eating while pregnant

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lundi 28 février 2011

Question 42. Can we have sex during a treatment cycle?

Posted on 10:02 by Unknown
Sometimes medical advice makes sense and sometimes it doesn't. Historically, fertility patients have been told to contracept during the month that they plan to start luteal lupron in order to avoid conceiving while on lupron. Actually, the registry of patients that have, in fact, conceived on lupron suggest no risk of birth defects in the children born after this little oops. Years ago in Long Island I had a patient that had 8 years of infertility. She and her husband finally got up the nerve to do IVF and boom, she conceived on lupron. Then 2 years later she wanted to have another baby and voila, she conceived on lupron again! Go figure.

So this recommendation against sex during a luteal lupron cycle has morphed into no sex during any treatment cycle which makes little sense except in a few cases as detailed below. Now if a woman is really bloated and unconfortable while on fertility drugs then that is a totally different issue. In that case we send the partner off to take care of business on his own or encourage then to pursue other ways to avoid delaying ejaculation for weeks before an IUI or IVF procedure.


42. Can we have sex during a treatment cycle?


In general, the answer is yes. Many experts, however, recommend no coitus for 2 to 3 days prior to an anticipated IUI to “build up” the male partner’s sperm count and volume. Also, some men may experience difficulty producing a specimen if they have recently had coitus. For men who have a low sperm count or motility, it is recommended that they abstain from sexual relations for 3 to 5 days prior to a planned IUI. In patients who are at risk for hyperstimulation syndrome, it may be wise to refrain from sex until the ovarian response has been assessed. In patients with an excessive response to fertility drugs the cycle may be abandoned and yet ovulation could still occur. Since the sperm can survive up to 5-7 days after intercourse, a pregnancy could occur even in the setting of a cancelled IUI or IVF cycle.
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mercredi 16 février 2011

Question 41. I read on the Internet that two inseminations are better than one. Is this true?

Posted on 11:29 by Unknown
The internet is quite an amazing place. You get anything you need at 2 am and research obscure medical disorders to your heart's content. But that can be a danger as well. I have been a bit under the weather recently and let me tell you that you do not want to type any ailment into that Google search box unless you are prepared to totally freak out. Seriously. Of course, medical professionals make the worst patients because we know too much about too little and often end up feeding into our own worst fears. It's never just a mole...it's melanoma. It's never just a superficial skin infection...it's flesh eating staph. It's never just a headache...it's a brain tumor. How does this relate to today's Question of the Day? I can' t remember because of my headache.

Oh, now I remember. Two IUIs vs. one......Well, here is the answer.

41. I read on the Internet that two inseminations are better than one. Is this true?

In general, one well-timed IUI is as good as two, and no advantage is obtained by performing a second IUI (providing ovulation was well monitored using blood hormone determinations and follicle ultrasound measurements). However, in patients who are undergoing IUI with less intense monitoring of ovulation, such as urine LH testing, or for those women who chose not to monitor their ovulation at all, two inseminations may be a better option.

Using basal body temperatures as the basis for an IUI’s timing is not recommended, because this method cannot prospectively pinpoint the optimal timing of ovulation for an IUI treatment. The rise in basal body temperature occurs after ovulation, so identifying this temperature increase would not help in scheduling an IUI procedure.
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lundi 14 février 2011

Question 40. How many office visits are required during a typical cycle using fertility drugs and IUI?

Posted on 12:24 by Unknown
TANSTAAFL. This acronym is well known to some. Back in my ill-spent youth I spent a lot of time reading science fiction. One of my favorite authors is Larry Niven (Ringworld, Ringworld Engineers, Children of Ringworld, Fertility Doctors Who Wish They Could Visit Ringworld, etc). He is very fond of acronyms and his protagonists often use these a great deal. TANSTAAFL is an oldie but goodie and means There Ain't No Such Thing As A Free Lunch. In other words, you get what you pay for....In fertility treatment that also can apply. In general, treatments that are more expensive and more invasive cost more than those that are not.

In using fertility drugs and IUI, the number of office visits relates to the goal of therapy and the desire to avoid unwanted complications (Jon and Kate plus 8, OctoMom). So in considering this approach of fertility drugs and IUI we want a couple of follicles but not too many. We also want to catch them before they release the egg so we can time the IUI with an hCG trigger shot. So how many visits does that mean? Or here in DC, how many trips in the HOV lane with an inflatable companion in my passenger seat? Well, that is the Question of the Day from 100 Questions and Answers about Infertility, 2nd Edition....


40. How many office visits are required during a typical cycle using fertility drugs and IUI?


For treatments using Clomid and IUI, only a couple of office visits per month are required. Clomid is usually prescribed at doses of 50-100 mg daily taken on cycle days 5-9. We typically have patients begin monitoring on cycle day 12. At a typical office visit for monitoring, the patient has her blood drawn for hormone analysis, and a pelvic ultrasound is performed to measure the size of the follicles and the thickness of the endometrial lining. The doctor uses this information to determine the optimal timing of the HCG trigger shot and the subsequent IUI. Most patients receive the hCG trigger injection once the follicle size is >20-22 mm mean diameter. This trigger shot will induce ovulation around 36-40 hours later so the IUI is scheduled accordingly or the couple is informed of the best timing for intercourse. Occasionally a patient will demonstrate an LH surge on her own and the timing of the IUI or coitus should take this into account.

For treatment using gonadotropins and IUI, closer monitoring is necessary, perhaps requiring 4 to 6 office visits per treatment cycle. Patients in our practice undergo a baseline sonogram on CD 2-3 to rule out any persistent ovarian cysts from the preceding treatment cycle. If the sonogram is normal, then patients begin the daily injections and usually return to the office after 3-4 days of medication to assess the response to the drugs. Adjustments in the dose of the medications may allow for the optimal treatment response and most patients require 10-12 days of shots before the follicles reach the ideal size. Once again the hCG trigger shot is used to induce ovulation at the appropriate time and the IUI is scheduled accordingly. The actual IUI takes only minutes to perform and is usually painless. We routinely ask our patients to lie on their backs for about 10 to 15 minutes following the IUI procedure. The woman may then return to her normal activities. A pregnancy test is performed usually 14 days following an IUI or 16 days following hCG in couples pursuing timed intercourse.
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mercredi 26 janvier 2011

Let It Snow, Let It Snow, Let It Snow

Posted on 10:57 by Unknown
Here I sit on a Wednesday afternoon watching DC clear out in anticipation of a "major snow event." In the mid-Atlantic this means that a snowflake may be spotted somewhere on the Beltway. I just returned from Boston where I spent a long weekend visiting my parents. As some of you may recall, Boston was hit with yet another major snowstorm last Friday (8-10 inches). Amazingly enough, we left DC on time Friday PM and I don't think that the kids in Boston even got a snow day! It was pretty impressive to see how clear the streets and sidewalks were within a few hours compared with the days of paralysis that we experience here. Oh well. As the Boy Scout motto says...."Be Prepared!" It helps to have a lot of snow removal equipment.

I am pleased to report that my parents continue to amaze us all with their resilience. Both are 87 years old and honestly I really thought that they were in trouble this past summer. My Mom can no longer climb up to the second floor of her house so she has dropped off of the list of active readers of this blog....that leaves 4....


The highlight of the weekend was a party for my older brother Steven who is off to Vermont to become the CEO of a small hospital in the Green Mountain State. There were 50 guests crammed into his home in Newton and it was fun to see cousins that I hadn't seen in years. Yours truly gave a heartfelt speech lauding my brother's accomplishments. My Dad, in true general surgeon form, first called me his "most verbose" child and then followed it up referring to my brother as "accomplishing more than I ever thought possible given how he was as a teenager..." Oh well. Perhaps verbose is accurate as here we are in the 3rd paragraph and you have learned nothing more about reproductive medicine.

So back to reproductive medicine....One pretty consistent truth about fertility treatment is that the treatments that are cheap and easy and require minimal effort don't work as well as those that are more expensive and more intense. However, some patients are ready for intense therapy and some cannot afford it. Also, some insurance companies mandate IUI before IVF so there are many factors that go into the decision to undergo an IUI treatment cycle. So how are the chances for success? Well, that is an excellent question....so excellent that it is today's Question of the Day from the 2nd Edition of 100 Questions and Answers about Infertility...

39. What are typical pregnancy rates for IUI?

The pregnancy rates for IUI vary widely, depending mostly on the female partner’s age and the presence or absence of any other infertility factors. In patients younger than 35 years old, an estimated one-third to one-half of patients will achieve pregnancy within 1 to 4 treatments. In patients with unexplained infertility, most studies demonstrate a per-cycle pregnancy rate of 6% for the Clomid/IUI combination and 9% to 12% for the gonadotropin/IUI combination, compared with a spontaneous pregnancy rate of less than 5% per month. Many fertility doctors will try 1 to 4 cycles of Clomid/IUI and then 1 to 4 cycles of gonadotropin/IUI. If pregnancy has not occurred after the fourth treatment, most experts would abandon these treatments and proceed with more aggressive therapy such as in vitro fertilization. The optimal number of IUI treatment cycles should be individually determined by the patient and her infertility specialist.

Some patients develop a seeming resistance to fertility medications, demonstrating reduced responses with repeated stimulations. This problem is especially prevalent in women who are more than 37 years old. Thus IVF should be considered as a first-line treatment in these patients as opposed to multiple gonadotropin/IUI cycles.
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jeudi 20 janvier 2011

New Year's Resolution

Posted on 11:31 by Unknown
So making my New Year's Resolutions on January 20th is probably not a good sign when one of my resolutions is to stop procrastinating....oh well. I hope that all of you are doing well in this new year of 2011. I think that once you get over the hill you start to pick up speed....that is the only way that I can explain how I managed to get to the 3rd week of January with no additional blogs.

My New Year's Resolutions involve the usual assortment of health related issues as well as being a better parent/spouse/friend/doctor/church member etc. In terms of this blog, however, I resolve to get through all 100 questions from the 2nd Edition of 100 Questions and Answers about Infertility before 2012!

So without further ado here is Question 38....and this question about the use of IUI is commonly asked as most patients would prefer less intense therapy compared to more intense therapy if they could be successful. Of course, if I knew who was going to conceive and who wasn't then I would be God and wouldn't have to come to work anymore.....

38. How do I know if IUI is an option for me and should I use fertility drugs in conjunction with an IUI?

IUI is a good option for many infertile couples. It can be performed in conjunction with a woman’s natural cycle or can be combined with the use of fertility drugs. IUI can also be effectively used in couples who have sexual dysfunction or infrequent coitus for either medical or nonmedical reasons. For example, some couples may have busy work schedules such that one or the other partner is frequently out of town around the time of ovulation. If the male partner’s sperm is obtained and cryopreserved (frozen) in advance of ovulation, the physician (or nurse) can perform an IUI and, ideally, facilitate pregnancy without the woman missing a menstrual cycle.

The best candidates for IUI are those couples without tubal disease (female partner) or severe male factor infertility (male partner). Women with severe endometriosis or a history of pelvic adhesions are not good candidates for IUI. Although couples with male factor infertility can attempt IUI, the success rates are fairly low in such cases, and prompt consideration should be given to IVF (and ICSI) if pregnancy fails to occur after three or four attempts.

IUI in combination with fertility medications may provide a reasonable treatment option for some patients. There appears to be a synergistic benefit to the combination of fertility medications (either Clomid or injectable gonadotropins) with IUI compared to either treatment by itself. For this reason, most infertility experts recommend IUI to their patients when treating them with fertility drugs even if the semen analysis is normal.

In women who fail to ovulate regularly, the goal of drug therapy is to induce the growth and release of a single mature egg. This treatment is known as ovulation induction. In contrast, the treatment goal for women with regular menstrual cycles is to induce the growth of multiple follicles with the subsequent release of multiple eggs. Hence the term superovulation (also called controlled ovarian hyperstimulation) is used to describe this treatement. During a cycle of superovulation and IUI, the goal is to develop 3 to 5 mature follicles, whereas the goal in an IVF cycle is to produce more.

Clomid is usually the fertility drug of first choice for both ovulation induction and superovulation with IUI. Women who fail to respond to Clomid or who fail to conceive may be candidates for treatment with injectable fertility medications (gonadotropins) combined with IUI. In some cases, it is best to skip the treatment with Clomid and instead proceed directly with gonadotropin therapy; this decision depends on the severity of the couple’s infertility situation.

In women who have normal menstrual cycles, it would appear on the surface that IUI alone without fertility drugs would be as successful as IUI with fertility drugs. Unfortunately, this simply is not the case. Instead, the combination of IUI and fertility drugs to induce superovulation yields a synergistic benefit over either treatment alone. However, superovulation (either with or without IUI) can lead to multiple pregnancy. Historically, nearly all of the multiple multiples (such as sextuplets and more) have been the result of superovulation. Unfortunately, there is really no way to control the outcome of this game of reproductive Russian Roulette. Patients must understand that if there are more than two follicles present then the possibility of a high order multiple pregnancy is a reality. In such cases a frank discussion needs to be held with the patient to review the risk and alternatives to avoid a poor outcome.


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jeudi 23 décembre 2010

Merry Christmas

Posted on 09:40 by Unknown
I am wishing you all a very Merry Christmas now as I will be taking some vacation time over these next 10 days. I hope that Santa brings you lots of nice goodies and also hope that you can handle the emotional turmoil that can come with the holiday season. Well-meaning and no so well-meaning friends and relations often feel quite comfortable weighing in on fertility and family matters. All I can say is to hang in there and know that I am hoping and praying for all of you!

And just for grins here is the results of the "Who got photoshopped into the Dominion holiday card" puzzler!



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lundi 20 décembre 2010

Photoshop and Other Holiday Traditions

Posted on 10:11 by Unknown
Here at Dominion Fertility we gather each year around the Christmas tree to take a staff photo. Unfortunately, trying to get everyone together is a bit like herding cats so I end up having to photoshop in the missing staff members. Since this photo doctoring represents the only digital work that I do each year, I end up having to relearn Photoshop each December. So here is the result of my hard work. In a future post I plan to identify which staff members were added after the fact. You may ask "what does this have to do with infertility?" The answer is absolutely nothing but there is nothing wrong with a little change of pace....




Happy Holidays!
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