The AFA Blog

Rachael Zoe's Next Project

by Merry Armentrout

 Baby rumors have swirled for weeks around celebrity stylist Rachael Zoe, and The American Fertility Association is excited to hear the rumors are in fact, true!

“Hey everyone!” The Rachel Zoe Project star tweeted today, “I want to officially confirm to my loyal friends and followers that I am pregnant!” Zoe continued, “I feel great, Rodger and I are beyond excited and so thankful for all of your love and support.”

The final episode of The Rachael Zoe Project Season 3 showed the Stylist to the Stars visiting a fertility clinic with her husband, Rodger Berman.  After meeting with her physician, Rachel expressed her obviously heartfelt concern that after spending 15 years building her career, and now finally being ready for a family, she's being told it might be too late.

This moment is important for two reasons. The first, no matter who you are or what you do, the biological clock is a real thing and can't be ignored, or washed away by fame. Second, Zoe's forthright honesty  has helped to educate millions of viewers by continuing the conversation about infertility, a subject often associated with shame or embarrassment that is in fact  a reality that won't go away no matter how long you try to ignore it. In fact, the longer you wait, the worse it gets.  

Surprisingly to many, one in 8 couples in the U.S. is infertile.  The American Fertility Association's goal is to have everyone not only know this statistic, but more importantly understand this statistic.  Many couples will be diagnosed with unexplained infertility - a frustrating prognosis for both the doctor and the patient. Something about infertility that is 100 percent certain- age and female fertility are related. The probability of a woman conceiving decreases 3-5 % per year after the age of 30, and at a faster rate after 40. 

One step to overcoming infertility is being aware, and being aware at an early age. That's why The AFA is launching a speaking tour at college campuses in 2011. We'll be talking with young women and men about navigating career, education and family, all with the biological clock ticking in the background. Though there are advancements being made in fertility treatments, there are no treatments for "turning back" the biological clock.

To Rachel: we're thrilled your story ended positively. Congratulations and our sincere best wishes to you and Rodger for a happy, healthy baby. And thank you. Thank you for sharing your story. It's one that we hear far too often, and sadly one that doesn't always end with a baby. We hope that many of your fans - especially the young women who look up to you as a role model - heard the message and will pay attention to it as they seek out what is best for their lives. We would be honored to work with you in the future to bring this message to as many young women as possible.

 

 Photo of Rachel: www.Style.com

Video: www.Bravo.com

A Baby at Last

 

by Carolyn Berger, L.C.S.W.

As those of you who religiously follow the AFA Blog know, Wednesday night’s

Illuminations NYC fundraiser was a remarkable success.

 My favorite part of the evening was giving Dr. Zev Rosenwaks, Dr. Marc Goldstein, and Mark Fuerst our Media Award for their recent book, A Baby at Last.

 If truth be told, I was just a bit anxious before getting up in front of our 170 guests. Would I suffer from “brain freeze,” forget someone’s name, or, even worse, trip on the step up to the stage?  To make matters even more dicey, I decided a minute before I went up that I wouldn’t follow my script, but would speak from my heart instead.  I just didn’t feel that what I had written was enough.

 So I got up there and told people that after I finished reading the first chapter of the book, “You Are Not Alone,” I knew I had to get a second copy.  I counsel fertility patients in two separate offices, and I wanted this book by my side in both places. It would make me a better therapist.

 I’ll tell you why.  The book takes the very complex world of fertility treatment and simplifies it—something that patients and clinicians alike can appreciate.  It intersperses scientific information with vignettes of true-to-life couples struggling to have babies—and it imparts hope.  Each chapter ends with “Take-Home Messages,” which cull the essential ideas and can act as quick reference points for busy patients who don’t have time to re-read chapters looking for one important piece of information.

 Something else I like about the book…. In a world where female fertility issues often take center stage, Dr. Zev Rosenwaks and Dr. Marc Goldstein, both of Weill Cornell Medical Center, have joined together to give male and female fertility equal play, including chapters on both male and female fertility evaluations and treatments. (This is all to the good since while male and female factors each count for 40% of cases of infertility, male-factor infertility has not gotten the attention it deserves.)

 So, my introduction of our Media Honorees went just fine in the end.  Dr. Zev Rosenwaks took out a sheaf of papers when he reached the podium—and then put them aside.  He spoke from his heart instead.  Dr. Marc Goldstein did the same. And Mark Fuerst followed suit.

 It was just that kind of evening, hopeful and celebratory all at once, and when I went home I was smiling.

 Carolyn Berger, LCSW, is Founding Board Chair of The AFA.  She has a practice devoted to Fertility, All Forms of Family Building and Adoption in Westchester and Manhattan.

 

The Mysteries of Funny Looking Sperm

by Craig Niederberger, M.D., F.A.C.S.

I was at a meeting recently, and one of the hottest topics of discussion was sperm shape. We call it “morphology”, and it’s how sperm look under the microscope. A technician counts up the number of normal looking sperm, and reports the percentage of the total. Here’s the odd part: with fairly generous criteria, (like normal means one oval head with one tail,) only about a third of a man’s sperm look normal. That means, for most men, most of their sperm are funny looking.

Is that a bad thing? Well, we all managed to get here with fathers that had for the most part funny looking sperm. Was it the best looking sperm that found its way into the egg and made you? That’s the million dollar question, and one for which we don’t yet entirely know the answer.

There are two ways to measure the look of sperm. One is using the World Health Organization (WHO) criteria, which for the most part say that if a third of sperm look fairly normal, the whole lot are O.K. These criteria have been around for a while, about a half century. The new kid on the block is about twenty years old, and uses a much stricter definition to call a sperm ‘normal’. Thinus Kruger invented this stricter system, and so it’s often called ‘Kruger morphology’ or ‘strict morphology’. To calculate strict morphology, the technician takes measurements of the sperm, and if any are outside the normal range, the sperm is counted as abnormal. The usual cutoff for strict morphology is 4%, which means that 95% of your sperm can be funny looking, and you’d still be considered to have normal morphology. That should give you an idea of how oddly shaped most sperm are in the typical male.

One big challenge in assessing morphology is that even though it appears to be an objective way to describe sperm shape, it still includes a great deal of subjectivity on the part of the technician. The technician is like a referee. Sometimes he or she will let a sperm pass the shape test, sometimes not. From some labs, almost no sperm are called normal in shape. So the first thing you’ll want to do if you’re told that your sperm are especially strangely shaped is to have the test repeated, preferably at a lab that does a lot of semen analyses.

For as many scientific studies that say morphology predicts how sperm do, there are those that say it doesn’t. You might think, as I did, that if a man has especially odd looking sperm, it would affect the chances of sperm getting into the egg and be a good reason to have the sperm injected into the egg using intracytoplasmic sperm injection (ICSI). ICSI is a technique used in in-vitro fertilization (IVF) where the sperm is injected directly into the egg. But in 2007, Keegan and colleagues published a study which reported that there was no advantage to using ICSI for semen with an abundance of funny looking sperm, meaning they did just as well getting inside the egg by themselves as men with “normal” looking sperm.

What does this all mean? Well, it could mean that sperm shape counts, but we don’t yet know how to measure it correctly. Or it could mean that the sperm shape doesn’t have much to do with its function–in other words, the shape of the boat doesn’t say much about how good the captain is that’s piloting it. I don’t know which is right, and I don’t think anyone does yet. So if someone tells you that your sperm is funny looking, don’t despair. It might not be the thing keeping you from becoming a father.

Craig Niederberger, M.D., F.A.C.S. is a highly published author and editor, and head of the Department of Urology, University of Illinois at Chicago. His blog, Male Health, and other writings will be syndicated on this page for The American Fertility Association's readership 

Checking Tubes: The HSG is better than the Saline Sonogram

by Fred Licciardi M.D.

Today we are going to finish discussing the difference between the HSG and saline sonogram. Last time we highlighted the differences as they relate to studying uterine problems. Today I will point out the differences as they relate to the tubes. We will see how the biggest mistake doctors make with the saline sonogram is when they see no fluid from the tubes and stubbornly say that the tubes must be blocked, therefore you need IVF. Let me explain.

The saline sonogram is not the best test to check the tubes. It gives a hint as to the tubal status, but the results are not definitive enough.

Last blog we discussed one of the basic concepts of the saline sonogram: water looks black on ultrasound, polyps and fibroids look white. We put water inside the uterus and the white polyps or fibroids float in the black fluid making them easy to see.

During a saline sonogram, the saline, after it fills up the uterus, will wander through the tubes and out into the pelvis. So it makes sense that if we can see some black fluid outside the uterus, around the ovaries and intestines, the tubes must be open.

Here is a picture of an ultrasound showing some free fluid in the pelvis. The arrow points to the free fluid. Presumably this fluid stated in the uterus and got squeezed through the tubes and ended up in the pelvis.



















However seeing water outside the tubes does not necessarily mean the tubes are in good shape. First of all, one can’t see much detail of the patterns of water flow; the flow can’t be seen as clearly as the dye on an x-ray. We may be able to see if there is water present but we can’t see how it got there. Let’s say, for example, that only one tube is open. This is easy to see on HSG, but on saline sonogram, you cannot tell if one or two tubes are open because you usually can’t see the water flowing from each tube.

Here is an HSG showing open tubes. In the second picture I places lines to show you the approximate place there the tubes ends and there the free flow of dye out the tubes starts. This is much better visualized on the HSG; you can see each tube and the flow of dye directly.

























In the case of a hydrosalpinx, the end of the tube can fill with fluid, and although the doctor should be able to tell the difference between and hydrosalpinx and an open tube, sometimes the distinction is difficult.



Here is an HSG of a hydrosalpinx. The arrow points to the blocked tube. You probably noticed that some HSGs show the dye in white and some in black. It just depends on the preference of the physician, they can be printed with either way.




















A hydrosalpinx is usually very easy to see on HSG, possible but more difficult to see on saline sonogram.
The point is that this hydro, using a saline sonogram, may have shown up as a little free fluid, and someone may have been told her tubes were indeed open. Severe tubal disease like this may be present even though there is some “free fluid” seen in the pelvis.

At the start of this blog I spoke of the biggest mistake docotrs make when interpreting the sonohysterogram. No fluid in the pelvis does not necessarily mean the tubes are blocked, and IVF may not be the next step after "failing" a saline sonogram. Do not use saline-sono tube tests to make decisions about IVF. A saline sonogram is not an adequate test to proclaim the openness of your tubes. If you want important information about your tubes, a hystersalpingogram is the only way, with very few exceptions, as in the case of a very obvious hydro. Sometimes there is no free fluid seen outside the uterus, but maybe this is because the catheter was not positioned properly, maybe the fluid just backed out the cervix instead of going upward, or maybe there was tubal spasm. In any event, if you were told no free fluid means IVF, talk to your doctor about having an HSG.

A Big List of Fertility Questions and Answers

by Fred Licciardi MD

Monica asked about DES exposure. Most women who were exposed to DES do not have any problems with their uterus or cervix, but a very small percentage of exposed women do. You definitely need a HSG and may need to be followed by a high risk OB if the cervix or uterus is abnormal. The older fertility doctors have a little more experience, as DES was mostly phased out by the early 70’s.

Sophia asked about what to do next after 6 failed ICSI attempts. You need to be in the best clinic available to you. You could consider travelling for a second opinion.

Mandy asked about Clomid vs Metformin. In general, I use more Clomid than Metformin. If you do not ovulate, but do on Metformin, and got pregnant easily, great, sounds good, use it again. If it took you a while consider Clomid. Doctors differ on when to stop Metformin during pregnancy, and it may depend on the severity of your case of PCO. I do not think you caused the miscarriage by changing the Metformin dose.

Laura asked if ICSI is safe. We will not know the specifics for decades. So far it looks relatively safe. You need to speak to your doctor and carefully read the consent forms.

Sperm of 20 million and 20% motility: repeat the test. You have all of the options available to you. IVF may be your best shot if the sperm counts remain consistent.

Veronica asked about ICSI in a natural cycle. You can do whatever you want, but a natural cycle, while it may be successful, has a very low pregnancy rate. Your lining is fine. If your last protocol gave you your best results, yes do the same again.

M asked about IVF for a low sperm count after vas reversal. I think the microflare is a good protocol. It’s hard to say if I think it’s best for you. It seems you did pretty well with your last, but without seeing the whole cycle I can’t say for sure. To go from cancelled to 12 eggs is quite good. Ask your doctor about keeping the same protocol but going a little longer before your hCG.

Emily asked about being on Metformin for 8 months. What’s the crime in putting you on clomid? You can take both. Most doctors do not follow insulin levels in their Metformin patients. Sounds like time is just passing buy.

MK: Yes, FSH levels drawn on day 23 are not useful. Your later progesterone levels look fine.

Sandy asked about PCO and miscarriage. For every doctor who says there is a connection, there is another who says the opposite. If you ovulate regularly on your treatment and you easily conceived, there is no reason to believe it can’t happen quickly again. If it took you a long time to get pregnant, you can consider getting more aggressive this time.

Kristina asked about mildly elevated THS levels, otherwise known as subclinical hypothyroidism. Your doctor is probably right, your levels are not a problem. However there are tons of endocrinologists who disagree, and would treat you with thyroid medication. In the past I did not give medication to people like you, however I got so much flack from the endocrinologists I just gave in and started treating. You can see an endocrinologist for a second opinion.

Mr and Mrs Oldham have a sperm count of 6.5 million. If your count remains in this range, IVF is by far the way to go. You can explore other options, but your highest odds will be with IVF and ICSI.
Arpee: Thank you, a search function on the blog is a great idea. I will give it a shot.

Megan has had 3 miscarriages. She has 6 frozen embryos, but had become pregnant on her own. She doesn’t know if she will have a lower chance of miscarriage if she does the frozens or tries naturally. Theoretically, in a frozen cycle you are putting more than one in, so if one embryo is abnormal, maybe one of the other ones are ok, lowering your odds of miscarraige. This effect is probably minimal but may hold true. In general I don’t like PGD, but you may want to at least consider this for your remaining embryos to lower your odds of miscarriage. No matter how you become pregnant, unless there is something else in your history, your odds of having a baby in your next pregnancy are 70% (unless you are in your 40's, then your odds are a little lower).

Chris was told to take 6 months of lupron for her adenomyosis. Get another opinion. It depends on the severity of your case. I would give 6 months of lupron only in the most extreme cases. 6 months is a lot of time to lose.

Trixie has a 10 day luteal phase. This is probably too short. A little progesterone may do. Ask your doctor.

Rose has a high estrogen on day 3, but has been taking estrogen. I don’t know if you need estrogen, but if you do, try repeating your bloods on day 4 and maybe 5. You may be able to start your cycle even though it’s later than day 3. You may have estrogen in your system left over giving you this high reading.

Someone with Klinefelters has never had a semen analysis. Yes, you need this test. If there is no sperm, find a good reproductive urologist and consider the biopsy. Ask about doing the biopsy and IVF at the same time. Many times there is a minute amount of sperm, enough for icsi, but not enough to freeze.

The Penis as Barometer

by Craig Niederberger, M.D., F.A.C.S.

You can’t fault a man for thinking his penis a single use tool.  But it’s more like a Leatherman or a good Swiss Army knife.  One great use is as a barometer for gauging the health of a man’s heart and blood vessels.

The structure of the penis is basically a sponge with a tiny artery that supplies blood.  The sponge fills with blood, and the penis becomes erect.  (It’s actually a really impressive piece of engineering, with veins at the outer edge of the sponge that are pressed closed as the penis fills, trapping the blood and holding the erection.)  The artery supplying the sponge is very small, only about half the diameter of the coronary blood vessels supplying the heart.  If the arteries are getting clogged, the arteries in the penis go before the heart ones do, giving a man a two to five years heads-up that something bad is happening, not just to the penis, but that may be life-threatening.

Recently published guidelines recommend that if a man is experiencing problems with erections, that he be evaluated for high cholesterol and other artery clogging problems, and that if the labs are out of whack, he be treated aggressively with medication.

As important as the penis is, the heart’s kind of necessary.

Craig Niederberger, M.D., F.A.C.S. is a highly published author and editor, and head of the Department of Urology, University of Illinois at Chicago. His blog, Male Health, and other writings will be syndicated on this page for The American Fertility Association's readership 

 

Scientific Strides With Embryo Transfers

 

by Iris Waichler

I was fascinated by a recent article I read in Time Magazine.  It announced that researchers at Stanford University had discovered they could film embryos developing during the first 2-3 days after they were placed in a Petri dish.  Why is this so important?  Having this information helps embryologists identify “the best embryo to transfer to a woman’s womb.” 

            Ten years ago my husband and I sat in our R.E.’s office. It was our last IVF treatment.  We had decided to stop infertility treatment if this treatment failed.  I had spoken with professionals, people who had experienced infertility treatment, and read everything I could about IVF treatment to prepare for this final attempt. 

            The embryologist popped his head in the room and said, “We have 3 embryos. One of them looks great, one is marginal, and the other doesn’t look so good.” I will give you 5 minutes to decide how many to transfer” and he disappeared.   It was one of the most difficult moments in my years of infertility treatment.  What did it mean when an embryo is described as “marginal”? How could we make a life changing decision with so little information? How dare they put us in this position? I realized all my preparations would not help with this choice.  We decided to go with the amazing looking embryo and leave the others behind.  I was concerned if I became pregnant with one of the other 2 embryos there was a danger of having a child with developmental or medical problems.  Ours was a happy ending with the birth of my healthy daughter. We called her “amazing Grace.”

            The science of observing and understanding embryo development has evolved so people trying to build their families today will have more valuable information than we did when facing our transfer decision.   Researchers have learned what to observe to identify the most “viable embryos.”

 

            1. “The time it took to cleave from a single fertilized egg into two cells.

            2. The time between each of the next two cell-division cycles. (Faster is better)”

 

            Stanford experts say this information offers a “93%” accuracy rate determining which embryos would make it through the next couple of days.  This means transfers can be done as soon as 2 days after the embryo is fertilized.  The Stanford team believes this film technique will improve pregnancy success rates and also reduce the need for multiple transfers resulting in fewer multiple births. 

 Iris Waichler, MSW, LCSW, is a licensed clinical social worker who has counseled people experiencing infertility.  Ms. Waichler is the author of the award winning book “Riding the Infertility Roller Coaster: A Guide to Educate and Inspire”. She currently writes freelance infertility and health related articles.

 

 

What’s the difference between a Hysterosalpingogram (HSG) and a Sono-Hysterogram?

by Fred Licciardi M.D.

This just happens to be one of my most frequently asked questions, and it’s a good one. Both are can be very important tests. Some women need only one, some both. In this blog you will see pictures and explanations. I enjoyed putting this blog together because I like taking things that are a little complicated and breaking them down into simple pieces to help make the readers understand every day things that were never made clear to them. Despite this I realize that there are some of you that get very intimidated when shown pictures of anything medically related, so I am sorry if some of this compounds your frustration. Give this one a shot and see how it goes.

Hysterosalpingogram, also known as the hysterogram or HSG. Hystero means uterus, salpingo means tube, so it’s a test to evaluate both the uterus and tubes. It’s a dye test that uses an x ray. As far as the patient is concerned, it starts with a speculum, like a pap smear. The doctor, through various techniques mentioned in previous blogs, squirts some dye into the uterus and it then runs out the tubes. The dye is actually as clear as water, but it’s called dye because it is white on an x ray. The dye then shows the shape of the interior of the uterus and the tubes.

Let’s start with the uterus. This is picture of a HSG x ray.



The uterus is perfect. The tubes are abnormal, but I am starting with this one because the view of the uterus is so ideal. You can see that is triangular in shape with the top being relatively straight across.
The hsg only shows us where the dye is, which is inside the uterus and inside the tubes. It does not tell us anything about the middle or outside of the uterus or tubes. The next picture is the same as above except I outlined the outside of the uterus and the approximate location of the ovaries.




You can see that the overall uterine size is greater than what is shown by the hsg, and how the outer uterus and ovaries are invisible using x rays.







The next picture shows what happens to an HSG when there are fibroids on the middle and outside of the uterus. I drew in some hypothetical fibriods in red. Fibriods like these would be invisible on hsg. As you can see, the shape of the inside of the uterus has not changed. So it is possible to have fibroids, and have a normal looking hsg. Fibriods that are closer to the cavity will make the HSG look abnormal. We will later see how certain fibroids can affect the look of the HSG, but in this case many fibroids did not change the HSG picture.


Now we will look an HSG that shows an abnormal uterus.









This hsg is abnormal. There is a black spot in the center, and this could be a number of things, all of which are abnormal. The center is dark because the dye cannot get to the center of whatever is growing in there. It is most likely a polyp, but it could be a small fibroid or even some scar tissue(less likely). The overall triangular shape of the uterus is good. This shows how an HSG can be used for diagnosing uterine problems such as polyps or fibroids that are growing in the cavity.

This is a good time to move over to salinosonohysterograms (sonohysts for short). Commonly called a saline infusion sonohysterogram (SIS). We will come back to HSGs in a bit. The sonohyst does not use an x-ray or x-ray dye. It instead is performed with a regular old ultrasound machine. Prior to performing the ultrasound, the doctor starts with a speculum and then puts a very little plastic tube inside the uterus and squirts some saline (salt water). The saline goes into the uterus and out the tubes.

Here is a normal uterine cavity on ultraound without the saline, its the regular old ultraound.










The next picture is the same, but I added white lines to show you the outline of the entire uterus.













Here is an ultrasound of a uterine polyp (could also be a fibroid). It’s that olive shape in between the arrows. No saline yet.















Here I put a circle around it to make sure you see what I am talking about.
















And below is a sonohysterogram of a similar polyp. The doctor put a little saline inside the uterine cavity. Saline or any watery fluid looks black on ultrasound. The black surrounds the polyp and makes it much easier to see. The arrows are not important, they are just pointing out the stalk of the polyp.















Here I would like to end on one very important point. Performing this sonohysterogram was not necessary. We can all see that the polyp is very obviously visible in the picture without the water. There is really no reason to do the sonohysterogram. However time and time again, the doctor will say, "it looks like a polpy, lets do a sonohysterogram to be sure." Yes the picture using the sonohysterogram is prettier, but what he is doing is having you undergo one more unnecessary test, that you may have to pay for, and it’s expensive. So if you are confronted with a sonohysterogram, ask your doctor if he is sure if it really needs to be done. Ask if it will give you any more information than you already have. The sonohysterogram is a great test and I use it all of the time, but not if I know the answer before it’s started.