Success Rates Newsletter 24-Hour Access for Patients Locations and Directions Referral HSG Services New Patient Forms Selecting a Physician Tubal Reversal Egg Donation Program Sperm Cryopreservation Minimally Invasive Surgery Recommended Links

Click title below to take you directly to article

Outpatient Surgery for Infertility and Gynecology

By:
Samuel Tarantino, M.D.

Outpatient surgery offers several advantages for patients with certain infertility or gynecological problems. The development of advanced optics and instrumentation has allowed for the utilization of more “minimally invasive” procedures, such as laparoscopy and hysteroscopy. These procedures are used to diagnose and treat a number of conditions, as discussed below.

Laparoscopy

Laparoscopy has become an increasingly important diagnostic and therapeutic tool for the Reproductive Endocrinologist. The first reported optical inspection of the pelvic cavity was performed by Ott in 1901. Unfortunately, at that time optics was extremely poor and adequate inspection was compromised. As optics have improved, the ability of the surgeon to perform complex surgical procedures became possible. Initially, laparoscopy was utilized only for diagnostic purposes and simple surgical procedures such as tubal ligations.

Today, more complex surgical procedures can be performed laparoscopically.

Laparoscopy is a minimally invasive outpatient surgical procedure, which allows visualization of the pelvic organs. In order to facilitate visualization, the abdominal cavity is filled with carbon dioxide gas creating a “bubble”, which serves as a window to observe the uterus, tubes, and ovaries. Usually a 5 or 10 mm incision is made in the naval and fiber optic laparoscope is placed within the abdominal cavity for visualization. Other small incisions in the pubic hairline may be utilized for manipulation, cutting and dissection.

Laparoscopy is a valuable tool in the infertility work up. Visualization of the pelvic organs allows the Reproductive Endocrinologist to determine if the fallopian tubes are open. During the laparoscopy, dye is passed through the uterus into the fallopian tubes. If the tubes are open, the dye will freely flow through each tube. Not only must the fallopian tube be open to function normally, but the fimbriated ends of the bue must also be free from scar tissue or fibrous bands (adhesions) in order to allow egg transport into the fallopian tube. Even though some patients may have a normal screening hysterosalpingogram (“dye test”) showing free flow of dye by x-ray exam, adhesions surrounding the tube may interfere with tubal pick up and can only be diagnosed and treated laparoscopically.

Endometriosis is a condition where tissue from the lining of the uterus spreads outside the uterine cavity. It may implant on the tubes, ovaries and lining of the abdominal cavity causing distortion of the pelvic anatomy and creating a hostile environment, potentially decreasing fertility potential and causing pain. At the time of laparoscopy the diagnosis of endometriosis can be made, and treatment may be accomplished by cauterizing, or excising, the endometriosis lesions. Some patients have an advanced stage of endometriosis, and may require removal of ovarian cysts filled with endometriosis (endometriornas).

Tubal obstruction at the end of the tube obviously will not allow the egg and sperm to unite for conception to occur. Treatment for this problem includes performing a laproscopic opening of the tube (tuboplasty), or using in vitro fertilization (IVF) to bypass the tube. An obstructed tube may allow a build up of fluid within the tube (hydrosalpinx), which may lead to pain and/or infection. IVF pregnancy rates are significantly reduced in the presence of a hydrosalpinx. Removal of the tube by laparoscopy restores better pregnancy rates.

In conclusion, the introduction of laparoscopy has revolutionized the treatment of many diseases that in the past usually required a large incision called a laparotomy. The Reproductive Endocrinologist can now treat many abnormalities and diagnoses on an outpatient basis that in the past would have required more complex surgery with long recovery times.

Hysteroscopy

Another valuable procedure used during an infertility work-up is hysteroscopy. Hysteroscopy is a technique used for visualization of the uterine cavity. The uterus is a small hollow organ which, when distended with fluid, allows for visualization of the cavity.

In order for an embryo to implant within the uterine cavity, an adequate lining must be conditioned hormonally. Any distortion of the uterine cavity will interfere with the ability of an embryo to implant. Various benign conditions including uterine growths in women can create a hostile environment, which will decrease fertility potential. Uterine polyps, fibroids (Submucosal) within the uterine cavity, or a septurn can interfere with embryo implantation. These uterine cavity abnormalities can create symptoms such as pelvic pain or uterine bleeding, but occasionally these patients have no symptoms.

Hysteroscopy is generally done under IV sedation or light general anesthesia with no incision since the fiber optic scope is introduced into the uterine cavity through the vagina and cervix. Submucosal fibroids, uterine polyps or uterine adhesions can all be removed hysteroscopically. Occasionally, a congenital abnormality of the uterus called a uterine septurn, a cause of recurrent pregnancy loss, is encountered. This abnormality can now be resected hysteroscopically, where years ago an opening of the abdomen (laparotomy) and uterine reconstruction were needed. Hysteroscopy is frequently utilized by Reproductive Endocrinologists to diagnose and treat multiple abnormalities that can impair fertility with minimal trauma to the patient.

Other Procedures

Tubal obstruction can also occur at the beginning (or uterine) part of the tube. This problem can often be treated by “unplugging” the tube of built up debris with very small catheters passed into the tube through a hysteroscope. A laparoscopy is often used to guide the catheter through the tube.

Tubal reanastornosis (putting “tied tubes” together again) with suitable patients is now being done on an outpatient basis. Dilation and curettage as well as biopsies can also be performed outside the hospital setting.

The Reproductive Medicine Group has recently opened a new IVF/Surgery Center, where we are able to perform outpatient surgical procedures. The facility is adjacent to our new North Tampa location. This state-of-the-art center was designed focusing on the needs, convenience, and safety of our infertility and gynecology patients. We are able to perform many of the procedures described in this article in our ambulatory surgical center. The center has been certified by the sate and accredited nationally by The Accreditation Association for Ambulatory Health Care (AAAHC). For more information please inquire at any of our four office locations.

Financing Infertility Treatment

By:
Barry S. Verkauf, M.D.

Many couples desire to have a family, none choose to be, or remain infertile. With modern technology, specialists can usually define the issue or issues contributing to a couple’s infertility. Even if one is not clearly identified, effective treatments are available. Insurance companies often fail to cover infertility, claiming it is a social problem rather than a medical disease. Often, insurance companies consider infertility treatments experimental. Nothing could be further from the truth.

With the exception of persons in the military, there are no federal laws dealing with infertility coverage. Most health insurance law is left to the states to decide. Only fifteen states (Florida is not one of them) have laws related to infertility coverage. These laws differ widely, are rarely comprehensive and often preclude contemporary effective treatment.

The decision of what is covered under an insurance policy is between the employer or purchaser of the policy and the insurance company. There are often exclusions under policy guidelines, infertility being a common one. Many efforts are underway to broaden health care coverage for infertility, and in fact there is some evidence this is occurring, but you can be your most effective advocate. Inquire from your employer whether infertility is a covered benefit under your health coverage, and if so, to what extent. If it is not covered inform your employer that it is important to you. Writing your state legislators is another proactive step you can take to broaden infertility benefits.

In order to maximize those benefits potentially available to you, several steps must be kept in mind:

1. Request a copy of the actual insurance contract under which you are covered.
   Is infertility defined in the contract? If so, what is covered? Is preauthorization required? What type of health care provider can perform infertility services? Are there limits to your coverage such as number of treatment cycles, age to which you can be treated, or maximum dollar limit on benefits? What is listed in the exclusion section?
2. Get these answers in writing.
   If infertility is not definitely excluded, you may be able to make a case that it is a covered diagnosis and treatment.
3. Be sure approval is obtained in advance.
   Often infertility benefits require preauthorization or a predetermination of benefits before you start treatment. Try to be specific in what treatments you need, any limits on coverage in dollars or number of attempts, and any components of infertility investigation or treatment by CPT codes that may be reimbursable. If coverage is denied, ask for the specific section in your contract that supports the denial to be supplied to you in writing. Be persistent.
4. Appeal denials.
   Be sure to talk with your physician about any denial particularly if it is on the basis of treatment that is determined to be “not medically necessary” or “experimental”. Your physician or members of his staff may be able to help you, but would need the specific contract to review in order to provide the best assistance.

While dealing with insurance companies can be frustrating, try not to get discouraged. The good news is coverage for infertility seems to be expanding. The bad news is, at present, getting your fair share may require effort and persistence on your part.

For those who do not have insurance coverage for infertility there are other options to help finance your evaluation and treatment. If your medical expenses exceed 7.5% of your adjusted gross income and you itemize your income taxes, you may be able to deduct those expenses. If they are contained within a specific tax year you may be able to find this works to your advantage. Good record keeping is necessary and you should seek advice from a tax advisor on whether this applies to you. Most infertility services can be paid for by a number of credit cards. Banks may provide you a loan at a better interest rate than a credit card, and personal loans from families or friends usually offer greater flexibility and advantage. Many independent services are currently available for financing infertility services and are easy to identify on the web or by talking to your physician. Another useful way to afford these services in a tax advantaged way is through medical expense plans at work.

It is troubling that so many couples have difficulty with financial support to deal with infertility, particularly since it is younger that usually have the least financial resources. Paradoxically, the chances of being helped for infertility are greater the younger you are. Many difficult choices face couples that are infertile. Whether to seek treatment, and how to access financial resources to help in their quest to have a family are merely a couple of those choices.

Should you desire any further information regarding insurance coverage for infertility do not hesitate to contact our business office at (813) 676-8850.

Office Stimulation for Ovulation Induction: A “Compassionate Team” approach links careful monitoring to successful healthy pregnancies

By:
Timothy R. Yeko, M.D.

Introduction

Office ovulation induction is used as a treatment for many conditions that cause infertility including anovulation, endometriosis, unexplained infertility and even some milder forms of male infertility. A variety of oral (Clomiphene Citrate, Metformin and Letrozole) and injectable (Gonal-F, Follistim and Repronex) drugs are used to stimulate one or more follicle(s). Results of stimulation however are quite variable making it almost impossible to predict how an individual woman will respond to treatment. Individualization of patient care begins with you and your physician choosing the treatment plan that is appropriate for the cause(s) of your infertility. Each woman’s response to treatment is then monitored using ultrasound (measuring follicle number and size) and blood estradiol measurements at baseline and throughout the cycle. Risks of ovulation induction include increased multiple pregnancy rates and ovarian hyperstimulation syndrome, a condition characterized by ovarian cyst formation and pelvic pain.

The Team Approach

The Reproductive Medicine Group physicians are proud of the well-trained team of nurses, laboratory technologists and ultrasonographers that provide the services and personable care that are indispensable to the overall success of a cycle of ovulation induction. Our front office staff and insurance billing department are also knowledgeable, helpful and committed to taking care of your needs efficiently.

Customized (not generic) Treatment Plan

The treatment plan for a cycle of ovulation induction is only determined after a comprehensive infertility evaluation has been completed. Further deliberation then aims at fully incorporating each couples unique set of conditions and circumstances including the cause(s) of infertility, patient age, duration of infertility, prior treatments as well as other factors that go into making a treatment plan that is both specific and as ideal as possible.

A couples customized treatment plan will usually include the following:

1. Type of drug (oral vs injectable) and starting dosage.
2. Method of monitoring (ultrasound and estradiol measurements vs LH kits)
3. Method of timing ovulation (HCG triggered vs spontaneous LH surge)
4. Choice of insemination vs timed intercourse.
5. Other supplemental agents to be used such as: Lupron, Antagon, progesterone, baby aspirin, Heparin and Lovenox.
6. In women undergoing ovulation induction with the more potent injectable agents specific therapeutic as well as cycle cancellation guideline criteria will be described:
• Therapeutic objective for number of follicles (example- 1 to 3 mature follicles)
• The number of follicles or estradiol levels in excess of which the cycle might be cancelled due to an increased risk of multiple pregnancy and ovarian hyperstimulation (example- cycle cancellation if more than 3 mature follicles or estradiol above 1,500 pg/mL.

Cycle Monitoring

The Reproductive Medicine Group physicians and nurses are aware of the stress and emotions that go along with the high hopes and expectations that you have for a successful and healthy pregnancy. To help patients balance their already busy lives with their cycle appointments, all four of our office locations are completely equipped to provide one stop monitoring. Complete monitoring capability at each office location also allows each patient the convenience and ease of going to the office that is nearest to either their home or work.

Baseline Assessment

Prior to beginning stimulation (cycle days 1-3), a baseline evaluation of resting ovarian function is assessed. In cycles being stimulated with oral agents (Clomiphene, Metformin or Letrozole) alone or in combination an ultrasound is usually all that is necessary. However, in cycles using the more potent injectable drugs (Gonal-F, Follistim, Repronex, etc) both ultrasound and estradiol measurements are required before stimulation can be started. At baseline the ultrasonographer measures and records the number of small follicles (<5mm) as well as the size and number of any cysts that may be present. Cycles are typically delayed or sometimes cancelled if cysts larger than 25 mm are detected. At baseline, estradiol levels should be low confirming that the ovary is at rest and ready to be stimulated. If a cyst is present, an elevated estradiol will demonstrate that the cyst is functioning, in which case, the cycle may need to be delayed or cancelled. Cysts that are present on baseline most likely will resolve within one menstrual cycle, however some cysts may require suppression with birth control pills or in the case of those that are due to endometriosis surgical removal may be required.

Monitoring Follicular Growth

Women taking injectable drugs begin their stimulation on a predetermined starting dosage such as two ampules or 150IU of drug. After four or five days at this dose they are brought in for ultrasound and estradiol testing. At this point, the dose may need to be adjusted up or down depending on the test results and the individual patient’s goals of stimulation as outlined in their customized treatment plan. Frequent monitoring and careful dose adjustments provide the best chance for obtaining a successful outcome while also limiting the potential for complications or cancellations from over stimulation.

Triggering Ovulation and Timing Insemination

Women undergoing ovulation induction using oral drugs do not require dose adjustments throughout the cycle and therefore are monitored more simply with a baseline and usually one additional late follicular ultrasound on around day 12. Ultrasound assessment (follicle size and number, and endometrial lining thickness) and estradiol levels around this time are routinely used to determine the optimal time to trigger ovulation. HCG is given as an injection to trigger ovulation when one or more lead follicles reach the critical size that signifies the presence of a mature or “ripe” egg and the optimal time to achieve a pregnancy. Inseminations are typically scheduled 36 hours after HCG has been given or the day following a positive LH surge when using an ovulation predictor kit.

The size criteria to trigger ovulation with HCG varies with type of cycle

Injectable cycles - 16-19mm

Natural spontaneous cycles - 18-22mm

Clomiphene cycles - 18-24mm

Luteal Phase Monitoring

Confirmation and adequacy of ovulation is usually determined by measuring a cycle day 21 progesterone level. Progesterone levels normally range between 10-30ng/mL. Your physician may choose to supplement your cycle if levels are in the low normal range.

When to Check a Pregnancy Test?

Pregnancy testing can be performed at home using simple urine kits or using the more sensitive blood pregnancy tests available only through a laboratory. A pregnancy test should not be checked sooner than 14 days after HCG is given. That is because HCG stays in the bloodstream for up to 14 days and can cause a false positive pregnancy test. Serial blood pregnancy testing is used to judge whether HCG levels are rising normally and are sometimes useful when vaginal bleeding occurs or there is a concern for the possibility of a miscarriage or tubal pregnancy.

Why a Cycle Might be Cancelled?

A treatment cycle may be cancelled if the response to treatment exceeds the number of intermediate (12-15mm) and full size (>16mm) follicles determined by the criteria of each patients specific treatment plan. In patients with polycystic ovaries it is more frequently an excess number of small and intermediate follicles, not large dominant follicles, that leads to the greatest risks of hyperstimulation and cycle cancellation. When a cycle is cancelled, HCG is not given and patients are told to abstain from intercourse for one to two weeks or until the next menses occurs. The next cycle would then be appropriately adjusted to a lower and safer treatment dosage.

Perspective

The Reproductive Medicine Group physicians believe that with appropriate specific treatment planning and careful cycle monitoring the overall risks of ovulation induction can be reduced, and results of each individual cycle can be optimized to increase the chance of the best of all outcomes; a single healthy baby.

Obesity, The Current And Future Epidemic
An Ounce Of Prevention Is Really Worth A Pound Of Cure

By:
Marc Bernhisel, M.D.

America is fast becoming an overweight and obese nation. More than 25% of adult Americans are now obese. Women tend to have more weight problems then men. While as a nation, we have always been heavier than our European, Asian and African cousins; the acceleration of this tendency has been dramatic over the last ten years. Four states out of 50 (8%) in 1991 reported that 15% or more of their population were obese. By the year 2000, 98% (49 out of 50 states) reported 15% or more of the population were obese.

The Centers for Disease Control (CDC), uses a standard measurement called a body mass index (BMI) to define what is considered as normal weight, overweight and obese. A person with a BMI greater than 25 kg/m2 is considered overweight, and a person with a BMI greater than 30 kg/m2 is considered obese (tables to convert inches and pounds into a BMI index are available at the Reproductive Medicine Group offices). Obesity is an enlargement of fat cells. Fat cells enlarge as there is an overabundance of energy intake (calories in) compared with energy expenditure (calories out). The average adult in the United States consumes approximately 2680 calories per day. The calories required by a sedentary man between 35 and 50 years of age is approximately 2200 calories and by sedentary woman of the same age group is1800 calories. This is a net gain of 880 calories a day in women. A pound of fat is the equivalent of 3500 calories; therefore 1 pound of fat could be gained in less than a week with this increase. Why are we gaining weight? The serving sizes of many popular foods today are approximately twice as big as they were fifteen years ago. In addition, only 45% of adults meet the government’s guidelines of at least thirty minutes of moderate activity-five days or more a week.

The result of obesity can lead to conditions such as diabetes, where the body does not produce enough of the hormone insulin to maintain glucose (sugar) balance. Overweight individuals are more prone to osteoarthritis (a loss of cartilage in the bones), heart disease, strokes and hypertension (high blood pressure). Obesity leads to a decline in the “good” cholesterol HDL and an increase in the “bad cholesterol” LDL, which is associated with insulin resistance and obesity. This tendency increases the risk of heart disease. The second factor in increasing cardiovascular disease in the overweight individual is a decline of natural substances produced by the body to limit clotting. The third risk is an increase in blood pressure. Long standing high blood pressure leads to vessel hardening which increases the risk of cholesterol lesions and clots that can block crucial blood flow to the brain (strokes) and heart (heart attacks).

Obesity is also shown to increase the risk of cancer of the breast, bowel, gall bladder and uterus. Infertility, largely caused by not ovulating, is increased in the overweight individual. Improvement in ovulation and fertility are improved with even a modest-10% weight reduction. The risk of miscarriage may also be increased with obesity. The good news is that all of these factors (heart, cancer and infertility risks) can normalize with weight loss.

Diets

One needs only to look at the checkout counter in the grocery store to find an abundance of so-called diet plans. Many popular diet plans have been reviewed scientifically in obesity research articles. Low fat diets include the Pritkin and Ornish diet that provide very low fat with fairly high carbohydrates. Moderate fat and carbohydrate diets include Sugar Busters, Weight Watcher’s, Zone Diet and the South Beach Diet. The third group advocates high fat and protein consumption with ultra-low carbohydrate use (Atkin’s Diet). The Atkin’s Diet specifically induces an early significant water loss, which leads to weight loss, but not necessarily fat loss. In the final analysis, the studies reveal that success with weight loss diets is ultimately a matter of calorie intake versus calorie expenditure.

Medications

Approximately 100 new products are in the early stages of development to help combat obesity. The drugs now in use include Phentermine, Meridia and Xenical. Phentermine and Meridia are appetite suppressants that work on the brain to control appetite and make the person feel full. Xenical works by blocking absorption of ingested fat in the intestines so fewer calories are absorbed by the body. These medications are effective in some dieting individuals, but at least in current form, they are not a cure all for obesity.

Surgical Treatment

Surgical treatment for the severely obese has become very popular. This year over 100,000 extremely obese adults will have weight loss surgery, the most common of which is called gastric bypass, which creates a smaller stomach.

In light of the medical problems associated with obesity as well as the effect on self esteem and other issues not addressed, we have an obligation to the coming generation to emphasize proper nutrition, exercise and weight control to maintain health. Appropriate body weight is also crucial in the prevention of heart disease, high cholesterol, diabetes and osteoarthritis (to name a few). Hence the basic premise “An Ounce of Prevention is Worth a Pound of Cure”. However, many of us need to make a concerted effort to lose weight. The process may seem almost like having a second job.

Doctor’s Formulation:

• Determine your weight, BMI, and waist and hip measurements.
• Determine appropriate caloric restrictions. An easy and relatively accurate way to determine the daily metabolic needs is to multiply your weight by 10 (a 180 pound woman would use up 1800 calories per day whereas a 110 pound woman would use 1100 calories). A pound of fat is equal to3500 calories, therefore when exercise expenditure exceeds calories eaten, a weight loss will occur. Calorie restrictions of less than 1000 calories per day should be approved and monitored by competent medical care providers.
• Oftentimes the process of losing weight is helped in a group setting. An accounting of the calories in and out to another person is very helpful to improve compliance.
• Begin an exercise program. For those who are not used to exercising, engaging in activities such as walking to the car, using stairs instead of elevators, doing housework or yard work for two to three hours a week may help substantially. Once an exercise program is started, it will tend to increase the rate at which weight is lost. One of the most important factors in maintaining weight loss once the desired weight has been obtained is to continue exercising. The tendency to re-gain weight often correlates with those who do not exercise.
• In determining foods to eat for the diet, avoid those foods with highly saturated fat or those carbohydrates with a high glycemic index (those carbs. with rapid conversion to sugar). Tables with glycemic indices are available. Be persistent and consistent. Your efforts will pay off.
• Sometimes weight loss is not seen readily but is reflected more in waist or hip inches being lost. Muscle is heavier than fat but it does metabolize calories more efficiently.

Here’s to your health!

Alternative Therapies in the Treatment of Infertility

By:
Marc A Bernhisel M.D. and Jessica Frome MPH, BSN, R.N.

“Can’t you recommend something ‘natural’ like some herbal products to help us get pregnant faster?” ask some very concerned patients. Most couples are not so direct with their physicians and don’t mention that they want to use, or are using alternative therapies for infertility or other medical conditions. It is conservatively estimated that 30% of Americans use complimentary or alternative methods (CAM), exceeding a billion dollars in purchases annually. A recent survey indicated that 33% of couples undergoing In Vitro Fertilization (IVF) used acupuncture or relaxation therapy, and 18% used herbal medications. In this article, we will review the most popular alternative therapies, and will discuss their relationship with traditional medicine during the infertility treatment process.

Western medicine (conventional or “traditional” medicine) is based upon the scientific method. Medical treatments are ideally formulated from multiple, well-designed studies demonstrating the effectiveness, safety and potential risks of a particular therapy. Eastern medicine, which encompasses much of CAM, relies on word of mouth (anecdotal) traditions. Unfortunately the few CAM studies available are generally small and fail to meet the basic standards of a “good study”.

What constitutes a “good study”? Physicians and scientists prefer studies in which participants are randomly placed into treatment groups (for example, the use of an herb to treat a medical problem) or a control group (taking a placebo, other alternative herb or traditional medication). This method is used to reduce biases and self-selection, or selection by the study managers. It is also preferable to have each group unaware of what they are taking (placebo or treatment). This is referred to as a “blind” study. An even more favored design is when the managers of the study are also unaware of what therapy the study participant is receiving (double blind study).

Often, complementary and alternative methods are used in conjunction with conventional practices. While some of these methods have been studied extensively, many have not been, therefore their safety and effectiveness is unknown.

Traditionally, complementary and alternative therapies are divided into five categories:

v     Mind-Body Interventions: Techniques used to enhance the mind’s ability to affect the body. Examples are patient support groups, prayer and cognitive-behavior therapy.

v     Alternative Medical Systems: Complete systems of theory and practice including homeopathic, naturopathic and Traditional Chinese Medicine.

v     Biologically Based Therapies: Vitamins, food and herbs.

v     Manipulative and Body-Based Methods: Massage, chiropractic and osteopathic treatment and manipulation.

v     Energy Therapies: Involves the use of energy fields by applying pressure to the body. Examples include therapeutic touch and electromagnetic fields.

Acupuncture

Acupuncture has been used to treat male and female infertility for over 3,000 years. Traditional Chinese Medicine uses a combination of acupuncture and herbs to “balance the body”. Acupuncture employs the use of fine needles in specific “points” on the body to stimulate invisible lines of energy (Qi). This is thought to create a change in the energy balance of the body, which acts to restore health. It has been postulated that acupuncture affects beta endorphins and other transmitters leading to an improved uterine blood flow and hence an improved pregnancy rate. This affect has not been demonstrated in all studies. Acupuncture has recently received attention from a study published in Fertility and Sterility (2002). In a perspective randomized study of In Vitro Fertilization patients, a group treated with acupuncture preformed twenty-five minutes before and after embryo transfer had a 42.5% pregnancy rate compared with 26.3% in the control group, which was statistically significant.

Male infertility has also reportedly been improved with the use of acupuncture. Unfortunately, most of the studies on males have been poorly done. However one well -designed study demonstrated an improvement in sperm function and a post acupuncture presence of sperm in 67% of control participants who were azoospermic (no sperm) before therapy. While several studies in well respected journals have shown that acupuncture positively affected sperm quality and increased pregnancy rates after an ART procedure, more studies are needed to determine the efficacy of acupuncture in both male and female infertility treatment.

Mind-Body Intervention

Believers in mind-body medicine (intervention) deem that the mind has the capacity to affect the capability of the human body to function. Techniques utilized include guided imagery, prayer, meditation, yoga, support groups and formal Mind-Body Connection programs. Several studies have linked anxiety and stress with a reduced pregnancy rate, and treatment with improved rates. Other studies, however, have not supported this relationship. A study from 2000, which was well controlled and randomized, demonstrated a statistically significant improvement in pregnancy rates in the group treated with a wide variety of both “intense” and “less intense” mind body therapy compared with those who did not receive therapy.

Manipulative therapeutic massage is thought to benefit infertility patients through the mind-body connection and relaxation process. There have not been any research- based reliable studies done to support claims of massage’s ability to restore estrogen levels, treat pelvic adhesions and infections, or unblock fallopian tubes.

Diet, Vitamins and Herbs

Healthy nutritional principles are important in all facets of life. This holds true for infertility treatment as well. Eating the recommended amount of fruits and vegetables; limiting fat, sugar and caffeine; and drinking plenty of water is essential. Excessive thinness can cause a woman to not ovulate. Obesity can cause infertility, resistance to fertility drugs and can increase the risk of miscarriage. As little as a 5-10% reduction in body weight can prove beneficial.

Zinc deficiency is linked to decreased sperm motility. Zinc may also improve female fertility, especially when used with vitamin B6. A number of vitamins containing L-carnitine, zinc, B complex vitamins including folic acid, and anti-oxidants have been developed for both male and female infertility (Fertile Blend for Women, Fertile Blend for Men, Fertile One and Proxceed). Well-designed studies for these products, published in reputable journals, are few. Production of sperm takes approximately 70 days. Therefore, the effect of treatment for sperm problems by any means including vitamins and supplements would take about two and one half months to be measurable.

Herbal supplements are not regulated by the Food and Drug Administration (FDA). No standardization exists as a quality control; the ingredients are often not identified, and the amount of the ingredient can vary greatly form one batch to another. In the United States, herbs are not classified as food or drugs, but rather as a dietary supplement. Manufacturers do not need to prove herbal medications as safe or effective. Presently, herbal manufacturers are allowed to claim their products treat only symptoms, not diseases.

Chinese herbs are generally utilized in combinations of 8 to 20 herbs, and are usually prescribed for specific individual conditions. For infertility treatment, herbs are often taken in the form of a brewed tea. It is common to have variations in herbal prescriptions from patient to patient, and to frequently change formulations. Thus, it is difficult to prove clinical significance. There have been very few studies published in research journals that document the efficacy of using herbs for either male or female infertility treatment. Many herbs actually have contraceptive effects, including: cayenne, ginger, aloe, bee balm, black cohash, extract of juniper berries, penny oil, Queen Anne’s lace, extract of English ivy, and St. John’s Wort. Furthermore, Echinacea, St John’s Wort and ginkgo have been associated with diminished fertilization.

In conclusion, many treatments and therapies, both Western and Eastern based, are utilized to enhance fertility. “One size fits all” does not apply to infertility treatment. It is important to alert your physician to alternative therapies that you are using, so that your treatment plan can be tailored to your needs, and optimal care can be achieved. Communication between you and your physician is essential to help you achieve your dream of a having a healthy baby!

Doctors Formula:

1. Achieve the best general health you can. Infertility and miscarriages are impacted by tobacco use, recreational drug and alcohol use, as well as excess consumption of caffeine. Being overweight or underweight can also affect fertility.
2. While no specific diet exists for infertility, a well-balanced diet supplemented with appropriate vitamins, minerals and other nutrients just makes good sense.
3. Addressing feelings of stress, anxiety and depression is important. Mind-body therapy will help make fertility therapy more tolerable, and may also improve pregnancy rates.
4. Traditional Chinese Medicine practices such as acupuncture and herbal therapy may be useful adjuncts to both male and female fertility. One should be discriminatory in selecting qualified practitioners. To receive the greatest possible benefit from acupuncture, it is important to receive treatment from an acupuncturist who is licensed and experienced in the care of infertility patients. Be sure to ask about success rates, treatment methods, and number of patients treated. The best recommendation for selecting an acupuncturist should come from your physician or other reliable health care providers who are aware of these practitioners. Use herbs cautiously, some are dangerous and can affect fertility. Herbal therapy should only be used under the guidance of an expert who is aware of the beneficial and detrimental effects on fertility.

References:

Wisot, A., Meldrum, D. Conceptions and Misconceptions 2nd Ed. 2004.
Sampey, A., Bourque, J., & Wren, K. Advance for Nurses, 5, (25), 2004.

Recurrent Pregnancy Loss

Jessica Frome, MPH, BSN, R.N. and Dr. Sandy Goodman have prepared this article. Dr. Goodman practices at the RMG North Tampa and Clearwater offices.

Pregnancy loss is a common occurrence. Unfortunately, approximately 20% of clinical pregnancies are lost to miscarriage. Miscarriage is defined as the loss of a pregnancy prior to 20 weeks gestation. Recurrent miscarriage, or recurrent pregnancy loss (RPL) is diagnosed after woman experiences 2 or more miscarriages. A causative factor for RPL will be determined in approximately 50% of couples that are identified. Common reasons for RPL include: genetic factors, uterine abnormalities, hormonal disturbances, infection, autoimmune and clotting disorders, maternal illnesses, and lifestyle factors.

Genetic Causes

Inherited or genetic factors are a major causative agent of early pregnancy loss, usually due to an abnormal number or structure of chromosomes in the fetus. Chromosomes contain genes, which carry genetic material. The most common chromosomal abnormalities include trisomies (extra number) of chromosomes 13, 14, 15, 16, 18, 21 and 22. Structural chromosomal abnormalities in one of the parents can be unevenly passed on to the fetus resulting in RPL. Karyotype (genetic) testing can be performed on both parents, as well as on the fetal tissue. If the karyotype results of one parent returns as abnormal, genetic counseling is often recommended. Preimplantation Genetic Diagnosis (PGD) allows for the selection of chromosomally normal embryos increasing the chance for a successful pregnancy. PGD is performed by testing the chromosomes from a cell removed from the 8 cell stage embryo during an IVF cycle. PGD may be a viable option for some patients diagnosed with RPL.

Uterine Abnormalities

An abnormally shaped uterus is diagnosed in 10-15% of women with a history of RPL. One of the more common examples of uterine abnormalities is a septate uterus. This condition occurs when a segment of poorly vascularized tissue (septum) extends into the uterine cavity. Pregnancy loss may occur more frequently in women with this condition due to implantation on the septum, which leads to an inadequate blood supply to allow for fetal support. Uterine fibroids may also affect the shape of the uterus. Fibroids are noncancerous growths that occur in the wall of the uterus, sometimes interfering with implantation and appropriate fetal growth. Another common uterine condition which may affect a healthy pregnancy is Asherman’s Syndrome, which is an overgrowth of scar tissue within the uterus. Your physician may recommend surgery to correct uterine abnormalities and help to ensure an optimal pregnancy outcome.

Hormonal Disturbances

Some of the most common hormonal abnormalities are disorders of the thyroid gland. These include hyperthyroidism, hypothyroidism and thyroid antibodies – all of which may be treated with medication after a diagnosis is confirmed.

A luteal phase defect, in which the endometrium (uterine lining) fails to adequately thicken for embryo implantation and growth, is caused by insufficient progesterone production. In the absence of optimal progesterone levels, the embryo may fail to implant securely within the endometrium. This defect is usually treated with progesterone supplementation in the form of suppositories or injections, although clomiphene citrate (clomid) or human menopausal gonadotropins (hMG) may also be utilized in an effort to enhance endometrial growth.

Hyperprolactinemia, elevated prolactin levels, may result in luteal phase disturbances; possibly interrupting embryo implantation. Prolactin is a hormone produced by the pituitary gland, and is essential for milk production. Medication is usually utilized as a successful treatment.

Infection

Cervical cultures to assess for infections caused by chlamydia, mycoplasma, and ureaplasma will often be performed if a couple presents with a history of recurrent pregnancy loss. If an infection is identified, antibiotics will be prescribed for both partners.

Autoimmune and Clotting Disorders

The human immune system is a complicated mechanism that works to maintain general health by responding to infection, foreign bodies or injury. Auto immunity occurs when an individual’s immune system produces antibodies against herself. Some autoimmune conditions can cause thrombosis, or blood clots, which affect the placenta. Thrombotic autoimmune causes include: anticardiolipin antibody (ACL-IgG, IgM, IgA), lupus anticoagulant (LAC) and antiphospholipid antibodies (APA). If these antibodies are present, they may cause blood clots in the placenta – which may lead to miscarriage. Aspirin, Heparin, and Lovenox are medications that “thin” the blood and are often used as an effective treatment.

Thrombophilia is a genetic condition characterized by excessive blood clotting. This condition may lead to thrombosis (clots) of the venous and arterial system. Heritable thrombophilia increases the risk of fetal loss, intrauterine growth retardation, and eclampsia (high blood pressure and seizures) during pregnancy. Patients are diagnosed with blood tests, and treated with Aspirin, Heparin or Lovenox to reduce the risk of blood clots.

Maternal Illness

Maternal illnesses, which may affect pregnancy loss, include: uncontrolled diabetes, autoimmune diseases (such as lupus), congenital heart disease, and severe kidney disease. Treatment of these illnesses, especially prior to conception and within the first trimester (first 12 weeks of pregnancy) is essential to improve the chances of a successful pregnancy.

Lifestyle Factors

Tobacco use, obesity and alcohol consumption increase the risk of miscarriage. There is also evidence that daily caffeine intake of 300mg or greater may affect a healthy pregnancy. Social class and low socio-economic status have also been linked as a causative factor for miscarriage due to high levels of physical and psychological stress.

Factors that DO NOT increase the risk of miscarriage include: exercise, work, intercourse, exposure to computer terminals, and the use of hair spray, hair coloring, or permanent solutions.

Emotional Aspects of Pregnancy Loss

Experiencing a miscarriage often creates conflicting feelings of shock, anger, guilt, depression and disbelief. These feelings are normal, and are often more compounded after recurrent losses. Men and women cope with loss differently, and it is important for couples to realize that while they should support each other, their reactions and coping mechanisms will often be different. Couples should talk about their feelings and pregnancy loss with family and friends, as well as a professional counselor. There are also support groups available, which may act as a source of “refuge” for some couples.

Conclusion

Information about miscarriage is still fairly limited within the medical community. No contributory factor is identified in up to 50 percent of couples who experience recurrent pregnancy loss. However, success rates after appropriate therapeutic treatment is high when a causative agent is identified. Please contact us for more information about recurrent miscarriage. The goal of the physicians and staff of The Reproductive Medicine Group is to help you achieve your dream of having a healthy baby.

Electroejaculation for the Treatment of Male Fertility

Sandy Goodman, MD and Jessica Frome, RN, BSN, MPH have prepared this article.

Men with conditions that impair neurological function such as spinal cord injury, diabetes, multiple sclerosis, spina bifida, and certain cancers requiring retropertoncal lymph node dissection may experience erectile and ejaculatory dysfunction. Ten thousand new cases of spinal cord injuries occur in the Unites States annually. Recent military conflicts have led to an increased number of young men with spinal cord injuries. The Haley VA Hospital in North Tampa has developed a state of the art spinal cord unit that has drawn reproductive age men who have sustained spinal cord injury to relocate to our community with their spouses. As these young men rehabilitate and rebuild their lives, many desire to parent children. It has been reported that greater than 90% of men with spinal cord injury have poor sperm production or anejaculation. Advances in the field of Reproductive Endocrinology have enabled men diagnosed with neurological impairments to father children. Among the most useful medical developments to assist such men is electroejaculation, which stimulates the nerves electrically allowing for ejaculation to occur. This method of sperm procurement was initially used in veterinary medicine. The first human pregnancy achieved utilizing electroejaculation with artificial insemination was in 1975. The techniques associated with this procedure have improved sufficiently to allow for widespread success.

Method:

The current therapy utilized for electroejaculation involves the use of a rectal probe with electrical current to stimulate the neurogenic arc required for ejaculation. Risks of the procedures are rare and minimal, and are usually related to autonomic dysreflexia. A roultidisciplinary team comprised of a urologist, reproductive endocrinologist, and specially trained nurses care for the patient during the procedure. Men with spinal cord injury do not generally require sedation prior to the electroejaculation procedure. The day prior to the procedure, the patient receives an appropriate dose of sodium bicarbonate to neutralize urinary pH. Additionally, nifodipine may be given sublingually as a prophylaxis to prevent autonomic dysreflexia.

Procedure:

The bladder is emptied with a catheter and an insemination medium is infused to limit the effect of urine on the retrograde ejaculate – which is commonly observed in this patient population. Protoscopy is then performed followed by placement of the electrical probe. Stimulation is then performed with a slow increase in electrical voltage until ejaculation occurs. Vital signs, voltage, electrical current, and probe temperature are closely monitored during the procedure. Stimulation is terminated if signs or symptoms of autonomic dysreflexia become evident, or when ejaculation is completed. The bladder is then catheterized to retrieve additional retrograde ejaculate.

A basic fertility evaluation is performed on the female partner of the patient (appropriate hormonal levels and hyserosalpingography). Electroejaculation can be utilized during an intrauterine insemination cycle or an in vitro fertilization cycle. Often times, obtained semen volumes are high, displaying a normal concentration of sperm, but with diminished morphology and motility. As such, many couples require IVF with intracytoplasmic sperm injection (ICSI). No correlation between patient age or interval since spinal cord injury and outcome of sperm retrieval has been demonstrated. Electroejaculation has proven to be beneficial for many couples desiring children. Ongoing efforts will continue to improve this therapy in the future.

In an effort to continue to provide fertility care to the entire Tampa Bay community. The Reproductive Medicine Group will begin providing electroejaculation in the near future. If you have a patient whose spouse would be a candidate for electroejaculation, please refer them to our new patient coordinator at (813) 676-8825 in order to schedule a consultation with one of our physicians.

Androgens and Aging

Dr. Barry Verkauf of The Reproductive Medicine Group has prepared this article. Dr. Verkauf sees patients in the RMG South Tampa Office.

In the early 1930’s Cole Porter wrote a catchy little song entitled, Let’s Fall In Love. It’s a toe-tapping tune with characteristically clever lyrics. The first verse goes: “Birds do it, bees do it, even educated fleas do it – let’s do it…” While Porter indicated that birds, bees, and educated fleas do “it”, Porter didn’t bother to tell us exactly what “it” is they do, whether all of them do “it”, whether they all do “it” with the same frequency, in the same way, or enjoy “it” equally!

In the 1930’s, advances in the chemical and physical sciences resulted in the ability to identify and synthesize sex steroids. Androgens have classically been associated with male characteristics; while estrogens and progestins are associated with female characteristics. The ability to isolate and experiment with sex hormones led scientists to explore the impact of androgens and estrogens on the causes of differences in male and female sexual anatomy, and how excesses or absence of them or other unidentified products altered these normal processes.

In the late 1940’s and early 1950’s, Dr. Alfred Kinsey, a young biologist at Indiana University, focused his professional interest on studying human sexual behavior. In the early 1950’s he published the first “scientific” assessment discussing sexual practices of the American male and female, disclosing the vast differences between what people actually did, and what American society thought they did. He observed great diversity in human sexual practices between couples, individuals, and within individuals over their lifetime. He concluded that each individual is “a little different”.

In the 1960’s and early 1970’s Masters and Johnson continued the observations begun by Kinsey on anatomic and physiologic changes during human sexual activity. But most importantly, they began to evolve methods to test sexual dysfunction – they began to work with androgens, but principally by psychological and re-educative methods. Initial public and scientific interest in their work faded into the background.

Recently, encouraged by the usefulness of Viagra and similar pharmacologic agents in treating erectile dysfunction (Impotence) in the (principally older) male, there is resurgent scientific inquiry into the importance of androgens with sexual function in the aging female.

We’ve heard a lot about estrogens in the menopausal woman and while there are still differences of opinion, practically everyone agrees on two clinical indications for their use: (1) to treat symptomatic hot flashes during the menopausal transition, and (2) to treat vaginal dryness and genital atrophy often leading to painful intercourse.

Androgens, like estrogens, decline in women as they age because of reduced production of testosterone by the ovaries and dehydroepiandrosterone and its sulfate by the adrenal glands. Androgens serve as precursors in the formation of estrogens. But, they also have many other functions – strengthen bones, increase muscle mass and affect mood and sense of well-being as well as sexual experience. Much investigation is currently centered on the newly coined entity “female androgens deficiency syndrome”. The physical signs of this “syndrome” are difficult to diagnosis and include: thinning of pubic hair, loss of muscle mass, and loss of bone density.

Symptoms do not include: unexplained fatigue, decreased sense of well-being, and diminished libido with decrease in sexual desire, fantasy, arousal and satisfaction. It is the last set of symptoms that physicians encounter the most frequently, and recognizes as Hypoactive Sexual Desire Disorder (HSDD). Some recent studies indicate that about forty percent of American women exhibit some sexual dysfunction – a large proportion of the population.

What does this information mean? Clearly, certain disease states such as pituitary tumors, ovarian failure, adrenal insufficiency, and corticosteroid therapy have been shown to reduce circulating androgens in women. However, these causes are uncommon. Paradoxically, estrogen replacement therapy has been associated with this disorder as well. Perhaps this is because estrogens increase the production of proteins in the liver, which affect testosterone circulating in the blood in a manner that reduces the amount that is physiologically active or “free”.

In the absence of these few medical disorders, the symptoms of HSDD are difficult to explain. They are often present in depression and can be linked to interpersonal, psychosocial or environmental factors. In some instances, but not most, measurement of androgens (testosterone and dehydroepiandrosterone) in the blood are low in these women. However, many women with low androgen measurements do not have reduced libido, sexual desire or arousal. Moreover, currently there are no consistently reliable measurements of testosterone in women available. The assays, originally designed for measuring testosterone in men, are not dependably accurate in the much lower levels usually circulating in women. Nonetheless, some symptomatic women respond to treatment with androgens and some physicians feel that even if there is no identifiable cause, if testosterone or DHEA measurements are low and estrogen levels are normal for age (estrogen is necessary for vascular engorgement in the clitoris and vulvar tissues allowing sexual arousal), a trial treatment of androgens may be justified. This is most safely and physiologically accomplished with transdermal patches. Because androgens can have negative effects on lipids, skin, and the liver and cause fluid retention, treatment must be carefully monitored.

Why this new interest in research related to androgen therapy and female sexuality? The larges cohort of women ever to exist in Western society – the “Baby Boomers” – are now reaching the menopausal transition or are just beyond it. Interest in topics seem to be cyclic, perhaps related to when social mores and tolerances permit them. Clearly issues of human sexuality particularly in the aging female are on the minds of contemporary society as is reflected by the increased amount of scientific physiologic, psychological, and sociological research happening in this area.

The best assessment of the current state of affairs seems to be the following: “In women who fit the clinical picture of ‘female androgen insufficiency’ in whom no pathologic cause can be identified, who are adequately estrogenized and measurements of testosterone in its active form or DHEA are low, a trial of androgen replacement seems justified. If measurements of free testosterone and DHEAs are normal, the symptoms are probably not due to androgen insufficiency and another cause of the symptoms need to be sought and corrected if present. Sexual function is dependent on a variety of factors including availability of partner, expectations, mood, psychosocial factors, general health of the woman and her partner and in some instances medications. The total or partial contribution of these factors to diminished libido and sexual desire always need to be competently assessed.