Question 35. Are there medical treatments for endometriosis?

Occasionally I am asked to see a patient with endometriosis who is not interested in fertility. Although I can certainly manage these patients, I honestly think that they are better served by going to a non-fertility clinic RE. Our practice is pretty much 100% geared to the needs of fertility patients and I wonder if those patients who are not seeking pregnancy ultimately feel like a fish out of water in our waiting room....

Fortunately there are some effective medical treatments for endometriosis. Unfortunately, all of these treatments shut down reproduction so they are not appropriate for the endometriosis patient seeking pregnancy.

Meanwhile I wanted to share the exciting news that the 2nd Edition of 100 Questions and Answers about Infertility is at the printers! Let the presses roll!

35. Are there medical treatments for endometriosis?

Several medications are used to treat endometriosis. All of these medications suppress ovulation and cause a hypoestrogenic state. Understandably, suppressing ovulation also prevents pregnancy from occurring so medical therapy is not appropriate in patients actively seeking fertility. In patients who are not trying to conceive, medical treatment of endometriosis can be very beneficial and relieve symptoms of dysmenorrhea and pelvic pain.

One common medical treatment is to prescribe the combination oral contraceptive pill. Although each of these daily pills contains estrogen, the progestin (progesterone-like component) in the pill overrides the estrogen effect, resulting in suppression of endometriotic lesions. Oral contraceptive pills are effective in 30% to 60% of patients with endometriosis-related pain.

Many physicians prescribe gonadotropin-releasing hormone (GnRH) analogs (such as Lupron), which reduce estrogen levels to postmenopausal levels for their patients with endometriosis. These medications suppress estrogen production, prevent ovulation, and cause atrophy of the endometriosis in 70% to 90% patients. Unfortunately, GnRH analogs are expensive and must be given as injections either once a month or every 3 months. GnRH agonists can cause side effects including headaches, hot flashes, moodiness, insomnia, and vaginal dryness. To counteract these side effects experienced by many patients treated with GnRH agonists, physicians often prescribe oral contraceptive pills or supplemental progestin therapy (such as norethindrone) along with the GnRH analogs. This combined therapy ay allow for improved treatment acceptance through the alleviation of the many side effects associated with the use of the GnRH analogs as single therapy. Patients tolerate this combination very well and achieve maximal benefits in suppressing the disease and its symptoms.

As noted previously, medical therapy is not indicated for patients with endometriosis who are actively trying to conceive, since all of these treatments will suppress ovulation. Instead, for these patients, the goal should be to promptly establish pregnancy before the endometriosis causes any further damage to the reproductive organs. Generally, these women should seek treatment from a fertility expert to maximize their chances for successful pregnancy.

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Question 34. Does surgery for endometriosis improve pregnancy rates?

Where does all the time go? Seems like just yesterday that I was writing the last post before I went on vacation and now I realize that a whole month has passed. You may have wondered "where is Dr. Gordon?" "Why hasn't he posted a new blog that will make our day a little brighter and put a little more zip in our step?" "Why do the 6 of us keep reading this blog if he doesn't care enough about us to spend just a few minutes posting his words of wisdom?" "Why didn't I buy Apple stock at $25?" Wait that last question is the one that I keep asking myself. Not to be a name dropper but my son was in preschool in California with Steve Job's son Reed. Man, if only they had become best buddies.....unfortunately, my son thought that Reed was weird and wouldn't play with him. Apparently, when you are 3 years old it doesn't matter when some kid's father is worth 6 Billion dollars. But I digress....

So in a couple of weeks we are having a CME (doctor's continuing education) course at Fairfax Hospital. One of the questions concerns surgery for endometriosis. Guess what? No one is really sure of what to do in some of these cases. Overall, we seem to be moving away from surgery for the infertile patient, and yet, there are still occasional patients that would benefit from a laparoscopy. The problem is figuring out who would benefit from surgery and who will not. In starting to address that issue I will present today's Question of the Day from the 2nd Edition of 100 Q&A about Infertility (which is currently being printed!):

34. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small implants of endometriosis can improve fertility by as much as 50%. In a large Canadian study, the monthly pregnancy rate following surgical treatment of minimal endometriosis rose from 3% to 4.5%. Although this finding represented a 50% improvement in the patients’ monthly chance of pregnancy, it does not compare very favorably with IVF pregnancy rates, which average above 30% for a single treatment cycle. Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most surgeons will do their best to destroy endometriosis at the time of laparoscopy by using either laser or coagulation techniques. In addition to improving fertility, surgery may often eliminate or improve symptoms of dysmenorrhea and pelvic pain.

Ovarian cysts that contain endometriotic tissue may grow quite large. They are often called “chocolate cysts” because of the dark brown fluid found within them, although endometriosis cysts are more correctly referred to as endometriomas. If left untreated, these growths may destroy part or all of the normal ovarian tissue, including the eggs. Endometriomas must be surgically removed, usually via laparoscopy, as medical therapy is ineffective in the treatment of endometriomas. The ultimate choice of whether to perform a laparoscopy or laparotomy depends on the operative findings and the skill and experience of the surgeon.

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Question 33. What is endometriosis and how is it diagnosed?

You know I should have really been an Orthopedic Surgeon. I have spent so much time in their offices recently that I could have been much more useful to my family if I had specialized in something more practical. Of course, then we probably would have had fertility problems instead.....

On the other hand, endometriosis is a problem that I know something about.....But that being said, our understanding of the link between endometriosis and infertility remains less than clear cut. It was not unusual to diagnose endometriosis in a patient undergoing a laparoscopic tubal ligation in a woman with several children so the impact on fertility may be difficult to predict on a case-by-case basis.

So today's Question of the Day concerns some basics about endometriosis....

33. What is endometriosis and how is it diagnosed?

Endometriosis is a chronic disease characterized by the growth of endometrial-like tissue beyond the normal confines of the uterine cavity, Endometriosis is usually diagnosed at the time of laparoscopic gynecologic surgery although endometriosis cysts (endometriomas) may be presumptively diagnosed on ultrasound. Endometriosis is the presence of endometrial-like tissue located outside of the uterine cavity. Most commonly, it is located on the ovaries, but it can also be found on any of the organs inside the pelvic–abdominal cavities.

Although there are several theories about formation of endometriosis, it seems likely that retrograde menstruation (the passage of menstrual debris out of the ends of the fallopian tubes and into the pelvis) plays a major role. Some women may be unable to effectively remove this tissue allowing lesions to form and grown with continued hormonal stimulation. Since the endometrium sheds through menstrual bleeding every month during menstruation, the endometrial tissue that comprises the endometriosis implants will also respond in kind. This phenomenon leads to inflammation of the pelvic reproductive organs, causing pelvic pain, painful periods (dysmenorrhea), and infertility. Pelvic adhesions or scar tissue may also develop. However, since endometriosis has been described in areas outside of the pelvis (eye, lung, brain, etc.), the retrograde menstruation theory cannot account for all cases of endometriosis.

Endometriosis may be suspected when patients complain of increasingly severe dysmenorrhea, pelvic pain, or infertility, but remember that it can be definitively diagnosed only via surgery. Most often, a diagnostic laparoscopy—a simple outpatient surgical procedure—is used to diagnose endometriosis. Other nonsurgical techniques such as ultrasonography, CT scan, or MRI can occasionally be helpful in their abilities to detect endometriosis.

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Question 32. Should I consider using a sperm donor to conceive?

So first we had Snowmaggedon and the Gordon family was without power for six days and now we have experienced Summerggedon! Sunday afternoon an intense thunderstorm ripped through the Washington DC area and did widespread damage. Over 300,000 taxpayers were without power and that included yours truly. Fortunately the power was restored last night after more than 48 hours of pioneer living. Needless to say we were very happy to rejoin the 21st century. On the other hand, the simplicity of going to sleep soon after sundown and waking up early in the morning fully refreshed should not be underrated. Simple can = good.

This concept can also apply to cases of severe male factor infertility. Not all couples are prepared to go the distance in terms of IVF/ICSI with testicular sperm in cases of azoospermia. A few years ago I had a couple that came to me following a talk that I gave regarding donor egg. She was relatively young and he had extremely low sperm counts. They had already spent almost $100,000 on fertility treatments and were now considering donor egg IVF using his sperm. Apparently no one had discussed the use of donor sperm with them. They quickly decided that this approach made more sense and 3 weeks later she had an IUI with donor sperm in a natural cycle (not even clomid). She delivered a full-term healthy baby 9 months later. Total cost....about $2200. Not a bad deal!

So should you consider using donor sperm or as Lois (our former beloved front-desk manager) used to call it - "man in a can"? Well that is the topic of today's Question of the Day from 100 Questions and Answers about Infertility.

32. Should I consider using a sperm donor to conceive?

Couples who desire a child but in whom the male partner has a very low sperm count (oligospermia) or no sperm at all (azoospermia) often consider using third-party sperm donation and artificial insemination. Donor sperm can also be used by single women or lesbian couples. Many high-quality, reputable commercial sperm banks exist. They recruit and thoroughly test the donors and provide a listing of their available donors and their characteristics from which the couple can then choose. The donated sperm is obtained from the donor, tested, and quarantined for at least 6 months at the sperm bank. The donors are then retested to ensure that they are still free from any sexually transmitted diseases.

The specimen is released for use only after the tests results confirm the donor is free from any infection. The frozen sperm is then shipped to the physician’s office, and artificial insemination is performed around the time of the woman’s ovulation. Placement of the sperm inside the uterus (IUI) results in better pregnancy rates than placement of the sperm in the vagina or cervix. Frozen donor sperm can also be used for more advanced fertility procedures such as gonadotropin/IUI or IVF with or without ICSI. If a woman wishes to use sperm from a known donor with whom she does not have a physical relationship, then the sperm may need to be quarantined for at least 6 months and the donor retested for infectious diseases before the specimen can be used for fertility treatments.

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Setting the Record Straight About NC-IVF

I am posting this recent blog by Dr. DiMattina which addresses some recent inaccurate information about Natural Cycle IVF that is circulating out in cyberspace.

DrG


Hello Everyone!

Recently, there have been many mistruths appearing on-line about our NC-IVF program. So, I am writing to set the record straight and provide you with honest information about our experience with NCIVF. As you well know, the internet provides a platform which all too often provides only one side of a "story" and unfortunately, far from reality too.

By way of background, because of our high success we experienced with our stimulated IVF program, in January, 2007, we decided to add a NCIVF program for our patients as most of our patients achieving pregnancy in our stimulated IVF program had only one or two embryos transferred. Thus, we believed that many of our patients did not require ovarian stimulation drugs and the high costs associated with stimulated IVF.

Six weeks ago, we submitted 4 papers describing our experience with NCIVF to the American Society of Reproductive Medicine(ASRM) annual meeting in October, 2010. All 4 abstracts were accepted by ASRM. First, let me say that after 3 and a half years of performing NCIVF, we remain most enthusiastic about the success of our program and especially so for 2010.

So, here are some of the facts about our NCIVF program from 2007 to 2009 as presented to the ASRM: First, on-line there are individuals claiming that most of our patients never made it to an egg collection and instead they underwent an IUI rather than the intended egg collection. The FACT is: 86% of our patients who started our NCIVF program went to egg collection and an egg was retrieved in 88% of these patients. So, the vast majority of our patients not only made it to an egg collection but also had a successful egg retrieval. IUI occurred in less than 15% of our patients! And successful embryo transfer occurred in 56% of the patients who had an egg obtained. Overall, 35.3% achieved a clinical pregnancy per embryo transfer. In my opinion, not bad for only one egg and one embryo! Cumulatively, of course, with more embryo transfers, the total pregnancy rate is even higher. In fact, our very first patient to deliver from our NCIVF program, delivered again last year from a repeat NCIVF treatment.

Second, misstatements were made concerning our costs and profit motives. We currently charge $4,400 for a completed NCIVF treatment and it is prorated. If a patient does not make it to an egg retrieval, then the cost is prorated to $1,400 and the rest either refunded to the patient or credited towards another treatment. In our NCIVF program, we routinely perform ICSI without an added charge since there is only one egg. Compare these costs to a stimulated IVF cycle where the drugs alone cost about $5,000, the treatment cycle itself about $9,500 and another $1,500 to $2,000 for ICSI. Thus, the total costs for a stimulated IVF cycle can be $15,000 or more. In my opinion, DF is not only cost conscious for our patients, but the most cost conscious fertility center in town since we were the first and perhaps still the only IVF center in the Washington DC area to offer and produce babies using NCIVF. Interesting to me that NCIVF is routinely performed in over 50 countries around the world but not so in the US.

Critics of NCIVF say that it may take many treatments before one achieves pregnancy. The FACT is: 64% of the pregnancies that occurred in our NCIVF program were achieved in the FIRST treatment cycle and 21% in the second. So, we usually only recommend one to three treatments of NCIVF to our patients.

So, here is the truth about our experience with our NCIVF program and we are most proud of our accomplishments and success. NCIVF is not a "cure-all" for infertile couples, rather another option for many. I wish all of you the very best in obtaining your fertility goals.

-Dr. Michael DiMattina

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Question 31. What can cause my husband to have no sperm at all and can we still have children together?

Summer is in full swing here in Washington DC and we are really getting cooked these past few weeks. I have been trying to be a real handyman this past week and have been granted a special dispensation by my wife in regards to the use of power tools. My project has been to strip off the paint and rust of an old patio set by using my power drill and a steel brush. Actually it has been very gratifying to see years of rust submit to my efforts. Does this have anything to do with infertility and IVF? Probably not, except that being a man is more than doing projects around the house and it is more than being able to father children. Being a father or a mother has everything to do with what happens after delivery or adoption.

We understand the desire to be genetic parents and will make every effort to accomplish that goal. However, every couple must decide what being a parent means for them. For some, the use of donor sperm or donor egg or both or adoption are all acceptable choices. For others, these are not options....or at least not options until the others have been fully explored.

Today the Question of the Day concerns men with no sperm at all on semen analysis. It is a true miracle of medicine that some of these men can become genetic parents through IVF and ICSI. So keep the AC cranked and read on. Plus, if anyone can explain why my hands get blue paint on them when I touch my repainted patio set even after it has dried I would really appreciate it....I must not be a real man after all...

31. What can cause my husband to have no sperm at all and can we still have children together?

Assuming that there was not a problem in collecting the specimen, the absence of sperm on a semen analysis—a condition known as azoospermia—requires thorough evaluation. Azoospermia can be divided into two major categories: obstructive and nonobstructive.

Obstructive azoospermia occurs when the duct carrying the sperm from the testicle to the urethra becomes blocked. This blockage may be the result of previous surgery on the scrotum or testicle, or even follow repair of an inguinal hernia. During hernia surgery, the vas deferens may be inadvertently damaged or even cut. Scar tissue that blocks the vas deferens can form either postoperatively or as the result of an infection (most commonly gonorrhea, though other infectious diseases may also cause blockage of the sperm duct).

Congenital bilateral absence of the vas deferens (CBAVD) leads to some men being born without a vas deferens on either side and is associated with the gene for cystic fibrosis. CBAVD is a rather unusual presentation of cystic fibrosis as it occurs in the absence of any chronic lung disease. For this reason, any man with azoospermia associated with congenital absence of the vas deferens should undergo genetic testing to determine whether he carries the gene that causes cystic fibrosis.

Nonobstructive azoospermia results from dysfunctional sperm production as opposed to an anatomic issue and can represent a more problematic situation. The failure of sperm production in an otherwise normal testis may be the result of either a testicular issue or a pituitary or hypothalamus issue. If a hormonal evaluation reveals normal levels of prolactin and thyroid hormone, then testicular sperm production may have failed. If this finding is associated with an elevated FSH level, then the chance of finding any sperm production in the testis is quite unlikely. A testicular biopsy is often performed to assess whether any sperm are present within the testis. Even very low levels of sperm production may allow for attempts at IVF using ICSI. Genetic testing to rule out a chromosomal problem is often suggested in cases of very low or absent sperm production. We suggest that men undergoing a testicular biopsy arrange for cryopreservation (freezing) of viable sperm in order to avoid having to undergo a second biopsy procedure.

The use of IVF with ICSI can allow couples to successfully achieve pregnancy even in cases of obstructive or nonobstructive azoospermia. Sperm that is removed from the epididymis or the testicle may look excellent but is incapable of fertilizing an egg since it has not undergone the final changes that result in fully capacitated sperm. The introduction of ICSI in 1993 revolutionized the treatment of male factor infertility. To obtain sperm for use in IVF/ICSI, a needle aspiration of the testis or epididymis can be performed under local anesthesia in cases of obstructive azoospermia. If the male partner has nonobstructive azoospermia, a urologist usually performs a testicular biopsy in the hospital while the patient is under general anesthesia as sperm production may be severely impaired necessitating the removal of more testicular tissue in order to have an adequate sample. In either case, the testicular tissue or the sperm aspirate can be frozen in liquid nitrogen and maintained relatively indefinitely. If a testicular biopsy reveals no mature sperm, then the only option is to use donor sperm or to pursue adoption.

Occasionally, the sperm retrieved through a testicular biopsy or needle aspiration is of exceedingly poor quality. In such cases, a repeat testicular biopsy on the day of egg collection for IVF or even use of a cryopreserved specimen from an anonymous sperm donor may be considered as a backup plan.

Rarely, men with diabetes or those taking certain antihypertensive medications may suffer from retrograde ejaculation. In this condition, there is no emission of fluid with male orgasm because all of the fluids travel backward into the bladder instead of out through the urethra. Retrograde ejaculation can easily be diagnosed by checking the post-ejaculation voided urine for sperm. Sperm present in the man’s urine can be washed and used for either insemination or IVF. Pretreatment with bicarbonate the night before sperm collection may improve sperm quality by increasing the pH of the urine.

One final (and interesting) cause of azoospermia is anabolic steroid abuse. Some men with azoospermia may have used testosterone or other steroids as part of their strength and conditioning training. High doses of these steroids can suppress sperm production. Sperm production can be reinitiated in such patients by stopping the steroids and starting gonadotropin therapy (analogous to ovulation induction therapy in women). Although clomiphene citrate has been used to improve sperm quality in men, most studies reveal it to have little to no benefit.

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Question 30. Is there anything my husband can do to improve his sperm count, such as wearing boxers not briefs, taking vitamins or undergoing surgery?

As we approach the all-star break in the MLB season (Go Red Sox!) I would like to present a theory I have about guys and their resistance to having a semen analysis. If I had a dollar for every husband or male partner that said "I don't need any tests. I am fine. I have gotten several women pregnant." then I would have a lot of dollars. Now, getting beyond the fact that most women would not choose such an insensitive dolt as the parent of their yet to be conceived child...I always tell the guys that the proof is in the pudding and we need to do the test.

So why the resistance? It could be embarrassment about producing a sample. But I think it is deeper than that....it is all about the numbers. For decades these men have been memorizing batting averages, on-base percentages, ERAs and the like. Suddenly they are going to be reduced down to a number....a sperm number and it is anxiety provoking.

When I tell women their FSH level or their AMH level or their antral follicle count, they almost never yell out or high five their husbands....not so when the guys get their numbers. So what can a guy do if his numbers are more suited to AAA ball than MLB...well, not a lot as we can see in today's Question of the Day from 100 Questions and Answers about Infertility.

30. Is there anything my husband can do to improve his sperm count, such as wearing boxers and not briefs, taking vitamins or undergoing surgery?

Semen analysis results demonstrate considerable variation from sample to sample, which complicates research efforts to identify specific dietary or lifestyle change that might potentially improve sperm quality. Although the presence of a varicocele has been suggested to play a role in male infertility, the benefit of varicocelectomy remains controversial.

Some studies have suggested that wearing boxers instead of briefs can improve a man’s sperm count. The avoidance of extremely high temperature may also improve sperm counts, so care should be taken to avoid prolonged exposure to extremely high temperatures, such as within a sauna or a hot tub. Years ago on Long Island, Dr. Gordon had a patient whose husband owned a pizzeria. Once he stopped working 18 hours a day in front of the pizza ovens and moved to the cash register and away from the heat, his sperm count normalized and they conceived spontaneously.

The effects of a variety of nutritional supplements on semen have been studied with some researchers suggesting that antioxidants may improve sperm quality, thereby leading to improved pregnancy rates (the desired outcome). Although the data on nutritional supplements with antioxidant properties are somewhat limited, a commercially available product based on this research is available (Proxeed, Sigma-Tau Pharmaceuticals). This nutritional supplement is available for purchase only over the Internet. Although it has been frequently prescribed by some urologists, additional studies are required to confirm its benefits.

Surgical treatments for male factor infertility are very limited. Historically, varicocelectomy has been the surgical procedure most commonly used to improve sperm quality. In this procedure, dilated veins in the scrotum (varicocele) are cut or occluded. One theory is that these dilated veins may increase the scrotal-testicular temperature, thereby diminishing the sperm quality. By cutting the veins, the scrotal temperature is restored to normal and fecundity may be improved.

Unfortunately, well-designed controlled studies have not shown any statistical increase in pregnancy rates following varicocelectomy. Furthermore, many fertile men have varicoceles. Today, this procedure is rarely, if ever, indicated. In most cases of male factor infertility, the best treatment involves intrauterine insemination (IUI) or, more often, proceeding directly with in vitro fertilization (IVF) and possibly intracytoplasmic sperm injection (ICSI).

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