting and only hope your liver doesn’t fail during that time.  A woman’s fertility is constantly declining and six months could mean the difference between being able to successfully conceive child and not being able to get pregnant.  You must act quickly.  Infertility is a huge problem.

My New Career

I mentioned I’m a ‘former journalist.’  Since July of 2008 I’ve been the Communications Director of The American Fertility Association.  We strive to create fewer patients; not more.  Our mission is simple:

To help people prevent infertility whenever possible and help people build families of choice, particularly when faced with infertility.

The AFA has been around for more than a decade and we’re doing better work now than we’ve ever done.  Our biggest push in 2009 is infertility prevention in men and women, which is why it disheartens me, the entire AFA staff, and our constituents, to see this type of inaccurate editorial.  In a perfect world, I’d like to see a retraction.  While that may not be necessary, I’d like this letter to at least be forwarded to Missing Out on Motherhood.  I’d also make the request that you post this letter in its entirety in your Letters to the Editor section.  Please accept this letter in the spirit for which it’s intended.

Best,

Brian Armentrout
Communications Director
The American Fertility Association
[email protected]
o: 205-425-3644

About The AFA

The American Fertility Association, a 501 (c) (3) national non-profit organization is a lifetime resource for infertility prevention, reproductive health and family building. AFA services and materials are provided free of charge to consumers and available to everyone without reservation. These services include an extensive online library, monthly online webinars, telephone and in-person coaching, a resource directory, hosted message boards, daily fertility news, a weekly newsletter and a toll-free support line.
http://www.theafa.org or 888.917.3777.

 

Categories
Family Building • Fertility • Fertility Drugs • Fertility Preservation • Infertility • Infertility Drugs • Pregnancy

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Georgia House Bill 388, The ‘Option for Adoption’ Act.

June 3, 2009 - Wednesday
Posted by admin

By:  Daniel Shapiro, M.D.

Georgia recently enacted Georgia House Bill 388, the ‘option for adoption’ act. The bill provides legal basis for patients using donated embryos to ‘adopt’ them under the Georgia family law code. This bill is the first of its kind to be enacted and represents one of many attempts by right to life groups to establish ‘personhood’ of embryos. By all prior legal standards and in all reproductive medicine clinics practicing embryo donation, embryos are considered property, not people.

The moral standard implied by this bill is likely to be unconstitutional because it violates the 1st amendment’s establishment clause (separation of church and state).  Though reasonable people can certainly argue for the ensoulment of a pro-nuclear embryo, the civil pacts by which we live in this country prevent the supremacy of one religious view over any other or over any irreligious view.  Since the concept of personhood is inherently a religious question, this law violates our nation’s constitution. The law also probably violates the 14th amendment (equal protection under the law) since it establishes a special class of human being with rights that supersede the rights of others in the class. Why should an IVF embryo have the right to be adopted and treated as an ‘individual’ while a naturally conceived embryo has no similar protection?

I had the privilege to testify before the Georgia committee hearing this bill before it passed. First let me say that what was originally written was so egregious and foolish that had the original language passed Georgia’s legislature would have looked plain stupid. An attorney with extensive experience in Georgia family law and third party reproduction rewrote much of the bill and eliminated the expressed intent to make all IVF embryos into full grown people. She also crafted the language in a way that makes the bill superfluous in that it only created the option for an expedited adoption process but does not require it. In effect the law does nothing except answer to the rantings of the religious right.

Because the law is vague as to how it is we are supposed to actually proceed with these cases, we in the REI community in Georgia do not foresee any change in our practice. Our consents and contracts with patients have provided for rescission of parental rights in the case of embryo donation from time immemorial. Unless a recipient patient actually tells outside parties how she achieved pregnancy, all anyone would see is a pregnant woman anticipating delivery.  Since the overwhelming majority of embryo donations are anonymous, the donor would not know if a) her embryos became pregnancies or b) who actually got pregnant. It is hard to imagine a case where a willing embryo donor would come back and sue for parental rights since said donor wouldn’t know if or when a donation took place. Even if she could discern the above from the unavailability of her former property, she would not know if the procedure actually worked. Someone would have to show a compelling reason for us to violate someone else’s right to privacy and reveal their identity and the circumstances of their embryo recipiency. Ain’t gonna happen. I defy anyone who claims to believe in freedom and autonomy (many are in the same party as the religious right) to explain why the state of Georgia has a compelling interest in unmasking HIPPA protected patients.

Dr Shapiro is board certified in Reproductive Endocrinology and is the former medical director of Reproductive Biology Associates (RBA). He is currently the clinical director of RBA’s egg donor program and the RBA egg bank.

In cases where the embryo donor is not anonymous (a rarity) the bill allows for expedited adoption. Though this may afford a greater level of protection for the recipient’s claim to parentage, the physical reality of labor and delivery is probably a good enough standard under which a couple may establish their claim. To the best of my knowledge, there are no cases of willing embryo donors coming back to claim parental rights. It is equally hard to imagine what would happen if they did. For this law to be applicable at all, the donation, gestation and residence of all the parties would probably have to be in Georgia. If any of the parties, especially the recipient lived out of state, the existing property laws and family statutes of the resident state would likely apply.

From a medical perspective, we could limit our donations only to embryos that came from egg donation and then offer them only to out-of state recipients. This is likely to be unnecessary as again the bill only provides for the adoption option. After the law is enacted on July 1st it would be prudent of us to be sure to document that we informed recipients of the adoption option. Beyond that we see no change to medical practice standards under this bill.

Dr Shapiro is board certified in Reproductive Endocrinology and is the former medical director of Reproductive Biology Associates (RBA). He is currently the clinical director of RBA’s egg donor program and the RBA egg bank.

Categories
Adoption • Embryo Donation • Family Building • IVF • Pregnancy

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Pretty Woman

June 1, 2009 - Monday
Posted by admin

By: David Kreiner, M.D.


“We at The AFA have received a large number of emails from women who are confused by Kate Gosselin’s diagnosis of PCOS because, in their eyes, she is simply too pretty to have it.  Many people seem to have the misconception that a woman with PCO is doomed to a lifetime of unattractiveness.  AFA blogger, David Kreiner, M.D., has written about PCOS today in an effort to further educate women about this disorder” - The AFA staff

Polycystic Ovary Syndrome (PCOS) is a condition in which a woman’s hormones are out of balance.  It can cause problems with your periods and make it difficult to get pregnant.  PCOS may affect the way you look and can be associated with a variety of health problems including diabetes, hyperlipidemia and hypertension.

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

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

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

Ovaries develop numerous small follicles that look like cysts hence the name polycystic ovary syndrome.  These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as Hyperstimulation syndrome.  Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs.  A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots.  Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation.  They may also prescribe aspirin to prevent clot formation. 

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

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

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

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

A diabetes medicine called metformin can help control insulin and blood sugar levels.  This can help lower androgen levels, regulate menstrual cycles and improve fertility.  Fertility medications, in particular clomiphene are often needed in addition to metformin to get a woman to ovulate and will assist many women to conceive.  The use of gonadotropin hormone injections without egg removal as performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use.  In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer.  Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

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

Sincerely,

David Kreiner, M.D.
Do Live in California?

To learn more about PCOS and how to control it, along with other steps you can take to prevent infertility, be sure to attend The AFA’s FREE Manicures & Martinis Infertility Prevention Series, which is coming to San Francisco and Laguna Niguel.  Enjoy complimentary manicures and martinis and learn about the reality of the biological clock, how STD’s can compromise your fertility, and how certain environmental toxins can jeopardize your ability to conceive a child. 


Manicures & Martinis San Francisco
Nova Nail Spa
811 Mission Street in San Francisco
Tuesday, June 9th, 6:00-7:30 PM
RSVP with Vivian:  [email protected] or 646-861-3226
More Details


Manicures & Martinis Laguna Niguel
Accent On Nails
28121 Crown Valley Parkway in Laguna Niguel
Tuesday, June 16th, 6:00-7:30 PM
RSVP with Vivian:  [email protected] or 646-861-3226
More Details

Categories
Fertility Drugs • Infertility • IVF • Ovulation • PCOS • Pregnancy

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