The AFA Blog

Can You be a Poor Responder and Get Pregnant on Your Own?

by Fred Licciardi, M.D.

So a little story about a couple I saw recently. She was a poor responder with borderline FSH levels, normal tubes and a favorable age. He had low sperm counts. They had been through IVF. I suggested that he see a urologist because maybe there was something that could be done to improve his counts. She still ovulates every month, so by upping the odds on the sperm side, maybe they could get lucky and get pregnant on their own.

My statements were very surprising to them. They had been told that because of her “fertility status”, meaning her FSH was a little high, pregnancy could not occur naturally, so why bother with the sperm.

This may be close to accurate but it is not completely true. Unfortunately, many couples with significant fertility problems never get pregnant, but for some, the pregnancy rate per month is not zero. Even if it is ½ percent per month, after a year, a few women with normal tubes, borderline FSH levels and good sperm will get pregnant (age helps).

Can you count on it?  No, but if there is something fixable, you might as well explore the options.

This is also the reason that some doctors suggest a laparoscopy after many failed IVF cycles. Even if the odds of tubal disease are low, correcting a small problem may improve the odds of a spontaneous pregnancy down the road.

Lupus, infertility and pregnancy

by Corey Whelan

Lupus is a chronic, autoimmune disease, which can damage any part of the body.  While teenagers and men are sometimes diagnosed with lupus, women of child bearing age comprise the largest statistical group affected.  Like all other autoimmune diseases, lupus "tricks" the body into thinking that it needs to defend itself against it's own healthy tissue and organs.  This malfunction of the immune system creates an invasion of auto-antibodies, which attacks the immune system itself.

Common symptoms can include inflammation, joint and muscle pain, sensitivity to light or sun, debilitating fatigue, headaches, mouth and nose ulcers, weight and hair loss, and low grade fever.  Some people will experience a rash that appears in a butterfly shape across the cheeks and the bridge of the nose.  

Lupus is a chronic disease marked by flares - meaning that symptoms can flare up and worsen, and then go into remission, in an unpredictable pattern over the course of many years.  

Most patients diagnosed with lupus will experience normal fertility, however, a common drug often utilized to treat the disease, marketed under the name Cytoxan, can reduce fertility potential in both men and women.  Cytoxan can lower the sperm count and also reduce testicle size in men that have taken the drug for five years or longer.  It is recommended that men freeze their sperm prior to beginning treatment with Cytoxan.  In women, Cytoxan reduces fertility potential by speeding up the rate at which a woman’s egg supply is depleted, thus pushing her into premature ovarian failure, or early menopause.it is recommended that women with lupus only take Cytoxan when vital organs are involved, and/or corticosteroids aren't effective

Around 50% of all women who have lupus will be able to experience a healthy, normal pregnancy.  However, pregnancy can often signal a flare up of symptoms and for women with this disease, every pregnancy should be categorized as high risk.  This means that a high risk obstetrician who is well versed in lupus and its symptoms should be chosen to oversee your pregnancy.  As with most high risk pregnancies, pro active behaviors, including frequent medical check ups and getting adequate rest will be extremely important.

Additional complications of pregnancy may include:

• Miscarriage during the first trimester
• Formation of blood clots during the second trimester that can interfere with the function of the placenta or cause miscarriage, caused by a lupus antibody known as antiphospholipid antibody.   
• Pre-term birth and low birth weight babies
• High blood pressure, or preeclampsia

If you have lupus and are considering pregnancy, all of this may seem daunting.  However, it is important to remember that women with lupus can, and do experience normal pregnancies and deliver healthy babies.  The keys are timing and communication.  If you are ready to get pregnant talk to your doctor, if possible.  Your doctor will recommend against attempting conception during flare up times when your lupus is active.  Discuss your current medication protocol as well as the medications that will be recommended for you during your pregnancy.  Take care of yourself, and have hope for the future.  With careful timing, most women with lupus will be able to become moms both safely, and successfully.

For more information, click on these sources:

http://www.everydayhealth.com/lupus/pregnancy-risks-with-lupus.aspx

http://www.healthcentral.com/encyclopedia/408/118.html

http://www.targetwoman.com/articles/systemic-lupus.html

http://lupus.about.com/od/lupus101/p/WhatIsLupus.htm

http://www.wegenersgranulomatosis.net/Cytoxan_and_Fertility.htm

Reprinted with permission from Examiner.com

The Royal Surgery

by Corey Whelan

You guys may remember the blog post I wrote, recapping my experiences at a Congressional briefing on toxins and reproductive health.  To tell you the truth, I, um, left out a minor detail about that day.  It was gorgeous weather wise, first real feeling of Spring I had experienced this year and i wanted to walk around the Capital.  After all, the cherry blossoms were in bloom, I had no choice, the air smelled so good!  I wasn't dissuaded by my five inch heels, even though I had been having some nagging pain in my right knee for quite some time.  About two blocks away from Union Station on my way home something in the back of said knee gave way and long story short, last week had to be surgically repaired.  

I watched much of the Royal Wedding that day from the recovery room.  The non profit teaching hospital I chose for the occasion was smack in the middle of China Town.  I now know the Chinese word for either Queen, or yellow, not sure which.  Had an amazing experience with wonderful docs and nurses, and really cool patients who managed to form a community, without language, for a couple hours.  My comic relief?  The guy to the bed next to me let out of prison for his surgery, lying there with leg irons and handcuffs.  Only in New York!  Anyway, that was nine days ago, and I'm now up and about, "running" errands and sashaying (yeah, right) through the streets of Brooklyn with a cane that I have in my hand more for emotional support than for physical stability. 

Now, I'm physically active by nature and a lover of movement.  Running, dancing, recently Zumba, all of it.  Coupled with a commitment to eat intelligently, this ideology has served me really well.  And I still stand by it, despite my current boo boo.  All things being equal, I would rather need to repair a knee than a clogged artery, and recognize that this is only a temporary situation.

You guys know that, along with the rest of my colleagues at The AFA, we believe in bringing health conscious messages to the fore because we know that health and fitness support fertility and the birth of healthy babies.  We care enough about all of you to tell you the truth about this stuff.  So I waffled about sharing my current situation, because I didn't want to frighten anyone off of an exercise plan that they may be starting.  But I had to share this story with you for a few reasons.

While i was in the now famous recovery room, two nurses came to talk to me privately.  Each of them had a friend grappling with infertility.  One friend was in her forties and looking at egg donor options.  The other was a young woman with endometriosis.  Even post surgery, I was able to give to these women, who were giving to me, and I swear that felt so good it aided my recovery that day.  Coupled with the fact that my doctor said my over all fitness level, due to my healthy lifestyle, is comparable to a 36 year old (I'm fifty five), I know that I am on the right track.  Stuff happens, and if I look back and tell myself the truth, I know that I probably should have been changing sneakers more often, and stretching more, but working out is a good thing and nothing about my current situation has changed my mind about that.   

So hang in there with me folks.  I am going to be chronicling my recuperation on this blog page, similar to what Stephanie Himel-Nelson did over at the Attain blog page, so that you can keep up with me.  I would love to hear about your own exercise programs during this time, your ups and downs, so please post often on the blog page.

Oh, and by the way.  I will be running my beloved race, the Tunnel to Towers 9/11 Firefighter's Memorial Race on September 25th for the fourth year in a row.  I invite everyone to join me every year, but especially this year.  I have 343 very good reasons to make this request of you, plus one more.  You.  Your health, your fitness, your wellness, your future.

Here's to the future.  May it bring health, happiness, fitness and peace for all of us.

 

 

Inspired by Embryo Donors

 by Craig R. Sweet, M.D.

Pay It Forward Day is April 28, 2011. The concept is pretty simple. According to the Pay It Forward Day Website, “Pay it Forward Day is all about people, from all walks of life giving to someone else and making a positive difference.” Is there a better example of paying it forward than donating embryos?

 Deciding what to do with frozen embryos is a tremendously difficult decision. Certainly, using the embryos to expand one’s own family is ideal, but some patients need to look for other options. Our goal is to decrease the number of frozen embryos that are cryopreserved indefinitely, abandoned or discarded. Donating embryos to science or to patients in need are decisions that pay it forward. While human embryonic stem cell research holds promise, its potential outcome is uncertain and may not be known for many years. Therefore, donating embryos to patients in need may be the best immediate option. Embryo donation has the potential to build families that would otherwise not exist.

 Infertility patients, when they come to the conclusion that they will not be able to have children of their own with other types of treatment, are also faced with difficult options. Adoption may be cost prohibitive, so embryo donation may be the last, best choice for them. Not only are the embryo donors paying it forward, but so are the recipients. The embryo recipients are giving a lifelong commitment to the offspring of these donated embryos.

 The reproductive facilities that have dedicated their efforts to build families through embryo donation are also paying it forward. The time, effort and complexities regarding embryo donation are daunting and reproductive facilities can certainly spend their time more profitably on other options. The practices dedicated to embryo donation feel that embryos deserve a heightened level of respect and are committed to their patients by offering an option for family building that few are able to provide.

 In a world that is increasingly complex and overwhelmingly busy, it is wonderful to know that the basic human experience is still really about caring for each other. Pay it Forward Day is the antithesis of this endeavor and who cannot be inspired by our courageous embryo donors and our committed embryo recipients?

 Pay it forward yourself on April 28 and please encourage patients with cryopreserved embryos to consider doing the same. Families are just waiting to begin.

Dr. Craig Sweet is the medical director and founder of Embryo Donation International, a private non-faith based, non-discriminatory reproductive endocrinology and infertility practice located in Fort Myers, Florida.

In a small way, Embryo Donation International has decided to make a positive difference. For every set of embryos donated, they will pay it forward by donating to one of ten international, national and regional charities selected by the donor(s), including The American Fertility Association. For more information and a full list of the designated charities, please visit www.embryodonation.com/donating-to-charity.php

 

 

 

Please exercise

by Fred Licciardi, M.D.

Please exercise.

In the preceding centuries, tremendous physical activity was required for human survival, and yet, reproduction carried on. Imagine the exhaustion and stress if we had to spend one week hunting or farming with few tools or resources. Yet probably, under these conditions, most women would be able to get pregnant.

Excessive extreme exercise causing weight loss will cause ovulation to stop because the body figures that there are not enough nutrients stored for both the woman and a fetus. If she can just barely feed herself, she can’t feed the growing baby. The same is true for an anorectic. But here we are talking about extreme extreme. Moderate exercise is fine.

Surprising to me, I did come across a paper from Harvard showing that women who underwent moderate levels of exercise had lower pregnancy rates that those who did not. Like we always say, it’s just one paper. I do not really believe it. The Harvard doctors that I know do not restrict moderate exercise.

Exercise is bad if you are taking fertility drugs because the medications make the ovaries grow. Normally the ovaries are about the size of a walnut, and the drugs increase the number of follicles, therefore the ovarian size increases. Sometimes the ovaries can get to the size of plums or even oranges. They hang inside the pelvis. As they become heavier, they become more likely to twist, and this is called torsion. Here the twisting cuts off the blood supply and causes the ovary to choke. This really hurts, and is treated by laparoscopy. Exercise will increase the odds of this twisting. So in this case, exercise is not good.

Exercise increases blood flow to all areas of the body. The uterus and ovaries are organs that would love to get as much blood flow as they could.

Exercise clears your head. Yes, endorphins are released with strenuous activity, and these can help us fell better, but I think it’s more than that. My theory is that it’s not just about increasing the good chemicals; it’s about getting rid of the bad. Increased blood flow flushes away the old stale thought chemicals that are just hanging around causing trouble. Get rid of them.

Even better, do exercise that requires tremendous concentration. This really clears you head. Any sport will do: sailing, golf, soccer, basketball, biking, you name it. Some are more strenuous than others, but they all work. Same thing; flood your brain with fresh blood and new thoughts, lose the waste products.

Exercise builds muscle mass. This is also good. It just makes you feel better if you have a little tone. Even if you think you are fat, the tone goes a long way. It’s healthier to have some tone and muscle. It helps with balance and lowers you chances of getting injured during an accident (falling, for example).

And people with a little tone just age better.

Not to mention all of the obvious benefits of upping your cardio-vascular reserve.

I am not an expert in Yoga, although I have happily done it a few times. It's very good alternative.

So you don’t have time for exercise? Yes you do, make time. If you are tired, go to gym tired, it works just as well. You will sleep better.

If you do decide to take my advice (and the advice of others), go all out. A little exercise once a week is better than nothing, but more is better. You need at least 2 sessions per week of vigorous activity to really make a difference. Don’t start on any aggressive workout without checking with our doctor first, and consider a trainer at least initially.

Immature eggs and infertility treatment

by Fred Licciardi, M.D.

Say you are undergoing IUI or IVF and your doctor has told you that you have a high percentage of immature eggs.

Remember, having a rate of 10-20% of immature eggs is normal.

However, having a high percentage of immature eggs can be a function of a few things. Firstly, maybe you received the hCG too early, and waiting 1-2 more days may have increased the percentage of mature eggs. Most people on average do not have an excess of immature eggs when receiving their hCG shot, once their biggest follicles reach about 18 mm. Some women however, need their biggest follicles to be 20 or 22 mm before most of their eggs are mature.

There is no way to know this in advance of the first cycle. But, if this is the case, changes should be made for subsequent cycles and you should discuss this with your doctor.

There are some women who, no matter how long we wait to give the hCG shot, will still have a large number of immature eggs. We can’t explain why this is so.  It is simply a case of dealing with what you have.

In general, we don’t want to wait too long before giving the hCG shot because eggs can become over-mature and this could show up later as poor quality embryos.

Insurance coverage for young adult cancer patients to preserve fertility

by Corey Whelan

Around 1.5 million American men and women are diagnosied with cancer annually.  Ten percent of those are under the age of 45 and one percent will be younger than 20.  That translates into around 70,000 young adults, all under the age of 20 years old, who will have to grapple with this disease.  Statistics aside, if you or a loved one are diagnosed with cancer, life may never be the same.  Mind reeling, you may or may not think about options for parenthood later on.  Of course, many cancer treatments including surgery, chemotherapy and radiation may have the effect of rendering the person on the receiving end infertile.  Of course, survival is the number one goal but many cancer patients report that their ensuing infertility was just as devastating to them as their original diagnosis.

Fertility can often be preserved prior to cancer therapy beginning, for both men, women, boys and girls.  These options can be as simple as collecting and freezing sperm, or can become more complicated and expensive, including testicular needle aspiration for young boys or egg freezing for young women.

According to change.org, the vast majority of insurance comapnies and HMO's in the United States do not cover fertility preservation treatments such as those referenced above.

Currently, legislation addressing this issue is being decided upon in California.  Bill AB 428 is being sponsored by Assemblyman Anthony Portantino but your help is needed.  No matter where you live, your name on a petition requesting support of this bill will be meaningful and will not go unnoticed.  

Click here to read the petition letter and to sign it. Please.

For more information on fertility preservation and your options, click here

To watch a short video on fertility preservation, click here

Be the change.

Finding Faith this Easter

by Merry Armentrout, The AFA's Director of Communications

For Christians, Easter is a time of celebration.  I always look forward to the church service on Easter Sunday because I know the pulpit will be filled with beautiful flowers, the hymns will have a festive tone and a huge brunch will follow the service where I will try desperately not to spill anything on my  new Easter dress.  We're celebrating the Resurrection of Jesus, and a time where Christians can't help but remember the love Jesus has for his children. 

What happens when Easter rolls around and you don't feel much like celebrating?  Maybe you're dealing with infertility, undergoing IVF or in the thick of the adoption process, and you're just not in the mood to be festive.  Maybe your problem has nothing to do with starting a family, but life's other challenges have you trying to keep your head above water.  This Easter, my family is struggling to find joy, to find faith.

My father has struggled with glaucoma for years, and lost most of the vision in his right eye a few years ago.  Last Thursday, he had a minor eye surgery on his left eye, and developed a staph infection in his eye.  Less than 10 hours later he had lost all vision in his left eye.  The doctors told him this week his retina might regenerate in a year, but there are no guarantees.  Hopefully he'll be able to see well enough to read, but he will never drive again. He is legally blind. This would be hard news for anyone to receive, but one of my dad's passions is collecting antique cars, and the thought of never driving again really hit him hard.

It has been a hard week for my family. I flew home and spent hours in doctor's offices and hospitals, getting a glimpse of the hell my dad has endured.  I watched the proudest man I know, ask me to walk him to the bathroom in an unfamiliar restaurant.  I helped my mom learn how to use the computer so she can help my dad check him emails.  I heard the bravest man I know say he needs a break from the hourly antibiotic drops he has to put into his eyes- could he just skip one time?  I heard both my parents crying as we sat in church yesterday, thinking I didn't notice their tears, as I wiped my own eyes.  We're trying to adjust to a new life, but are left questioning why we were put in this situation.  My prayers are intertwined with pleas for dad's sight to return, and angry accusations as to why God would have this happen.  It's very difficult to watch someone you love so much go through something so terrible.  What I need right now is faith, and it's the one thing I'm having a hard time finding.

For me, faith is not blaming God, but trusting Him.  Trusting everything will be okay, trusting my father will find the determination to get through this and trusting the same man that raised me with such temerity, will be the same man who emerges from this battle.   I just spent the last week looking at my father's face- it was not full of faith, but fear and dejection, and my father is the ringleader of our group, the one who drags us to church every Sunday since we were children.  If he can't find faith, how possibly can I?

I don't know.  I'm sure you're looking for something more inspirational, but it's the truth.  I don't know how I'm going to find it, but I have faith I will.  I might not be in a celebratory mood this Sunday, but I will put on my new Easter dress, go to church and appreciate the beautiful flowers and uplifting hymns.  I will then turn to one of my dad's favorite bible verses.

Philippians 4:6-7

⁶ Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. ⁷ And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus.

 

If I have to read it a hundred times, a thousand times, I will. I'll read it until I find the faith, until I find the peace.  And so will my dad.

I don't know what battle you're fighting, or if you're even fighting a battle at all.  But I do know it helps to realize you're not alone in battle.  My cousin always told me she smiles at everyone because you never know what that person might be going through.  Life is tough.  Life is unexpected. But as one of my favorite poets, Robert Frost said, "In three words I can sum up everything I've learned about life.  It goes on."

Might as well go with it.  And find time to celebrate.

 

 

 

Passover and PCOS - a Guide to Healthy Eating

by Corey Whelan

Tonight, Jewish families and their friends will be gathering around Passover seder tables, to tell the story of Moses and the exodus of the Jewish slaves from Egypt, centuries ago.  Like most holidays, this one will feature an abundant feast as well as the camaraderie of loved ones.  For many women who have  polycystic ovarian syndrome however, the feast on the holiday table may feel like a carbohydrate laden land mine waiting to go off.  As someone who has successfully combated PCOS through diet and exercise, I wanted to share some info on PCOS as well as a few of my own eating strategies with you.

First off, Polycystic Ovarian Syndrome, or PCOS, affects around 10% of women of reproductive age and is quite prevalent among Jewish women, particularly those of Ashkenazi descent.  An endocrine disorder, PCOS is categorized by insulin resistance and results in irregular menstrual cycles, hirsutism and struggles  with weight, as well as infertility.   There is thought to be a genetic component to PCOS and insulin resistance, which is why it is more prevalent in certain populations than in others. 

A hormone, one of insulin's jobs is metabolism of carbohydrates, fats and proteins.  For women who are insulin resistant, the body's normal metabolic response is reduced, causing weight gain, which is triggered by the intake of foods that are high in simple carbohydrates.  Some research currently links the insulin resistance - carbohydrate connection to decreased fertility as well.

So what's a girl to do when faced with the potato kugel, matzoh ball soup, and sweet wine that are mainstays at the Passover table?  Here's what I do.  

• While eating  matzoh is pretty much required this time of year, remember that just one sheet of unleavened bread has the equivalent in carbs and calories as one slice of the leavened stuff, and limit your portions.  For other foods, consider making substitutions.  It's easier than you might think.
• Instead of the usual potato kugel, break tradition by making a delicious new variety using  spinach or zucchini and mushrooms as the main ingredients.
• Instead of sweet wine, pour a drier variety, and drink in moderation.
• Hold the matzoh balls!  Your mom's chicken soup will be just as tasty without this usual plop in, and you won't feel laden down and sleepy by the end of the seder.
• As with every meal you eat all year round, fill up on healthy veggies, lean protein and some fruit instead of going for the starchier foods.
• Impress everyone by reaching for the fresh fruit when its time for dessert instead of the candied ones.

Another wonderful new holiday tradition to consider is a late night walk as a family after the meal to help burn off calories and build muscle. 

Take advantage of the fact that many people are now trying to limit their carbohydrate intake in order to break the insulin resistance cycle, and lots of cookbooks and websites are cleverly catering to this population of health conscious folks.  There are tons of free recipes available for you to download, here are a few you can try:

• http://cookeatshare.com/popular/low-carb-kosher-for-passover-recipes
• http://lowcarbdiets.about.com/
• http://kosherfood.about.com/od/pesach/Passover.htm

For those concerned with gluten or who have been diagnosed with Celiac Disease, you can buy gluten free matzo here:

http://glutenfreebay.blogspot.com/2008/03/new-source-for-gluten-free-oat-matzo.html

Next year in Jerusalem!

 

The dreaded biochemical pregnancy

by Fred Licciardi, M.D.

Here I will tell of a typical story about a woman who has been suffering from infertility, and finally becomes pregnant. After the relief of a positive pregnancy test her doctor repeats the test and says, “Well Lisa, it looks like your pregnancy is biochemical”.
Now I can’t completely describe what Lisa is saying to herself, but it’s probably something like this.
“What is he talking about? A biochemical pregnancy? Did I get pregnant? Am I pregnant? Biochemical? It's bad enough I have felt like a science experiment, now I’m biochemical?”
Let me try to straighten this out. The definition of a biochemical pregnancy is a pregnancy that stops growing before it is large enough to be seen on ultrasound. It’s a very early miscarriage. The causes are the same as for any miscarriage. By far, the most common reason is that the embryo is genetically abnormal, that is it doesn’t have the right number of chromosomes. And although it has the tools to grow for a while, as the embryo grows and needs to become more complex, the tools run out and the embryo can grow no more. There are other causes of miscarriage and that will be topic of a later blog.
The word “biochemical pregnancy” is a terrible term. It’s very cold and scientific and inhumane. I try not to use it, I just say it’s a very early loss. I thing the fertility community should throw out the word. I’m going to ask them if they will.