Recurrent Pregnancy Loss- Emotional Limbo
By jmiller on June 22, 2010
Recurrent pregnancy loss or recurrent miscarriage is emotionally and physically devastating to undergo. Rarely addressed, however is the “limbo” that patients are in prior to the actual physical loss of the pregnancy. Formerly one could only be given the diagnosis of recurrent pregnancy loss if she had experienced 3 consecutive miscarriages. Today, as serial ultrasounds can be employed as early as 5 weeks of pregnancy, abnormal growth can be detected before 7 or 8 weeks. It is heartbreaking for both the patient and the doctor to see that the pregnancy is viable – or growing – but just not growing normally. This is the devastating “limbo period”. The patient is pregnant but this pregnancy will not produce a human being. She feels pregnant. It is impossible to accept that this is not normal! For the doctor it is heartbreaking as well: the measurements of the yolk sac and embryo are abnormal, as is the sac size and shape. There is nothing we can do except wait for the heartbeat to stop in a few days or weeks. Once this occurs, it is acceptable to wait a week to see if the patient miscarries on her own but this, again, is another “limbo” period. A gentle suction curettage should be done to “clean out” the uterus and allow cycles to resume.
And then what? For many women this scenario has happened before. Is it fair to have to endure 3 consecutive miscarriages before instituting a workup for recurrent pregnancy loss? Of course not! Fortunately there are tests that can be done and up to 60% of patients will have successful pregnancies following a recurrent miscarriage. Although this is an encouraging statistic it is vitally important for the loss of the pregnancy and the ensuing grief to be acknowledged and respected.
Beyond the SART Statistics – How to Choose a Good IVF Program
By jmiller on December 14, 2009
The Fertility Clinic Success Rate and Certification Act (HR 4773) was signed into law in 1992. The Act requires IVF programs to report their success rates to the Center for Disease Control. The CDC, in turn, makes this information available to the public via their website (http://www.cdc.gov/ART/ART2006/index.htm). Because the Act also required IVF programs to submit their success rates to an external validation process, the Act reduced the number of clinics advertising unsubstantiated and highly inflated success rates. Unfortunately, the validation process takes more that two years to complete. This year (2009), consumers of infertility services can view validated success rates from 2006. Preliminary rates are available for 2007.
Couples seeking assisted reproductive technologies must consider several important factors when comparing clinic success rates. The CDC has provided a guide for patients (http://www.cdc.gov/ART/ART2006/ifct.htm#Important Factors). Furthermore, reproductive medicine is renowned for the speed at which new methodology, technology, and drugs are incorporated into clinical treatment. Therefore, the success rates from two years ago are of limited value to the patient. Some clinics advertise more recent success rates, but these rates are unverified and should be interpreted with caution. So how do you determine your chances of success at a given clinic? The truth is you cannot. That’s why there is a disclaimer on every clinic-specific report stating that programs cannot be compared based on success rates.
However, there is a way to generally compare programs using the SART clinic-specific report. The great equalizer in IVF is the use of donated eggs. Many of the confounding variables such as diagnosis, maternal age, egg number and quality are eliminated and the entire IVF process is optimized when eggs from a young donor are used. Therefore, the best way to compare programs is to compare the live birth rates for cycles in which donated eggs are used. This will give you a pretty good idea of the competency of the physicians and the quality of the laboratory.
Beyond the SART statistics, there are several factors to look for when choosing an IVF program. One very important factor is the credentials, experience and personality of the physician. SART recommends that a board-certified or board-eligible Reproductive Endocrinologist (RE) act as the Medical Director of the IVF program. A board-certified RE has successfully completed a 2-3 year fellowship training program, a written examination and an oral examination. A board-eligible RE has completed the fellowship training program, but has not yet completed the written and/or the oral examinations. Some doctors who are board-certified in obstetrics and gynecology also offer infertility treatments, but they have not completed subspecialty training in infertility. In addition to formal training, the number of years of experience the doctor has will also play a part. An RE just out a fellowship program may be up to date in the theoretical aspects of infertility treatment, but lack hands on experience. On the other hand, an RE who has been in practice many years (and remained up to date) likely possesses the knowledge and experience to suggest the best treatment option for you. Finally, the doctor’s personality will also play a role in your choice of programs. During your initial consult and in subsequent treatment, you should feel free to ask as many questions as you like and be satisfied with the depth of the answers you receive. A doctor that appears hurried or dismisses your questions with quick answers can leave you anxious and stressed. The more information you have, the more relaxed you will be throughout your treatment.
The IVF laboratory will also play a very significant role in determining your success, but assessing the quality of the laboratory can be tricky. The quality of the laboratory will depend on the credentials and experience of the laboratory staff and the effectiveness of the laboratory procedures and technology employed. According to the CDC guidelines, the Director on an IVF laboratory must be a doctoral level scientist (Ph.D.) or physician, board-certified in clinical embryology. However, the law does not require that the Director perform the procedures or, for that matter, be physically present in the laboratory. In most large programs, the Director provides administrative oversight and does not actively participate in the day-to-day operation of the laboratory. This means that, in many cases, the IVF procedures (insemination, ICSI, embryo culture, assisted hatching, embryo biopsy, etc) are being performed by embryologists. This is not exactly a comforting thought, so you should inquire as to who performs the laboratory procedures and what are their credentials and experience before choosing a program.
The technology utilized by the laboratory is very important. There is no standard IVF method and every IVF laboratory has its own protocols and methods. Some protocols work better than others, but most protocols work reasonably well. Beware of programs offering brand new (and untested) technology, as you may end up being an unwitting research subject. You should also be aware that IVF technology has developed rapidly during the past few years and so programs that have not changed their technology to keep up may not have the highest success rates. Recent advances in the composition of culture medium now make it possible to routinely culture embryos to the blastocyst stage of development prior to embryo transfer. There are several advantages to transferring blastocyst stage embryos. Although programs differ in deciding which patients should have a blastocyst stage embryo transfer, any program that discourages transferring the embryos at the blastocyst stage should probably be avoided.
What should you do if you were referred to or choose and program and now you are not happy with the treatment you are receiving? Simple – change programs! Having established a relationship with a doctor, some people find it very difficult sever that bond of trust. However, one of the biggest mistakes a patient can make is staying with a program that is not meeting their needs. If you are unhappy with your treatment, seek a second opinion or change to a program that meets your needs. When seeking a second opinion, it is important to obtain all the pertinent medical records, lab reports and embryology records.
When choosing an IVF program, the SART-verified success rates, the credentials of the physicians and laboratory staff and the quality of the laboratory should weigh significantly in your decision.
Where’s my doctor?
By jmiller on December 1, 2009
I can’t tell you how many times I’ve heard the same complaint: “After my first visit, I never saw my doctor again”. This is a chronic problem in the large, volume based, fertility factories. When couples seek out an infertility doctor to help them have a baby, they want to establish a bond with their doctor. That is impossible to do if patients are passed off to the doctor of the day every time they come for treatment. In medical parlance, it’s called a breakdown in the continuity of care. Unfortunately, there’s no solution for this problem within a large infertility practice. However, in a smaller infertility practice such as North Hudson IVF, it is not only possible to maintain continuity of care, it is encouraged. We’ve built the practice around the idea that continuity of care is essential and that your relationship with your doctor is a sacred trust. We strive to be available to patients day or night. If you have questions or concerns about your infertility treatment, I encourage you to call our office or page me day or night. We want to help.
Infertility Treatment in New York and New Jersey – You get what you pay for.
By jmiller on November 17, 2009
As health insurance providers cut costs and maximize profits by denying access to care and treatment to their policy holders, one thing is becoming painfully obvious: you get what you pay for. Most employer-provided health insurance policies do not pay for infertility treatments. Their reason for not covering infertility treatments is pretty straight forward. While undergoing infertility treatments, employees will probably come in late a few times, miss some days of work, and if successful, take time off for maternity leave. From the employer’s point of view, covering infertility treatments is a losing proposition. Some of the more compassionate employers will offer their employees the opportunity to purchase a rider to their policy that covers infertility treatments, but the policy rider may restrict treatment to in-network providers. That brings us to the next problem.
Contracted, in-network healthcare providers (like large IVF centers), have agreed to accept the reimbursement schedule of the health insurance companies. To maximize profits for the health insurance company, the reimbursement the IVF center for each IVF cycle is low. But, the insurance company guarantees the IVF center a large number of patients through their in-network referral system. In this way, the low reimbursement rate can be compensated for by a higher volume of patients. Although this makes sense from a business point of view, nothing could be worse for the patient. To accommodate the high volume of patients, individualized treatment is abandoned for a one-size-fits-all approach. Laboratory procedures are streamlined and embryo transfers occur on Day 3. Communication between the doctor and the patient is minimized and most patient calls are triaged by the office staff. Patients don’t see the same doctor throughout treatment. Continuity of care is replaced by the doctor-of-the-day. The patient feels caught up in the whole impersonalized process and rightly so. Welcome to the Fertility Factory.
Out-of-network providers are under no such constraints. They can, and do, provide the level care that they believe to be the most beneficial in treating the infertility patient. However, there’s a catch. Out-of-network providers charge extra. But, like most things in life, you get what you pay for. North Hudson IVF is an out-of-network provider and, as such, can provide personalized treatment that has a high probability of success.
Advanced Infertility Treatments in New Jersey – Sperm Morphology: The importance of being in shape.
By jmiller on October 16, 2009
The shape (morphology) of a sperm is an important determinant of its fertilizability. The egg is enclosed in a protein coat called the zona pellucida (ZP). The ZP performs many functions, but its first task is to select which sperm will fertilize the egg. The ZP bases its selection on the shape of the sperm head. In order to pass through the ZP, the sperm must be vigorously motile and the sperm head must be a symmetrical, oval shape of the appropriate size. Sperm possessing heads that are irregular in shape, too round, too long, too big or too small are prevented from passing through the ZP. It turns out there’s a pretty good reason for this. Abnormally shaped sperm often contain abnormal DNA. That is, an abnormally shaped sperm may be short a chromosome or have an extra chromosome or the DNA is packed into the sperm head in such a way so that, if that abnormally shaped sperm were to enter the egg, the DNA would get all tangled up when it tries to form chromosomes inside the egg. Therefore, nature has evolved a way to keep abnormally shaped sperm from getting inside the egg and thereby maximizing the genetic development potential of the embryo.
A sperm morphology score is usually determined during the course of a semen analysis. A microscope slide is prepared with a very thin coating of semen. The slide is stained to make the sperm clearly visible and several hundred sperm are then viewed under high magnification and individually scored “normal” or “abnormal” based on their shape. The percentage of normally shaped sperm is then calculated. There are two criteria currently in use to evaluate the normalcy of the sperm morphology. The World Health Organization developed the original criteria. Using these criteria, sperm with borderline morphology (slightly abnormal) were considered good enough and scored as normal. Unfortunately, sperm morphology scores using WHO criteria were not predictive of the fertilizability of the sperm. In 1987, new stricter criteria (Kruger Strict) were introduced. These new criteria classified borderline sperm as abnormal. The sperm morphology scores using the strict criteria classification system were highly predictive of the fertilizability of the sperm. Based on results from in vitro fertilization studies where a fixed number of sperm were used to inseminate each egg, when the percentage of normally shaped sperm dropped below 14%, fertilization began to decline. When the percentage of normally shaped sperm dropped below 4%, fertilization was very poor or non-existent.
Needless to say, poor sperm morphology may have a significant impact on the outcome of therapeutic procedures such as intrauterine insemination (IUI) and in vitro fertilization (IVF). However, recent studies suggest that below normal sperm morphology appears to have less of an impact on the success of IUI. This is probably because of the number of sperm used to inseminate. The normal morphology score is, after all, a percentage of the total number of sperm. Because it is common to places tens of millions of sperm in the uterus when performing an IUI, there’s probably enough normally shaped sperm to get the job done. However, IVF is a different story. To compensate for when the normal morphology is between 4% and 14%, more sperm can be placed with each egg. This usually overcomes the problem, unless there is a concomitant problem with the sperm motility. However, when normal morphology falls below 4%, the problem can no longer be overcome by simply adding more sperm. In these cases, intracytoplasmic sperm injection (ICSI) is usually performed to ensure adequate fertilization. However, this is not a panacea since fewer embryos continue development to the blastocyst stage following ICSI with sperm from individuals with poor sperm morphology (even when great care is taken to inject only normally shaped sperm).
When I report semen analysis results to patients that have below normal sperm morphology scores, invariably I’m asked, “What can I do about it?” There are three main causes of poor sperm morphology: (1) a genetic trait, (2) exposure to toxic chemicals and (3) increased testicular temperature. Nothing can be done if it is a genetic trait, however, the other two causes may be reversible. People can be exposed to toxic chemicals in the workplace or at home. For example, people working in automotive paint shops or as janitors are often exposed to a myriad of chemicals known to be detrimental to fertility. Individuals with occupational exposure to toxic chemicals need to be mindful of the impact of these chemicals on their fertility and follow all safety guidelines. Many household items, if used without proper ventilation, can also cause problems with sperm morphology. Increased testicular temperature is another common cause of poor sperm morphology. Seemingly benign occupations that require individuals to spend the majority of their day sitting at a desk can also be problematic. When sitting for a prolonged time, the testicles are drawn up close to the body resulting in an increase in testicular temperature. Those individuals may be advised to get up and walk around periodically to return the testiclular temperature to normal. Sleeping in tight fitting clothing (like jockey shorts) can increase scrotal temperature to a point where sperm morphology is affected. A varicose vein in the scrotum (varicocele) will increase scrotal temperature. The urologist can usually repair a varicocele surgically. However, improvement in sperm morphology is seen in only about half the cases and it may take up to 18 months to see an improvement.
As a final note, sperm morphology scores can change a few percent from month to month and vary considerably amongst labs evaluating the same semen specimen. A single abnormal sperm morphology score is not conclusive. This is true for all seminal parameters. When the results of semen analysis are abnormal, the test should be repeated in 1-2 months to confirm the abnormality.
Happy Holidays from North Hudson IVF
By jmiller on December 19, 2008
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For more information regarding infertility treatment options in Bergen County, New Jersey, please fill out the form below.
North Hudson I.V.F.
385 Sylvan Avenue,
Englewood Cliffs,
New Jersey 07632
Ph. (201) 871-1999
Fx. (201) 871-1031