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jeudi 24 avril 2008
vendredi 4 avril 2008
Sorry for the large gap between posts but I actually took some vacation and have been paying for it ever since. Usually it takes at least a week to catch up and handle all the questions that have been raised over the previous week. This torture explains why my vacation schedule is pretty sparse!
Once back here at Dominion I was interested in the Grand Rounds lecture given at Inova Fairfax Hospital this past Monday. The topic was the surgical treatment of endometriosis and infertility. Specifically the question of removal of endometriomas was raised and discussed. Basically, there are no good randomized studies so one is left with the choice of doing IVF with an endometrioma just sitting there, or taking a patient to the operating room before IVF. There may be an increased risk of infection after egg collections where an endomtrioma is pierced. However, the absolute risk of infection after egg collection remains very low. Removing the endometrioma removes this risk but may further damage the ovary reducing the egg count… Decisions, decisions…
Ultimately, there is no clear cut answer here so I try to individualize based upon the patient and her history. Hopefully, your RE will do the same.
So after much delay here is today’s Question of the Day from the book that we shamelessly promoted on the Kane Show (click here to hear us on the air) on 99.5 FM here on Tuesday .
37. Does surgery for endometriosis improve pregnancy rates?
Well-designed medical studies clearly show that destroying even small amounts of endometriotic tissue 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 around 30% for a single treatment cycle.
Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most doctors will destroy the abnormal endometriotic tissue at the time of the diagnostic 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. Sometimes, however, laparotomy is required. The ultimate choice of which surgery is performed depends on the operative findings and the skill and experience of the surgeon. Medical treatment of endometriomas is insufficient and will not cause these cysts to resolve.
Once back here at Dominion I was interested in the Grand Rounds lecture given at Inova Fairfax Hospital this past Monday. The topic was the surgical treatment of endometriosis and infertility. Specifically the question of removal of endometriomas was raised and discussed. Basically, there are no good randomized studies so one is left with the choice of doing IVF with an endometrioma just sitting there, or taking a patient to the operating room before IVF. There may be an increased risk of infection after egg collections where an endomtrioma is pierced. However, the absolute risk of infection after egg collection remains very low. Removing the endometrioma removes this risk but may further damage the ovary reducing the egg count… Decisions, decisions…
Ultimately, there is no clear cut answer here so I try to individualize based upon the patient and her history. Hopefully, your RE will do the same.
So after much delay here is today’s Question of the Day from the book that we shamelessly promoted on the Kane Show (click here to hear us on the air) on 99.5 FM here on Tuesday .
37. Does surgery for endometriosis improve pregnancy rates?
Well-designed medical studies clearly show that destroying even small amounts of endometriotic tissue 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 around 30% for a single treatment cycle.
Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most doctors will destroy the abnormal endometriotic tissue at the time of the diagnostic 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. Sometimes, however, laparotomy is required. The ultimate choice of which surgery is performed depends on the operative findings and the skill and experience of the surgeon. Medical treatment of endometriomas is insufficient and will not cause these cysts to resolve.
mercredi 12 mars 2008
Before I jump into today’s topic I wanted to put a plug in for a local patient information seminar sponsored by RESOLVE. The volunteers at RESOLVE do an outstanding job and this conference (April 12, 2008, 8 am til 5pm at the Bethesda, MD Hyatt Hotel) provides a real resource for patients especially in regards to adoption information. http://www.resolve.org.
Now back to our issue at hand…
Every week it seems that I discuss fibroids with my patients…and it is often a rather complex discussion. Fibroids are extremely common, benign tumors of the uterus. They are found in over 50% of women and can range in size from <1cm>50% inside the cavity may be removed with hysteroscopy but those that are not require laparotomy (bikini incision). I am not a proponent of laparoscopic myomectomy unless the fibroid is on a stem. I believe that the repair is inferior through the laparoscope.
Uterine fibroid embolization is a newer approach that should not be used in fertility patients as the technique leaves a large amount of devascularized (no blood supply) tissue and may thus adversely affect fertility.
So here is today’s Question of the Day.
96. Can fibroids or other uterine problems cause infertility or miscarriage?
Anatomical abnormalities can predispose a woman to preg- nancy loss. In particular, congenital uterine abnormalities such as a uterine septum (fibrous band separating the uterine cavity into two smaller cavities) or a unicornuate uterus (a small malformed uterus that is usually connected to a single fallopian tube) can lead to poor reproductive outcomes. Uterine malformations as a result of prenatal exposure to diethylstilbestrol (DES; see Question 66) can also increase a woman’s risk of a poor pregnancy outcome. The presence of uterine fibroids within or abutting the endometrial cavity has been proposed as a source of pregnancy loss (see Figure 7); the same is true of uterine polyps. Extensive intrauterine adhesions from a previous dilatation and curettage (D&C) procedure may also lead to reduced reproductive success. All of these abnormalities may be amenable to surgical correction, but the decision to pursue surgery requires a careful discussion with your physician.
Now back to our issue at hand…
Every week it seems that I discuss fibroids with my patients…and it is often a rather complex discussion. Fibroids are extremely common, benign tumors of the uterus. They are found in over 50% of women and can range in size from <1cm>50% inside the cavity may be removed with hysteroscopy but those that are not require laparotomy (bikini incision). I am not a proponent of laparoscopic myomectomy unless the fibroid is on a stem. I believe that the repair is inferior through the laparoscope.
Uterine fibroid embolization is a newer approach that should not be used in fertility patients as the technique leaves a large amount of devascularized (no blood supply) tissue and may thus adversely affect fertility.
So here is today’s Question of the Day.
96. Can fibroids or other uterine problems cause infertility or miscarriage?
Anatomical abnormalities can predispose a woman to preg- nancy loss. In particular, congenital uterine abnormalities such as a uterine septum (fibrous band separating the uterine cavity into two smaller cavities) or a unicornuate uterus (a small malformed uterus that is usually connected to a single fallopian tube) can lead to poor reproductive outcomes. Uterine malformations as a result of prenatal exposure to diethylstilbestrol (DES; see Question 66) can also increase a woman’s risk of a poor pregnancy outcome. The presence of uterine fibroids within or abutting the endometrial cavity has been proposed as a source of pregnancy loss (see Figure 7); the same is true of uterine polyps. Extensive intrauterine adhesions from a previous dilatation and curettage (D&C) procedure may also lead to reduced reproductive success. All of these abnormalities may be amenable to surgical correction, but the decision to pursue surgery requires a careful discussion with your physician.
vendredi 29 février 2008
Many of the questions that I answer on the INCIID bulletin board revolve around issues of stimulation. High responders, low responders, unusual responders…you name it. Of course, making pronouncements on cycles that I have never seen, from clinics that I have never heard of and with REs that I personally have never met represents a difficult proposition.
IVF is really an art on some level and we need to carefully pick stimulation protocols and make trigger shot decisions after careful consideration of all the data. We sometimes really agonize over these decisions and that is why we prefer to do our own sonograms so we can get a real feel for whether the follicles are ready….and yet sometime it just doesn’t work out the way you thought that it would….
So after much delay, here is another question from the book that every fertility patient should buy or borrow or steal (OK, not steal) although we have yet to see a dime from our publisher…
62. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?
Although several drugs and protocols are available to stimulate the ovaries to produce extra eggs for IVF, most clinics The first method, called luteal suppression, involves suppression of the ovaries using a GnRH-analog (Lupron) during the luteal phase of the menstrual cycle preceding the planned IVF treatment cycle. Once the ovaries are suppressed, ovarian
stimulation is accomplished with daily injections of gonadotropins (e.g., Gonal-F, Follistim).
In the second method, called flare stimulation, the woman does not take any medications until the second day of her menstrual cycle. At that time, a microdose (most commonly) of Lupron is used to “flare” the pituitary gland and induce it to release its store of FSH and LH. Simultaneously, gonadotropins are started, producing a “one–two punch” in terms of ovarian stimulation. Premature ovulation of the eggs rarely occurs despite the low dose of GnRH agonist utilized in this protocol.
A third, more recent option is GnRH-antagonist stimulation, in which GnRH antagonists are added later in the stimulation to prevent premature ovulation. In this method, the gonadotropins are started on cycle day 2 of a normal menstrual period. Once the follicles have reached a specific size (usually 12 to 14 mm), the woman begins the GnRH-antagonist medication, which almost instantaneously prevents the pituitary gland from generating an LH surge.
Some reproductive endocrinologists prescribe oral contraceptive pills to their female patients prior to beginning the actual ovarian stimulation drugs, but this practice varies between patients and fertility clinics. We have found that the use of birth control pills often results in oversuppression of the ovaries and cycle cancellation except in those patients known to be high responders (women with PCOS, in particular).
The type of protocol selected for any patient (i.e., luteal suppression, flare stimulation or GnRH antagonist) depends on the individual patient and the philosophy of the fertility clinic. Factors that may influence the type of stimulation protocol selected include the patient’s age, her day 3 hormone levels, her follicle antral count as determined by ultrasound, and her previous responses to any other attempts at ovarian stimulation.
IVF is really an art on some level and we need to carefully pick stimulation protocols and make trigger shot decisions after careful consideration of all the data. We sometimes really agonize over these decisions and that is why we prefer to do our own sonograms so we can get a real feel for whether the follicles are ready….and yet sometime it just doesn’t work out the way you thought that it would….
So after much delay, here is another question from the book that every fertility patient should buy or borrow or steal (OK, not steal) although we have yet to see a dime from our publisher…
62. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?
Although several drugs and protocols are available to stimulate the ovaries to produce extra eggs for IVF, most clinics The first method, called luteal suppression, involves suppression of the ovaries using a GnRH-analog (Lupron) during the luteal phase of the menstrual cycle preceding the planned IVF treatment cycle. Once the ovaries are suppressed, ovarian
stimulation is accomplished with daily injections of gonadotropins (e.g., Gonal-F, Follistim).
In the second method, called flare stimulation, the woman does not take any medications until the second day of her menstrual cycle. At that time, a microdose (most commonly) of Lupron is used to “flare” the pituitary gland and induce it to release its store of FSH and LH. Simultaneously, gonadotropins are started, producing a “one–two punch” in terms of ovarian stimulation. Premature ovulation of the eggs rarely occurs despite the low dose of GnRH agonist utilized in this protocol.
A third, more recent option is GnRH-antagonist stimulation, in which GnRH antagonists are added later in the stimulation to prevent premature ovulation. In this method, the gonadotropins are started on cycle day 2 of a normal menstrual period. Once the follicles have reached a specific size (usually 12 to 14 mm), the woman begins the GnRH-antagonist medication, which almost instantaneously prevents the pituitary gland from generating an LH surge.
Some reproductive endocrinologists prescribe oral contraceptive pills to their female patients prior to beginning the actual ovarian stimulation drugs, but this practice varies between patients and fertility clinics. We have found that the use of birth control pills often results in oversuppression of the ovaries and cycle cancellation except in those patients known to be high responders (women with PCOS, in particular).
The type of protocol selected for any patient (i.e., luteal suppression, flare stimulation or GnRH antagonist) depends on the individual patient and the philosophy of the fertility clinic. Factors that may influence the type of stimulation protocol selected include the patient’s age, her day 3 hormone levels, her follicle antral count as determined by ultrasound, and her previous responses to any other attempts at ovarian stimulation.
vendredi 15 février 2008
Trust is at the heart of the doctor-patient relationship. You, the patient, put your trust in me to make the correct treatment recommendations, and I, the doctor, trust that you are being honest with me regarding your history, symptoms, insurance issues etc.
Patients will sometimes ask me to use non-fertility codes during their care in order to get their insurance to cover a particular visit or procedure. This request is known as insurance fraud and I explain that although I am sympathetic to their situation, I am not willing to go to the "big house" on their behalf.
The problem is that doctors may differ in their philosophy, approach and personality. There may be multiple acceptable options for each couple and it takes time to discuss all options as one works towards making a decision.
So how do you know that you can trust the advice that you are getting? First, consider the source. What is your physician's training background...how long has he/she been in practice...does he/she look as young as Doogie Howser (I used to get that a lot but not anymore)....and what services does your doctor offer (full range of fertility treatments; no IVF; only IVF; no Donor Egg etc etc).
Then when you can no longer figure out where to go you can always ask if your RE ever worked as a camp counselor at a Boy Scout Camp...
Have a great weekend!
Patients will sometimes ask me to use non-fertility codes during their care in order to get their insurance to cover a particular visit or procedure. This request is known as insurance fraud and I explain that although I am sympathetic to their situation, I am not willing to go to the "big house" on their behalf.
The problem is that doctors may differ in their philosophy, approach and personality. There may be multiple acceptable options for each couple and it takes time to discuss all options as one works towards making a decision.
So how do you know that you can trust the advice that you are getting? First, consider the source. What is your physician's training background...how long has he/she been in practice...does he/she look as young as Doogie Howser (I used to get that a lot but not anymore)....and what services does your doctor offer (full range of fertility treatments; no IVF; only IVF; no Donor Egg etc etc).
Then when you can no longer figure out where to go you can always ask if your RE ever worked as a camp counselor at a Boy Scout Camp...
Have a great weekend!
mardi 22 janvier 2008
Clearly one of the biggest issues facing our patients is advancing age. We cannot turn back the biologic clock and it is not fair that Strom Thurman can become a father at age 84 and for women after age 35 fertility really starts to drop. If only we had a way to determine the number of health eggs remaining in a woman, then we could give accurate assessments of the chances for success. Unfortunately, there is no test for egg quality that is definitive.
So now that egg freezing seems to be working a bit better the use of this technology to preserve fertility has been debated. A few general issues need to be understood. First of all, although almost 5 MILLION babies have been born after traditional IVF, there have been perhaps around 500 babies born from frozen eggs. The problem is multi-factorial. Many eggs fail to freeze or thaw successfully and those that do need ICSI to endure fertilization. With the increasing adoption of vitrification (rapid freezing that instantly occurs) success rates are on the rise.
However, should this still be considered experimental?? Probably. Should patients have to pay for an experimental procedure? I guess...although this seems inappropriate to me personally (but since we don't offer fertility preservation from egg freezing -- yet, I guess my view is biased).
So this remains controversial. Here is a PDF file of the most recent position statement by the ASRM about egg freezing. It is comprehensive and pretty informative...I think.
Of course, if you want to debate egg freezing with us in person, be sure to drop by the Clarendon Barnes and Noble bookstore on Saturday January 26th from 12 noon until 2 PM. You don't even need to buy a book...
So now that egg freezing seems to be working a bit better the use of this technology to preserve fertility has been debated. A few general issues need to be understood. First of all, although almost 5 MILLION babies have been born after traditional IVF, there have been perhaps around 500 babies born from frozen eggs. The problem is multi-factorial. Many eggs fail to freeze or thaw successfully and those that do need ICSI to endure fertilization. With the increasing adoption of vitrification (rapid freezing that instantly occurs) success rates are on the rise.
However, should this still be considered experimental?? Probably. Should patients have to pay for an experimental procedure? I guess...although this seems inappropriate to me personally (but since we don't offer fertility preservation from egg freezing -- yet, I guess my view is biased).
So this remains controversial. Here is a PDF file of the most recent position statement by the ASRM about egg freezing. It is comprehensive and pretty informative...I think.
Of course, if you want to debate egg freezing with us in person, be sure to drop by the Clarendon Barnes and Noble bookstore on Saturday January 26th from 12 noon until 2 PM. You don't even need to buy a book...
jeudi 17 janvier 2008
Many of the questions that I answer on the INCIID (www.INCIID.org) bulletin board revolve around medication protocols especially the use of oral contraceptives. Personally, I have had poor results with the use of oral contraceptives except in known high responding patients. I know that many clinics use pills in protocols without any problems but my own experience has not been very positive.
So here is today’s “Question of the Day” from the book that really needs some more reviews on Amazon.com…100 Questions and Answers About Infertility. As the snow starts to fall here in Washington paralyzing the government, I want to invite all local readers of this blog (and their friends and family) to the Barnes and Noble Bookstore in Clarendon, VA for a book signing of this book on Saturday January 26th from Noon until 2 PM.
64. My reproductive endocrinologist has recommended a protocol that uses birth control pills. Why would birth control pills be used in IVF?
Birth control pills or, more correctly, oral contraceptive pills (OCPs) can be used as a part of the IVF stimulation protocol in several different settings. First, in patients who are known or suspected to be high responders, OCPs may help mitigate the risk of ovarian hyperstimulation syndrome (OHSS; see Question 67).
Second, in patients without predictable regular menstrual cycles, OCPs can be used in combination with Lupron to initiate an IVF cycle. In our practice, we usually start OCPs in such cases after confirming with a blood test that the woman has not recently ovulated. Then, after 1 week, we add Lupron. After 1 more week, we stop the Lupron and wait for withdrawal bleeding. Once a patient has bled, we begin the gonadotropin stimulation.
Third, some clinics use OCPs for microdose Lupron (MDL) flare, traditional flare, or patients who are taking Antagon in the hope that pretreatment with OCPs will prevent one follicle from growing faster than the other follicles once the stimulation has begun. We have not routinely use OCPs with our MDL flare patients, as we have rarely had problems with the emergence of a single dominant follicle compared with the more common problem of oversuppression and a cancelled cycle. Given that prolonged OCP use can lead to oversuppression in low responders, we use these medications very carefully.
So here is today’s “Question of the Day” from the book that really needs some more reviews on Amazon.com…100 Questions and Answers About Infertility. As the snow starts to fall here in Washington paralyzing the government, I want to invite all local readers of this blog (and their friends and family) to the Barnes and Noble Bookstore in Clarendon, VA for a book signing of this book on Saturday January 26th from Noon until 2 PM.
64. My reproductive endocrinologist has recommended a protocol that uses birth control pills. Why would birth control pills be used in IVF?
Birth control pills or, more correctly, oral contraceptive pills (OCPs) can be used as a part of the IVF stimulation protocol in several different settings. First, in patients who are known or suspected to be high responders, OCPs may help mitigate the risk of ovarian hyperstimulation syndrome (OHSS; see Question 67).
Second, in patients without predictable regular menstrual cycles, OCPs can be used in combination with Lupron to initiate an IVF cycle. In our practice, we usually start OCPs in such cases after confirming with a blood test that the woman has not recently ovulated. Then, after 1 week, we add Lupron. After 1 more week, we stop the Lupron and wait for withdrawal bleeding. Once a patient has bled, we begin the gonadotropin stimulation.
Third, some clinics use OCPs for microdose Lupron (MDL) flare, traditional flare, or patients who are taking Antagon in the hope that pretreatment with OCPs will prevent one follicle from growing faster than the other follicles once the stimulation has begun. We have not routinely use OCPs with our MDL flare patients, as we have rarely had problems with the emergence of a single dominant follicle compared with the more common problem of oversuppression and a cancelled cycle. Given that prolonged OCP use can lead to oversuppression in low responders, we use these medications very carefully.
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