The International Council on Infertility Information Dissemination, Inc

The Miscarriage Manual: Coping with the Emotional Aspects of Pregnancy Loss by Elizabeth Carney

Miracles and Memories Family-Building Pins

Miracles and Memories Family-Building PinsFourteen years ago I gave birth to a baby girl. Four hours later she died because of an internal malformation that was undetectable during my pregnancy. During my short hospital stay, nurses and doctors seemed to avoid me and my questions. What they did say was about the same as what my friends and family were saying. "You're young. You'll have other babies. Try to forget." 

I didn't want any other baby; I wanted that one! Forget? How could I forget? Instead I was overwhelmed with crushing, breathtaking grief. I remember how empty I felt the day I left the hospital...an empty womb and empty arms. I never really knew her but I missed her and ached for her so desperately. 

Soon after I returned home, everyone acted as if they had already forgotten her, as if they expected me to also. Someone had removed all the baby items I had acquired before coming home, hoping to spare me the pain. Instead, it felt like a further denial of her existence. When I tried to talk about her everyone became very quiet, or changed the subject, or left the room. Friends were very careful not to say anything that might remind me of my experience. Baby shower invitations didn't come in the mail. Birth announcements didn't come in the mail. Many stayed away because they simply did not know what to say. My husband had three days to "get over it" before he was expected back at work. The world kept on spinning as if nothing had happened. I remember thinking that I must have lost my mind. I thought that if my baby had lived for a while, if people had gotten to know and love her, maybe then I would have been given the affirmation to grieve the way I needed to. But I was the only one with any memory of her, the only one who had the chance to love her. I had no one to share that with, not even my husband. Most of his grief was for me and for the dreams we had shared for this child. I felt all alone as I began my mourning. 

Over the years, after much healing, I have had the opportunity to speak with other parents who have had experiences which were similar to mine. As a result of that, and also as a result of my search for answers to all those unanswered questions, I have compiled a list of several "truths and non-truths" concerning the grieving process as it relates to perinatal bereavement. 

This is not intended to be the absolute word on the subject, but rather a gauge for the unexpected emotions felt by parents who have suffered this type of loss. Most of the parents I have spoken to agreed that the uncertainty of their grief was frightening and may have been alleviated had they known what to expect. 

Friends and family may also benefit from reading this over so they might understand the special kinds of pain and emotions involved in this type of loss and allow them to be expressed. 

The Truth Is...

1. The truth ISN'T that you will feel "all better" in a couple of days, or weeks, or even months. 

The truth IS that the days will be filled with an unending ache and the nights will feel one million sad years long for a while. Healing is attained only after the slow necessary progression through the stages of grief and mourning. 

2. The truth isn't that a new pregnancy will help you forget. 

The truth is that, while thoughts of a new pregnancy soon may provide hope, a lost infant deserves to be mourned just as you would have with anyone you loved. Grieving takes a lot of energy and can be both emotionally and physically draining. This could have an impact upon your health during another pregnancy. While the decision to try again is a very individualized one, being pregnant while still actively grieving is very difficult. 

3. The truth isn't that pills or alcohol will dull the pain. 

The truth is that they will merely postpone the reality you must eventually face in order to begin healing. However, if your doctor feels that medication is necessary to help maintain your health, use it intelligently and according to his/her instructions. 

4. The truth isn't that once this is over your life will be the same. 

The truth is that your upside-down world will slowly settle down, hopefully leaving you a more sensitive, compassionate person, better prepared to handle the hard times that everyone must deal with sooner or later. When you consider that you have just experienced one of the worst things that can happen to a family, as you heal you will become aware of how strong you are. 

5. The truth isn't that grieving is morbid, or a sign of weakness or mental instability. 

The truth is that grieving is work that must be done. Now is the appropriate time. Allow yourself the time. Feel it, flow with it. Try not to fight it too often. It will get easier if you expect that it is variable, that some days are better than others. Be patient with yourself. There are no short cuts to healing. The active grieving will be over when all the work is done. 

6. The truth isn't that grief is all-consuming. 

The truth is that in the midst of the most agonizing time of your life, there will be laughter. Don't feel guilty. Laugh if you want to. Just as you must allow yourself the time to grieve, you must also allow yourself the time to laugh. Viewing laughter as part of the healing process, just as overwhelming sadness is now, will make the pain more bearable. 

7. The truth isn't that one person can bear this alone. 

The truth is that while only you can make the choices necessary to return to the mainstream of life a healed person, others in your life are also grieving and are feeling very helpless. As unfair as it may seem, the burden of remaining in contact with family and friends often falls on you. They are afraid to "butt in," or they may be fearful of saying or doing the wrong thing. This makes them feel even more helpless. They need to be told honestly what they can do to help. They don't need to be told, "I'm doing fine" when you're really NOT doing fine. By allowing others to share in your pain and assist you with your needs, you will be comforted and they will feel less helpless. 

 

8. The truth isn't that God must be punishing you for something. 

The truth is that sometimes these things just happen. They have happened to many people before you, and they will happen to many people after you. This was not an act of any God; it was an act of Nature. It isn't fair to blame God, or yourself, or anyone else. Try to understand that it is human nature to look for a place to put the blame, especially when there are so few answers to the question, "Why?" Sometimes there are answers. Most times there are not. Believing that you are being punished will only get in the way of your healing. 

9. The truth isn't that you will be unable to make any choices or decisions during this time. 

The truth is that while major decisions, such as moving or changing jobs, are better off being postponed for now, life goes on. It will be difficult, but decisions dealing with the death of your baby (seeing and naming the baby, arranging and/or attending a religious ritual, taking care of the nursery items you have acquired) are all choices you can make for yourself. Well-meaning people will try to shelter you from the pain of this. However, many of us who have suffered similar losses agree that these first decisions are very important. They help to make the loss real. Our brains filter out much of the pain early on as a way to protect us. Very soon after that, we find ourselves reliving the events over and over, trying to remember everything. This is another way that we acknowledge the loss. Until the loss is real, grieving cannot begin. Being involved at this early time will be a painful experience, but it will help you deal with your grief better as you progress by providing comforting memories of having performed loving, caring acts for your baby. 

10. The truth isn't that you will be delighted to hear that a friend or other loved one has just given birth to a healthy baby. 

The truth is that you may find it very difficult to be around mothers with young babies. You may be hurt, or angry, or jealous. You may wonder why you couldn't have had that joy. You may be resentful, or refuse to see friends with new babies. You may even secretly wish that the same thing would happen to someone else. You want someone to understand how it feels. You may also feel very ashamed that you could wish such things on people you love or care about, or think that you must be a dreadful person. You aren't. You're human, and even the most loving people can react this way when they are actively grieving. If the situations were reversed, your friends would be feeling and thinking the same things you are. Forgive yourself. It's OK. These feelings will eventually go away. 

11. The truth isn't that all marriages survive this difficult time. 

The truth is that sometimes you might blame one another, resent one another, or dislike being with one another. If you find this happening, get help. There are self-help groups available or grief counselors who can help. Don't ignore it or tuck it away assuming it will get better. It won't. Actively grieving people cannot help one another. It is unrealistic, like having two people who were blinded at the same time teach each other Braille. Talking it out with others may help. It might even save your marriage. 

 

12. The truth isn't that eventually you will accept the loss of your baby and forget all about this awful time. 

The truth is that acceptance is a word reserved for the understanding you come to when you've successfully grieved the loss of a parent, or a grandparent, or a beloved older relative. When you lose a child, your whole future has been affected, not your past. No one can really accept that. But there is resolution in the form of healing and learning how to cope. You will survive. Many of us who have gone through this type of grief are afraid we might forget about our babies once we begin to heal. This won't happen. You will always remember your precious baby because successful grieving carves a place in your heart where he or she will live forever.

 

Please visit the INCIID Memorial Gardens

 

The Infertility Evaluation: Basic Testing with a Reproductive Endocrinologist By INCIID Advisors

Basic Infertility Evaluation - Fertility Tests

This article is a basic overview or review of an infertility evaluation for those individuals and couples struggling with infertility and trying to conceive or carry a pregnancy to term and delivery.

The American Society of Reproductive Medicine (ASRM) revised the definition of infertility to encourage earlier evaluation and treatment in the highest risk group. Infertility has traditionally
been defined as the inability to conceive after twelve months of regular, unprotected intercourse

INCIID suggests seeking evaluation early with a reproductive endocrinologist (RE). Seeking help from a specialist (RE) is
particularly important if you are 30 or over and/or have experienced
more than one spontaneous abortion (miscarriage).

The following experiences suggest seeking specialized help from a reproductive endocrinologist.

·       Regular unprotected intercourse with no pregnancy for a year

·       Trying 6 months when 30 years of age or older

·       Irregular menstrual cycles

·       A history of pelvic pain or other problems such as infection or abdominal or reproductive surgery

·       DES Exposure

·       Two or more miscarriages (under 30) and one if 30 or older

·       Male reproductive problems that may alert you to a problem may include:

  • Reproductive surgery
  • Low sperm count and./or problems with morphology etc.
  • prostatitis
  • Urinary infections

 
Reproductive Endocrinology and Infertility (REI): Why seeing an RE is important.

Education

The reproductive endocrinology specialist is usually an Obstetrician-Gynecologist with advanced education, research and professional skills in the field of Reproductive Endocrinology and Infertility (REI). Reproductive endocrinology is a surgical subspecialty of obstetrics and gynecology that trains physicians in reproductive medicine addressing hormonal functioning as it pertains to reproduction as well as the issue of infertility and multiple pregnancy loss.

Generally, OB/GYN enter into a 3-year fellowship or training program leading to board certification in Reproductive Endocrinology and Infertility by the American Board of Obstetrics and Gynecology. These fellowships provide clinical training in reproductive endocrinology, reproductive surgery, assisted reproductive technology (i.e. IVF and other ART procedures), genetics, embryology, and andrology. The programs are rigorous with comprehensive requirements. The physicians in the program are also required to pass a written examination and an oral exam by a team of REI experts. Once passed the physicians are sub-specialty board certified.

INCIID is often asked, “who is the best”. The most important first decision is seeing a specialist. Seeing an RE is the consummate “gold standard”. OB/GYNs will have some basic knowledge about infertility but that information and practice are minimal. The research required during an REI fellowship will support improved clinical outcomes and fewer clinical errors. This sub-specialty also requires updating physician knowledge to continue to provide evidence-based practice.

When looking for a board-certified reproductive endocrinologist check the Society of Reproductive Endocrinology and Infertility (SREI)website. The SREI required board certification in Obstetrics and Gynecology as well as the RE subspecialty. INCIID also offers a biographical overview including the specialty of physician members who support INCIID’s mission. Search the directory by zip code or state.

Patients should not be shy about asking their fertility doctor if they are “Sub-specialty” board certified as a reproductive endocrinologist.

Many patients are reluctant to switch from their OB/GYN. Some sight the expense. But the business of Obstetrics and Gynecology concentrates on routine gynecological care and delivering babies for their bread and butter. While evaluation of a fertility problem can be expensive, to stay with an OB/GYN can waste valuable time and actually become more expensive.

INCIID stresses the importance of seeking early care with qualified practitioners and outlines the criteria for moving to a specialist.

Having a family is an individual or couples’ decision. Whatever your situation, partners are in this together.

Basic Infertility Evaluation

Please note that every reproductive endocrinologist (RE) has his or her own standard protocol, and the following is intended to be a helpful basic guideline. Patients should be in a partnership with their physician and feel comfortable asking questions about any test or procedure. 

FIRST APPOINTMENT: History and Physical Exam

At the first appointment, most REs also do a routine screening of both partners such as HIV, hepatitis, etc. Medical histories for both partners will be taken. Try to keep track of the length of your menstrual cycles for several months beforehand. Charting Basal Body Temps (BBTs) for several months will also give your doctor some insights---as will using home Ovulation Predictor Tests (OPTs) and recording the results. A semen analysis will be scheduled. Some doctors will accept your medical records for review prior to your appointment. If not, bring your medical records with you.

The doctor will generally start with some type of comprehensive questionnaire providing an overview of reproductive history for both partners. He or she may also ask questions about the reproductive history. Some of those questions may include information about:

  • Previous pregnancies (if any)
  • Irregular periods or menstrual cycles
  • Pre-existing conditions or diagnosis such as polycystic ovary syndrome, pelvic inflammatory disease, tubal pregnancy, endometriosis
  • Problems with ovulation,
  • Male infertility issues, sperm count, motility, urinary or prostate issues

The physician may do a vaginal ultrasound. Consider scheduling the first consultation with the RE during the first or second day of the menstrual cycle. Why? Because during the exam, the doctor may be able to do several tests that are cycle-day specific. Instead of re-scheduling for another date, patients may be able to arrange for time-sensitive tests and move forward with evaluations and a plan more quickly.

Assessment of Ovarian Reserves

Human Ovary Antral Follicle Count (Guided Vaginal Ultrasound)

One test and a good predictor of ovarian reserve is the antral follicle count. The count is done of cycle days 2, 3, or 5 using guided vaginal ultrasound. Antral follicles are immature eggs. The number of immature follicles correlates with ovarian reserves.  that looks at the ovaries. Keep in mind that antral follicles vary from month to month.

A vaginal ultrasound can also discover abnormalities within the Pelvis. Infections in the pelvic region often go unnoticed but are a significant cause of infertility (i.e. blocked tubes, uterine scarring, tubal damage, endometriosis, fibroids, adhesions, etc.) 

 If the antral count is too low (generally less than 4 according to Dr. Richard Sherbahn) chances of a successful pregnancy and live birth are low, the higher antral counts can be indicative of PCOS (Poly Cystic Ovarian Syndrome)

Anti-Mullerian Hormone Testing of Ovarian Reserve (AMH) (Blood Test)

The human egg is "housed" inside a structure called the follicle. The follicle is comprised of specialized cells called granulosa cells. The granulosa cells produce a specific hormone directly and predictably linked to egg quality, and that hormone is called AMH. While other means of examining ovarian reserve may offer indirect, and possibly less accurate, less specific, and less predictive tests of egg quality (such as cycle day 3 FSH/estradiol levels and the Clomiphene Citrate Challenge Test), many reproductive endocrinologists believe women are better served by examining their AMH level -- a more direct, more accurate, more specific, and more predictive test of egg quality.

The AMH test has been found particularly useful in the following clinical situations:

·     

Women who either need a Clomiphene Citrate Challenge Test (CCCT) or previously had a CCCT and want to confirm/refute the results;

·      Women of advanced reproductive age (35 years or older);

·      Any women with a diagnosis of "unexplained infertility";

·      Women who have shown a poor response to ovulation induction with either Clomid/Serophene or injectable fertility drugs;

·      Women who have been told they need IVF with donor eggs -- a normal AMH level may permit them to do IVF with their own eggs, while an abnormal AMH level may confirm the need for IVF with donor eggs

For more information on AMH testing, see the article by Scott Roseff, MD

Day 3 Follicle Stimulating Hormone (FSH) and Estradiol (E2) Testing (Blood Testing)

On the third day of the menstrual cycle, the clinic may draw blood and test the FSH levels. This test is not as reliable as other but can give an indication if a woman is closer to menopause (with low ovarian reserves). FSH is a hormone secreted by the anterior lobe of the pituitary and stimulates the maturing of the ovarian follicles in women. In men, the hormone is important in maintaining spermatogenesis.

Unfortunately, a high FSH is always bad but a good level may not mean there are egg reserves either.

Adding to the confusion is the fact that FSH bounces around quite a bit. One month the result may be a 7 and the next month it may be a 13. For a while, it was thought that waiting for a month to cycle may yield a better level and improve the odds that a given cycle would work. Unfortunately, the intermittent high FSH is as bad a prognostic sign in months where the FSH is normal as in months where the level is high.

For more information on FSH testing read the David Sable, MD article.

Other Blood Work May Be Ordered

Depending on the individual or couple’s needs, there may be other blood tests ordered. Blood tests that might be needed include:

Luteinizing hormone (LH): A pituitary hormone that stimulates the gonads. In the male LH is necessary for spermatogenesis (Sertoli cell function) and for the production of testosterone (Leydig cell function). In the woman LH is necessary for the production of estrogen. When estrogen reaches a critical peak, the pituitary releases a surge of LH (the LH spike), which releases the egg from the follicle.

LH controls the length and sequence of the female menstrual cycle, including ovulation, preparation of the uterus for implantation of a fertilized egg, and ovarian production of both estrogen and progesterone. Theca cells in the ovary respond to LH stimulation by secretion of testosterone, which is converted into estrogen by adjacent granulosa cells. In women, ovulation of mature follicles on the ovary is induced by a large burst of LH secretion - the preovulatory LH surge. Residual cells within ovulated follicles proliferate to form corpora lutea, which secrete the steroid hormones - progesterone and estradiol. Progesterone is necessary for the maintenance of pregnancy, and, in most mammals, LH is required for continued development and function of corpora lutea. For more information read this article.

Dr. Geoffrey Sher, “It is certainly time for us to reflect seriously on what and why e use specific protocols and drugs in IVF.” Dr. Sher thinks the focus might be better by optimizing ovogenesis rather than simply on how to increase the total egg yield.” He goes on to say he favors the use of FSHr-dominant, long pituitary down-regulation protocols that reduce LH. Dr. Sher is experienced in treating older women. Read more about LH regulation here.
Estradiol (E2), 

Prolactin is a hormone produced by the pituitary gland. The pituitary gland sits below the hypothalamus at the base of the brain.

Prolactin causes breasts to grow and develop. It also causes milk production in the breasts of a lactating or pregnant woman. Prolactin can be found in both males and females. A blood test will determine the prolactin levels and your doctor will have a normal or out of range level and recommend the best course of action.

During pregnancy prolactin levels increase. After the birth of a baby, a woman’s estrogen and progesterone levels drop and prolactin levels rise. These high levels of prolactin cause milk to “come in” or milk production to begin so a baby can be breastfed. In women who are not pregnant, prolactin is one of the hormones that regulate menstrual cycles.  In males, high levels of prolactin may be related to sperm production and sexual dysfunction. For more information on prolactin, read this article by Carolyn Coulam, MD.

Testosterone (T): The male hormone responsible for the formation of secondary sex characteristics and for supporting the sex drive. Testosterone is also necessary for spermatogenesis.

Progesterone (P4): The hormone produced by the corpus luteum during the second half of a woman's cycle. It thickens the lining of the uterus to prepare it to accept implantation of a fertilized egg. It is released in pulses, so the amount in the bloodstream is not constant.

17-hydroxyprogesterone (17-OHP) An over-secretion of androgen can cause elevated 17-OHP levels which can, in turn, interfere with ovulation. This is called congenital adrenal hyperplasia. Once this condition is found it can be corrected with medication to help patients ovulate normally.

Thyroid Releasing Hormone (TRH) and low levels of Thyroxine(T4) can also result in an excess of prolactin (normally produced by the pituitary gland to promote lactation) and TSH both of which can have a negative effect on fertility by preventing ovulation or result in irregular or absent periods.

Thyroid Stimulating Hormone (TSH): Women are far more likely and more often (than men) experience thyroid disease during their reproductive years. The most common test done to assess thyroid function is TSH (Thyroid Stimulating Hormone). TSH is produced by our pituitary gland. TSH stimulates the thyroid to produce the hormones T4 (thyroxine) that can interfere with ovulation. 

Different clinics and laboratories standardize testing in different ways. Below is an overview generally of the ranges for the different levels.

Luteinizing Hormone (LH)

·       Follicular Phase (day two or three): <7mIU/ml

·       Day of LH Surge: >15mIU/ml

Follicle Stimulating Hormone (FSH)

·       Follicular Phase: <13mIU/ml

·       Day of LH Surge: >15 mIU/ml

Estradiol

·       Day of LH Surge: >100 pg/ml

·       Mid Luteal Phase (seven days after O): >60 pg/ml

Progesterone

·       Day of LH Surge: <1.5 ng/ml

·       Mid Luteal Phase >15 ng/ml

Prolactin:<25 ng/ml 
Free T3: 1.4 to 4.4 pg/ml 
Free Thyroxine (T4): 0.8 to 2.0 ng/dl 
Total Testosterone: 6.0 to 89 ng/dl 
Free Testosterone: 0.7 to 3.6 pg/ml 
DHEAS: 35 to 430 ug/dl 
Androstenedione: 0.7 to 3.1 ng/ml

KEY: < = less than;
        >= greater than; mIU=milli International Units;

ml=milliliter;

pg=picograms;

ng=nanograms;

uIU=micro International Units;

dl=deciliter; ug=micrograms
 

Additional Testing

After the initial workup, many doctors continue with some of the following tests.

HYSTEROSALPINGOGRAM (HSG):

This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This "dye" appears white on the x-ray, and allows the radiologist and your doctor to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If you are trying to get pregnant in the same cycle as an HSG, make sure to schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo. Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who DO have blockages, report intense pain. Speak to your doctor about taking a pain medication about 30 minutes prior to the actual procedure.

Transabdominal Saline Contrast Sonohysterography

Although HSG is the standard screening test for the diagnosis of tubal infertility, there are studies that confirm a higher sensitivity, safety and acceptability of Transabdominal Saline Contrast Sonohysterography (compared to HSG) for the evaluation of tubal patency in infertile women.

This technique uses sound waves to produce pictures of the inside of a woman’s uterus and help diagnose unexplained vaginal bleeding. Hysterosonography is performed very much like a gynecologic exam and involves the insertion of the transducer into the vagina after you empty your bladder.

Using a small tube inserted into the vagina, your doctor will inject a small amount of sterile saline into the cavity of the uterus and study the lining of the uterus using the ultrasound transducer. This can also be injected into the fallopian tubes for evaluation of patency. Ultrasound does not use ionizing radiation, has no known harmful effects, and provides a clear picture of soft tissues that don’t show up well on x-ray images.

This technology is readily available, easy to interpret. It is not only safer and cheaper but it’s as accurate as HSG in evaluating the fallopian tubes and the uterine cavity in infertile patients. Some physicians advocate its use as a replacement. (Read more here.)

HYSTEROSCOPY

(Transabdominal Saline Contrast Sonohysterography can be also used in place of Hysteroscopy)

If a uterine abnormality is suspected after the HSG, your doctor may opt for this procedure, performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths. "Photos" are taken for future reference. This procedure usually is performed in the early half of a woman's cycle so that the build-up of the endometrium does not obscure the doctor's view. However, if the doctor is planning to do an endometrial biopsy at the same time, it is done near the end of the cycle.

LAPAROSCOPY

A narrow fiber optic telescope is inserted through a woman's abdomen to look at the uterus, fallopian tubes, and ovaries and to discern endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the ovaries. This test is usually done two or three days before menstruation is expected, and only after an HCG beta blood test ensures the woman is not pregnant.

ENDOMETRIAL BIOPSY

In the past, the endometrial biopsy was a routine part of the fertility evaluation, but currently, it is performed mainly on patients at risk for endometrial cancer or with repeated IVF failures. An endometrial biopsy is a simple office-based procedure that is performed just before the onset of a woman's menses.

Baseline tests for follicle stimulating hormone (FSH) and luteinizing hormone (LH) must be done on day three of your cycle. If your consultation should take place before that, you'll be instructed to come in for these tests on day three of your cycle. Additional tests will be conducted on the day of Luteinizing Hormone (LH) surge (mid-cycle), and again about seven days after ovulation.

Luteinizing Hormone (LH)

·       Follicular Phase (day two or three): <7mIU/ml

·       Day of LH Surge: >15mIU/ml

Follicle Stimulating Hormone (FSH)

·       Follicular Phase: <13mIU/ml

·       Day of LH Surge: >15 mIU/ml

Estradiol

·       Day of LH Surge: >100 pg/ml

·       Mid Luteal Phase (seven days after O): >60 pg/ml

Progesterone

·       Day of LH Surge: <1.5 ng/ml

·       Mid Luteal Phase >15 ng/ml

Prolactin:<25 ng/ml 
Free T3: 1.4 to 4.4 pg/ml 
Free Thyroxine (T4): 0.8 to 2.0 ng/dl 
Total Testosterone: 6.0 to 89 ng/dl 
Free Testosterone: 0.7 to 3.6 pg/ml 
DHEAS: 35 to 430 ug/dl 
Androstenedione: 0.7 to 3.1 ng/ml

KEY: <= less than; >= greater than; mIU=milli International Units; ml=milliliter; pg=picograms; ng=nanograms; uIU=micro International Units; dl=deciliter; ug=micrograms

Semen Analysis

A semen analysis is a  very important test and it should be done early in the evaluation. If there is a significant sperm problem, the female analysis may be modified to more basic tests and certainly, the analysis should be conducted before more invasive female surgical interventions are attempted.

About a quarter of infertility cases are due to a sperm defect. Almost half of the infertility patient cases will include a sperm deficit as a contributing factor in the causation of infertility. Take a closer look at the male reproductive system and the way sperm is analyzed here.

Multiple Miscarriages, Stillbirth and Pregnancy Loss

Until the last decade, there was little a couple could do if they suffered from recurrent pregnancy losses. Miscarriages that couldn't be attributed to chromosomal defects, hormonal problems or abnormalities of the uterus were labeled "unexplained," and couples would continue to get pregnant, only to suffer time and again as they lost their babies. New research, however, has provided information on the causes of the heretofore unexplained pregnancy losses allowing more effective treatment enabling women to carry their babies to term.
 
About 15-20% of all pregnancies result in miscarriage, and the risk of pregnancy loss increases with each successive pregnancy loss. For example, in a first pregnancy, the risk of miscarriage is 11-13 %. In a pregnancy immediately following that loss, the risk of miscarriage is 13-17 %. But the risk to a third pregnancy after two successive losses nearly triples to 38 %.

There are a number of tests for multiple pregnancy loss. Those patients with unexplained infertility may also want to read this article by Carolyn Coulam, MD and investigate immunological issues that may curtail or prevent pregnancy. (A list of tests can be found in the article.)

If you have questions about a basic fertility evaluation, please contact INCIID.

 

Miracles and Memories Pins

Miracles and Memories Pin

Miracles and Memories PinConsider the first and ONLY family-building INCIID Miracles and Memories pin for yourself, your family and friends - or if you are a reproductive endocrinology and infertility clinic or a patients who might want to provide them to your extended family members or to friends. INCIID was the first to come out with a pin covering all aspects of family-building.

Providing these particularly during "parenting" holidays (Christmas, Mother's Day, Father's Day etc.) can be supportive and helpful to those struggling to build their family. For thousands of reproductively challenged couples, the holidays can be a difficult time, as their only wish is to have a family of their own. If you are a doctor caring for patients,  INCIID is asking you to give out “Miracles and Memories” family-building pin to show patients and staff in a small but caring way that you support efforts to build a family. The idea is to build awareness and support for INCIID, a non-profit organization, providing scholarships for couples with infertility diagnoses as well as support and information on family building options. If you are a patient, or the family of a patient struggling with fertility, pregnancy loss or making the decision to adopt - Miracles and Memories Pins can provide added support.

Because INCIID is a non-profit organization, it relies solely on donations and contributions to maintain the success of the “From INCIID the Heart” scholarship program.  The INCIID team has created “Memories and Miracles” pins. INCIID is asking  couples, doctors, family members to donate just $25 to increase infertility awareness while at the same time providing a tax deductible donation to increase awareness and in support of creating a family.

The pins are packaged in a small clear plastic baggy attached to a white card that explains representation of each color on the pin and that pins support INCIID’s work and the IVF Scholarship.

The MAM (Miracles & Memories) Family-Building Pin :

Download the Bulk order form (for bulk orders of 100 or more pins) including a photo of the Miracles and Memories (MAM) pins

 

 

THE PAIN OF THE "PARENTING HOLIDAYS" FOR THE PRE-PARENT by Helen Adrienne, LCSW, BCD

 

[Register for the Webinar to talk directly to Helen Helen has valuable and common sense approaches to the holidays. We know you will feel better after the discussion] When I was a little girl, I remember putting rolled up socks in my undershirt to create the "breasts" that a mommy has. This made playing house that much more authentic. Although it was hard to recruit the little boys in the neighborhood to join in, it was not impossible. Yet their resistance was not a statement about not wanting to be a father someday, but rather that the game itself didn't resonate with a young boy's typical need for more rigorous physical activity in play than females.

Reproduction is germane to being alive, human or otherwise. It sometimes seems that you are surrounded by babies: birds, bees, dogs, sloths, and more galling than anything, your friends or neighbors who aren't sure that they want a baby but find themselves pregnant by accident. And as the cynical expression goes, you're born, you grow up, you pay taxes, you reproduce, and you die. That is, everyone and everything reproduces but you. There is only one word to describe the infertility experience: agony.

So many articles on infertility lay out all of the feelings that cascade from the situation, and conclude with a statement about feeling out of control. To me, the centerpiece of this emotional agony is feeling out of control. The one thing that you long for the most, you cannot have. Whether this creates (a normative, but arduous) anxiety for you, or depression, marital imbalance, or friction in the family, the workplace or in friendships, these symptoms take a back seat to the sometimes protracted amount of time that resolution of the infertility struggle can take. And the bottom line of that results in the feeling of being painfully out of control with no end in sight.

Now add to this Christmas, Mother's Day and Father's Day. This is an emotional ordeal because parenthood is what you want so much for yourself. It can be even more painful if you either want to or are expected to honor your parent in a setting which is a gathering of siblings, in-laws and maybe "out-laws" who show up with their babies, toddlers and/or bellies.
I take the position that in your circumstances, you need to be protected from the salt that would unwittingly be rubbed in your wound by people who might very well want the best for you, but do not have the emotional sophistication to access from within them what sensitivity you need from them. Or they may have no awareness of the need for sensitivity because you haven't shared the struggle with them, probably for some very good reason. 
Given all of this, what form does protection take? Sometimes, protection means simply not showing up. As a young couple, you might not have the clarity or the experience of setting boundaries around yourselves as "a couple", free to and entitled to write your own script according to your needs. This takes a willingness to be straightforward and expect those who love you to respect your decision. It doesn't mean that you do not honor or love your parent; it does mean that Christmas, or Mother's day and Father's day is an arbitrary social declaration. You can arrange for a private time with each mother and father and bypass the hoopla that is more a boon to Hallmark than anything else. In a more realistic world, any day or every day can be mother's/father's day.

But protection can mean something else, exemplified in this story. I recently had a conversation with a woman who was in one of the mind/body support groups that I run for New York City RESOLVE, a national organization that provides advocacy, educational seminars and support of all kinds for infertility patients. She called to tell me that she was pregnant. Among other things, I asked her if the experience of having been in the group last year had made a difference. She said, "Absolutely!" I asked how. She said that what she learned from me and the whole gestalt of the group experience "gave her the stamina to just keep going."

The strength implied in the word stamina is very important when it comes to coping with stress. And no one would debate that infertility ranks way up there in the stress department. Everyone wants life to be easy. It isn't. Everyone wants safety and stability. This is a sensible goal, but a more sensible goal is to expect the unexpected which can ruin the best laid plans. But if you have stamina, you've got most of what you need in this unpredictable world. No doubt you never predicted that you would be dealing with infertility.
There are all kinds of strength, all valuable. The stamina to "pull up your socks and get on with it" figures in heavily in the "job" of bringing the fertility struggle to resolution by whatever means. This kind of strength protects you from giving up too soon. If my patient hadn't forged ahead, her doctor never would have discovered the heretofore undiagnosed disorder that, when corrected, yielded a pregnancy the next month.
Another kind of strength surpasses all others as far as I am concerned. It is the inner strength of self-esteem. This is easier said than done. We all have wounds from our early years to a greater or lesser degree. These wounds handicap us a little or a lot in the formation of a healthy sense of assertiveness, entitlement, ability to communicate, ability to relax, to know what we feel, to see things clearly, and to take on challenges without feeling victimized. 
Infertility is so demanding that however emotionally healthy we may havebeen before, now we need every ounce of inner strength we can muster to navigate the process successfully. The good news is that however you may have been handicapped, and however infertility throws your need for emotional growth into high relief, you may be one of those people/couples who come out of the experience stronger. Any aspect of self-esteem or inner strength that is needed is a skill which can be learned, practiced and integrated.
The challenge of infertility is raised exponentially at certain times, Christmas, Mother's Day and Father's Day among them. It is highly recommended that rather than getting lost in your grief and upset, take it as an opportunity to get a panoramic view (best accomplished with a seasoned therapist) of what skills you and your partner need to develop or enhance so that you can be among those who come out of the experience with both a family and a clearer sense of your strength and capacities.

 

Helen, a long-time advisor to INCIID, is the author of On Fertile Ground: Healing Infertility. She teaches stress reduction classes at NYU Fertility Center in NY City. Read her blog, The Baby Manifest-O™ 

Helen's web site has many resources for infertility.

Helen Adrienne, LCSW, BCD
Psychotherapist, Clinical Hypnotherapist,
Practitioner of Mind/Body Therapy
420 East 64th Street - 1D(East)
New York, New York 10065
212-758-0125
helen@mind-body-unity.com
www.mind-body-unity.com

Mike Berkley - Complementary Medicine, Acupuncture and Herbal Medicine

Mike Berkley, L.Ac.
Founder and Director,
The Berkley Center for Reproductive Wellness

Mike Berkley, Founder and Director of The The Berkley Center for Acupuncture & Herbal Medicine in New York City, is licensed and Board Certified in Acupuncture in New York State. Mike is also certified in Chinese Herbology by the National Certification Commission for Acupuncture and Oriental Medicine.

Mike graduated from The Pacific College of Oriental Medicine in New York in 1996, and he has been treating reproductive disorders since then. Mike is the first acupuncturist/herbalist in the United States to work exclusively in the field of reproductive medicine

He works exclusively in the area of reproductive medicine and enjoys working in conjunction with some of New York’s most prestigious reproductive endocrinologists.
 

TELEVISION AND RADIO APPEARANCES
1997   Dr. Robert Atkins Radio Show, WEVD, New York, NY
1997   News All Day, NY1-TV, New York, NY
2002   Today in New York, WNBC (NBC), New York, NY
2002   Live With Regis & Kelly, WABC-TV (ABC), New York, NY
2002   The Early Show, WCBS-TV (CBS), New York, NY
2004   Interviewed on WHLV Talk Radio, Buffalo, NY
2006   WBAI - Global Medicine Radio. Interviewed by Dr. Kamau Kokayi
2006   Interviewed on the ROSHOW with Rolanda Watts
2007   Karma Radio, Myths and Realities of Infertility
2007   Conceive On Air, Talk Radio with Kim Hahn
2007   Interviewed on WWOR-TV Channel 9 News by Tena Ezzeddine

Mike Answers your questions on the Hearling Arts Complementary, Acupuncture and Herbal Medicine Forum here on INCIID!

 

Press Release - GARDASIL VACCINE NOT PROVEN SAFE

MERCK'S GARDASIL VACCINE NOT PROVEN SAFE FOR LITTLE GIRLS
National Vaccine Information Center Criticizes 
FDA for Fast Tracking Licensure

 

 

Washington, D.C. - The National Vaccine Information Center (NVIC) is calling on the CDC's Advisory Committee on Immunization Practices (ACIP) to just say "no" on June 29 to recommending "universal use" of Merck's Gardasil vaccine in all pre-adolescent girls. NVIC maintains that Merck's clinical trials did not prove the human papillomavirus (HPV) vaccine designed to prevent cervical cancer and genital warts is safe to give to young girls.

"Merck and the FDA have not been completely honest with the people about the pre-licensure clinical trials," said NVIC president Barbara Loe Fisher. "Merck's pre and post-licensure marketing strategy has positioned mass use of this vaccine by pre-teens as a morality play in order to avoid talking about the flawed science they used to get it licensed. This is not just about teenagers having sex, it is also about whether Gardasil has been proven safe and effective for little girls."

 

The FDA allowed Merck to use a potentially reactive aluminum containing placebo as a control for most trial participants, rather than a non-reactive saline solution placebo.[1] A reactive placebo can artificially increase the appearance of safety of an experimental drug or vaccine in a clinical trial. Gardasil contains 225 mcg of aluminum and, although aluminum adjuvants have been used in vaccines for decades, they were never tested for safety in clinical trials. Merck and the FDA did not disclose how much aluminum was in the placebo.[2]

 

Animal and human studies have shown that aluminum can cause nerve cell death [3] and that vaccine aluminum adjuvants can allow aluminum to enter the brain, [4 5] as well as cause inflammation at the injection site leading to chronic joint and muscle pain and fatigue.  [6 7] Nearly 90 percent of Gardasil recipients and 85 percent of aluminum placebo recipients followed-up for safety reported one or more adverse events within 15 days of vaccination, particularly at the injection site.[8] Pain and swelling at injection site occurred in approximately 83 percent of Gardasil and 73 percent of aluminum placebo recipients. About 60 percent of those who got Gardasil or the aluminum placebo had systemic adverse events including headache, fever, nausea, dizziness, vomiting, diarrhea, myalgia. [9 10] Gardasil recipients had more serious adverse events such as headache, gastroenteritis, appendicitis, pelvic inflammatory disease, asthma, bronchospasm and arthritis.

 

"Merck and the FDA do not reveal in public documents exactly how many 9 to 15 year old girls were in the clinical trials, how many of them received hepatitis B vaccine and Gardasil simultaneously, and how many of them had serious adverse events after being injected with Gardasil or the aluminum placebo. For example, if there were less than 1,000 little girls actually injected with three doses of Gardasil, it is important to know how many had serious adverse events and how long they were followed for chronic health problems, such as juvenile arthritis."

 

According to the Merck product manufacturer insert, there was 1 case of juvenile arthritis, 2 cases of rheumatoid arthritis, 5 cases of arthritis, and 1 case of reactive arthritis out of 11,813 Gardasil recipients plus 1 case of lupus and 2 cases of arthritis out of 9,701 participants primarily receiving an aluminum containing placebo. Clinical trial investigators dismissed most of the 102 Gardasil and placebo associated serious adverse events, including 17 deaths, that occurred in the clinical trials as unrelated.

 

"There is too little long term safety and efficacy data, especially in young girls, and too little labeling information on contraindications for the CDC to recommend Gardasil for universal use, which is a signal for states to mandate it," said Fisher. "Nobody at Merck, the CDC or FDA know if the injection of Gardasil into all pre-teen girls - especially simultaneously with hepatitis B vaccine - will make some of them more likely to develop arthritis or other inflammatory autoimmune and brain disorders as teenagers and adults. With cervical cancer causing about one percent of all cancer deaths in American women due to routine pap screening, it was inappropriate for the FDA to fast track Gardasil. It is way too early to direct all young girls to get three doses of a vaccine that has not been proven safe or effective in their age group."

 

The National Vaccine Information Center (NVIC), founded in 1982 by parents of vaccine injured children, has been a leading critic of one-size-fits-all mass vaccination policies and the lack of basic science research into biological mechanisms and high risk factors for vaccine-induced brain and immune system dysfunction. As a member of the FDA Vaccines and Related Biological Products Advisory Committee (VRBPAC), Barbara Loe Fisher urged trials include adequate safety data on pre-adolescent children and warned against fast tracking Gardasil at the November 28-29, 2001 VRBPAC meeting .[11]

Full 2001 FDA Transcript:http://www.fda.gov/ohrms/dockets/ac/cber01.htm#Vaccines & Related Biological

For more information go to www.NVIC.org.

 

-end-

 

 

 

 

1. Merck & Co., Inc. 2006. Gardasil [Quadrivalent Human Papillomavirus Types 6,11,16,18) Recombinant Vaccine] product insert. Table 6.

2. Food and Drug Administration. May 18, 2006. FDA Background Document for Vaccines and Related Biological Products Advisory Committee: Gardasil HPV Quadrivalent Vaccine.

3. Kawahara M et al. 2001. Effects of aluminum on the neurotoxicty of primary cultured neurons and on the aggregation of betamyloid protein. Brain Res. Bull. 55, 211-217.

4. Redhead K. et al. 1992. Aluminum-adjuvanted vaccines transiently increase aluminum levels in murine brain tissue.Pharmacol. Toxico. 70, 278-280.

5. Sahin G. et al. 1994. Determination of aluminum levels in the kidney, liver and brain of mice treated with aluminum hydroxide. Biol. Trace. Elem. Res. 1194 Apr-May;41 (1-2):129-35.

6. Gherardi M et al. 2001. Macrophagaic myofastitis lesions assess long-term persistence of vaccine-derived aluminum hydroxide in muscle. Brain, Vol 124, No. 9, 1821-1831.

7. Shingde M eta la. 2005. Macrophagic myofastitis associated with vaccine derived aluminum. MJA, 183 (03):145-146.

8. Merck & Co. May 18, 2006. Merck briefing document for Vaccines and Related Biological Products Advisory Committee: Gardasil. Table 24.

9. Merck & Co., Inc. 2006. Gardasil product insert: Serious Adverse Experiences.

10. Food and Drug Administration. May 18, 2006. FDA Background Document for Vaccines and Related Biological Products Advisory Committee.: Gardasil. Table 32.

11. Food and Drug Administration. November 29, 2001. Vaccines and Related Biological Products Advisory Committee. Excerpt from transcript.

 

HPV Vaccine - Potential for Fertility Preservation

This article is part of the June 2006 INCIID Insights Newsletter

HPV Vaccine (Gardasil) - Potential Benefits for Fertility Preservation

Dr. Sogol Jahedi, OB/GYN resident, Lutheran General Hospital

Angeline Beltsos,M.D., Fertility Center of Illinois

 

 

Genital HPV infection is a sexually transmitted disease (STD) that is caused by human papillomavirus (HPV). Human papillomavirus is the name of a group of viruses that includes more than 100 different strains or types. More than 30 of these viruses are sexually transmitted, and they can infect the genital area of women and men including the skin of the vulva, vagina, cervix, penis, anis or rectum.  Most people who become infected with HPV will not have any symptoms and will clear the infection on their own.

 

Most women are diagnosed with HPV on the basis of abnormal Pap tests. A Pap test is the primary cancer-screening tool for cervical cancer or pre-cancerous changes in the cervix, many of which are related to HPV. Also, a specific test is available to detect HPV DNA in women.

 

Some types of HPV can infect a woman’s cervix and cause the cells to change. Most of the time, HPV goes away on its own. When HPV is gone, the cervical cells go back to normal.  However, there are cases where HPV lingers and continues to change the cells on a woman’s cervix. These cell changes can lead to cancer over time, if they are not treated.

 

The American Cancer Society estimates that in 2006, over 9,700 women will be diagnosed with cervical cancer and 3,700 women will die from this cancer in the U.S.  At least 50% of sexually active people will get HPV at some time in their lives. Every year in the U.S., about 6.2 million people get HPV. HPV is most common in young women and men who are in their late teens and early 20s.

 

On June 8, 2006, an HPV vaccine (manufactured by Merck) was licensed by the Food and Drug Administration (FDA) for use in females, ages 9-26 years. The vaccine is called Gardasil and it protects against four types of HPV, including two that cause most (70%) cervical cancers (types 16, 18), and two that cause most (90%) genital warts (types 6, 11). The vaccine is given through a series of three injections over a six-month period. The second and third doses should be given two and six months (respectively) after the first dose.

 

The licensed vaccine has been found to be 100% effective in preventing cervical precancers caused by the targeted HPV types. It has also been found to be almost 100% effective in preventing precancers of the vulva and vagina, and genital warts that are caused by the targeted HPV types.  Ideally, the vaccine would be administered before females become sexually active—since this vaccine is most effective in females who have not yet acquired HPV infection.  The proposed recommendations are to provide routine vaccination for 11-12 year-old girls and catch-up vaccination for 13-26 year-old females.

 

However, females who are sexually active may also benefit from the vaccine. Those who have not been infected with any vaccine HPV type would get the full benefits of the vaccine. Those who have already been infected with one or more HPV type would still get protection from the vaccine types they have not yet acquired. Few young women are infected with all four vaccine HPV types (6,11,16,18).

 

In the realm of fertility, the HPV vaccine may indirectly assist a woman in maintaining her fertility.  HPV infection itself does not cause infertility.  However, the treatment can infrequently lead to cervical problems that then cause infertility.  The treatments for HPV-related severe precancerous or cancerous conditions such as cone biopsy or LEEP excision can lead to scarring and narrowing of the initial highway of the female reproductive pathway leading to the egg.  It can also compromise the cervical mucus, which normally assists in sperm transport.

 

Furthermore, women who have had cervical surgery and then become pregnant can suffer from cervical incompetence, which can lead to preterm birth.  Therefore, the HPV vaccine indirectly may lead to less chance of infertility by maintaining cervical health.  Because HPV is a sexually transmitted disease, clinical trials are currently in place to examine the efficacy of giving this vaccine to young men as well.  The less that the male partner is infected also benefits the woman because there is less chance that she would be infected. 

The HPV vaccine is an exciting new prospect in preventing the spread of HPV among young women and men, leading to better overall health and improvements in maintaining a healthy pregnancy.

 

 

Bibliography:

1.  CDC  www.cdc.gov 
2.  UpToDate  www.utdol.com Barbara McGovern,MD Human papillomavirus vaccines  2006
3.  UpToDate Reichman, R and Negron G. Clinical presentation and diagnosis of human papillomavirus infections  2006

 

Uniting as a Couple to Beat the Holiday Stress

UNITING AS A COUPLE TO BEAT HOLIDAYSTRESS

by Helen Adrienne, MSW, ACSW, BCD

 

 

 

Infertility is stressful; the holidays are stressful. Taken together, one plus one equals way more than two. Yet just as the Chinese character for crisis is a combination of the characters for danger and opportunity, the crisis of infertility can present an opportunity to turn to the marital relationship as a refuge from holiday stress.

 

It is no longer in dispute that both the mental and physical experiences of stress land in the body. That’s about the last thing that an infertility patient needs. Your body is the stage upon which the drama of treatment gets played out. Being poked and prodded physically evolves very naturally into a mental ordeal. And in this society, many of us are already living in a state of red alert, tolerating high levels of stress.

 

At holiday time, tensions abound even in the best of families. The backdrop for get-togethers may have to do with who expects what, who can’t stand whom, whose house is center stage, whose traditions “win,” who’s impossible to buy presents for and who’s jealous of what. And of course, a sharp and very long thorn is who’ll be present at celebrations with babies. The who’s whose and what’s go on ad nauseum.

 

This does not mean that all families are Looney Toons. It does mean that families can’t ever be perfect, and you are not likely to be in the mood for anyone’s imperfections. Often, well-meaning people who know about your struggle do not know what to say and say the wrong thing. If they don’t know, keeping the secret creates additional stress for you.

 

Infertility may be the first crisis of major proportions that has hit you in the time that you’ve been together. Any crisis will demand that a person locate his or her coping methods, and infertility might put you in a spin if you need better coping mechanisms. It is only the rare couple whose coping mechanisms are congruent at the time a crisis hits.

 

The holiday opportunity for any couple lies in the fact that it is critically important to be on the same page when it comes to making decisions about how to handle the holidays. You may already be supportive of one another; most couples are. But there is a difference between the general support that flows out of compassion for someone you love and the achievement of a united front, which works best.

 

Whether on your own or with professional help, successfully deciding and declare your decisions about the holidays will help to minimize the impact of family holiday stress on your bodies. It may feel dangerous to set limits to holiday celebrations with one or both families. But it is very important for any couple to define their “coupleness.” As married adults, it is your job and your right to let both families know what your boundaries are. It is highly recommended that if you cannot get past the pull of your families, you seek the guidance of a therapist with skills in both infertility counseling and family counseling.

 

Beyond the logistics, now is the time to explore holiday activities and techniques of mind/body relaxation that you can enjoy together. Being on the same page, and feeling loved and understood, is palliative. 

 

As hectic as the holiday time can be, it would make a difference if you could find a nonsexual way to release physical stress together. Perhaps you can locate a yoga or massage class for couples, or go to a spa together for a weekend. Couples can learn methods of breathing, muscle relaxation, mindfulness meditation and self-hypnosis that go a long way toward breaking the grip of the infertility challenge from the inside out. These techniques are extremely empowering at a time when couples tend to feel powerless. By focusing on gaining physical relief from tension, you can break the grip that the infertility challenge has on your bodies.

 

Infertility is nasty. But the silver lining in the clouds is that as a couple, you can and should put your needs front and center. You need to keep your love alive, for each other and for yourselves. The best way to do this is to acknowledge the enormous stress involved and take the opportunity to learn to communicate so you can land on the same page. And you can pursue the myriad of techniques available these days to reduce stress on the body and the mind.

 

HELEN ADRIENNE, MSW, ACSW, BCD, is a PSYCHOTHERAPIST and PRACTITIONER OF MIND/BODY MEDICINE in private practice in New York.

 

Acupuncture and Traditional Oriental Medicine to Enhance Fertility

Acupuncture and Traditional Oriental Medicine  To Enhance Fertility

Randine Lewis, Ph.D. L.Ac. and Susan Fox, M.S., L.Ac.

 

 

Although Chinese medicine has been used to address fertility for thousands of years, only recently has acupuncture received notable press in the West for its ability to address fertility issues. In the 1990’s the World Health Organization of the United Nations first publicly recognized acupuncture’s therapeutic effect to overcome infertility. Following behind, a Swedish study noted acupuncture’s ability to improve ovarian blood flow and increase pregnancy rates. And in Germany a study verified acupuncture’s ability to improve embryo implantation rates. Because of this, there has been a trend toward utilizing acupuncture, either alone or in conjunction with other advanced fertility methods, to support the journey to pregnancy or parenthood.  Some of the most cutting edge reproductive clinics in the West have begun to study Chinese medicine and incorporate acupuncture treatments to increase pregnancy rates. Acupuncture is but one tool in the entire system of Traditional Oriental Medicine, which relies upon a proper individual diagnosis, and also includes herbal medicine, lifestyle and nutritional counseling, QiGong and meditation.  

 

Acupuncture is a system that identifies energy pathways in the body, which are referred to as meridians. There are twelve meridian systems that traverse every tissue of the body.  Stimulation of acupuncture points has a regulatory effect on the nervous, circulatory and endocrine systems, reducing the tendency to be in hypersensitive Sympathetic (flight or fight) state, and shifting energies toward the Parasympathetic (rest and cleanse) system.  Acupuncture alone can regulate the hormones, restoring menstrual regularity. Acupuncture points are identified for specific health issues, and an acupuncture prescription is designed to address an individual’s unique presentation of symptoms.  This is particularly evident, for example, when two patients with the same conventional diagnoses will present with distinctly different symptoms. 

 

Our “flight or fight” response directs blood flow to our extremities, which impedes circulation to our detoxification and reproductive systems.   Acupuncture and abdominal massage (referred to in Traditional Oriental Medicine as Chi Nei Tsang) help redirect our energies and provide nutrition via increased circulation to our reproductive organs.   Patients frequently experience a deep sense of relaxation while undergoing acupuncture treatment. which is the very source of balance they are seeking during the oftentimes stressful periods of focusing on fertility challenge.

 

A significant component of healing that occurs for patients undergoing acupuncture for fertility care results from the degree of intimacy that Traditional Oriental Medicine incorporates into its methods in inquiry and treatment. Because our system does not separate the emotional and spiritual “bodies” from the physical, we are often able to address these aspects as part of the whole person’s imbalance.  This can be viewed from the physical effects; i.e., how acupuncture can positively affect the hypothalamus -> pituitary -> ovarian axis, or it can be viewed holistically; i.e., attending to the emotional body of the person(s) undergoing a life challenge.  Certainly, should the mind/body inquiry reveal the need for psychotherapeutic intervention, one should be prepared to address such issues with a licensed psychotherapist. 

 

Beyond the clinical setting, there is a wonderfully supportive program entitled The Fertile Soul, which holds retreats for women and couples experiencing challenges with fertility.  Randine Lewis has developed a healthy, supportive retreat system that empowers attendees to understand and recapture their innate creative potential, develop lifestyle choices to prepare for and support family building and to heal patterns that do not serve their life’s goals.

 

To find an acupuncturist whose specialty is in the area of fertility, contact The Fertile Soul’s Clinical Excellence in Fertility practitioners at www.thefertilesoul.com.

 

Ovarian Cryopreservation by Michael Opsahl, MD

Ovarian Cryopreservation 
by Michael S. Opsahl, MD 

 
Cryopreservation of ovarian tissue is a technique to bank oocytes (eggs) in situations where the woman may lose all her eggs from a medical treatment, disease process or even the natural loss from natural aging. Potential uses for this technique include restoring fertility and normal ovarian hormone production without the use of medications. The technique of ovarian tissue cryopreservation and transplantation of the thawed tissue is experimental. Since the first significant publication on ovarian tissue cryopreservation and transplantation in 1994(1), over 100 publications attest to the scientific interest in this technique or treatment strategy.(2-36)

Background

Several diseases and their treatments threaten to destroy all the eggs in a woman's ovaries. Diseases rarely have a direct effect on the eggs in the ovary. Exceptions include genetic disorders such as women with a single X chromosome (Turner Syndrome) or women missing a specific piece(s) of an X chromosome, in which case the eggs die quickly and the women have premature menopause. Chemotherapy or radiation used to treat cancer or some non-cancerous disorders have the unfortunate side effect of destroying the eggs in the ovary as well as the diseased cells.

Unlike sperm production in men which is continuous, women are born with all their eggs and they do not produce any more. The natural process of each menstrual cycle consumes approximately 500-1000 eggs until the supply is exhausted (about age 51, menopause). Any treatment that accelerates the loss of eggs threatens to decrease fertility and will cause menopause at an earlier age than expected. Surgery to remove all or a portion of one or both ovaries, some chemotherapy (cyclophosphamide, doxorubicin, vinblastine, etc.), and radiation therapy all have known toxic effects on eggs. The number of eggs that die from these treatments depends primarily on the agent(s), the dose, and the age of the woman when treated. The higher the dose and the older the woman, the more likely that most eggs will be lost and that menopause will occur.

Men have been able to cryopreserve (freeze) their sperm for decades. However, women have not been able to freeze their eggs reliably because the eggs are hard to retrieve and unfertilized eggs have generally not survived freezing. With the advent of IVF, egg or embryo freezing became possible. IVF has several significant limitations. IVF takes time to complete since the hormones used to stimulate the ovary are administered at specific times of the menstrual cycle and then are administered for 2-4 weeks. Many cancer patients must begin their cancer treatment before IVF can be completed. Many cancer patients are young and unmarried; therefore, they do not have a partner to provide sperm to fertilize the eggs. Cryopreservation of unfertilized eggs is an alternative that has gained interest with newer freezing techniques and there are successful pregnancies. Further, IVF is medically inappropriate for many women with hormonally responsive tumors such as breast cancer. The ovaries can be surgically moved from the field of radiation in selected cases but this technique does not help women with chemotherapy.

Ovarian hormone suppression (gonadotropin releasing hormone agonist) during chemotherapy significantly protected human eggs in one research study. Follow-up studies by other centers and with larger numbers of women will clarify the value of this approach. Gonadotropin releasing hormone agonist administration is inexpensive, relatively safe and unlikely to compromise other treatments; therefore, it deserves serious consideration despite limited data on its effectiveness. Donor eggs, for those women who have irreversible ovarian failure, provide very high rates of successful pregnancies, if other options fail.

Perhaps the largest group of women who may benefit from egg banking, are those women who delay child-bearing, for whatever reason, until the late thirties or forties. It is widely recognized that female reproduction becomes progressively more inefficient with advancing age and pregnancies are quite rare by the mid-forties. Whether, egg banking at an early age will be practical or effective remains speculative.

For all these reasons, a technique to bank eggs would allow women to have the same reproductive options as men when faced with a serious disease that threatens to destroy their eggs.

 

Dr. Roger Gosden's published paper in Human Reproduction in 1994 demonstrated the ability to cryopreserve ovarian tissue, transplant it after thawing and obtain functioning ovarian tissue that led to successful births of healthy animals.(1) His team also demonstrated long-term functioning of transplanted cryopreserved ovarian tissue for about two years in sheep.(21) The fertility rate after ovarian cryopreservation in mice was approximately 50 - 75% after ovarian tissue autotransplantation.(27;33) Human tissue was viable after transplantation into a mouse model.(9;15;29) Whether human results will be as successful as animal results will require time and experience. Consequently, until clinical trials demonstrate the viability of this technique, ovarian tissue cryopreservation and transplantation must be considered highly experimental.

Based on preliminary animal data, human trials of ovarian tissue cryopreservation began in 1995.(30) These ongoing trials have produced limited human data since humans often require many years to be free of cancer, or they may not have partners and may not be ready for pregnancy.

 

Techniques

Ovarian tissue cryopreservation begins with laparoscopy or mini-laparotomy. Ordinarily, the surgeon removes only one ovary to allow normal ovarian hormone production from the other ovary during treatment and because the woman may have ovarian function after treatment of her disease. The laboratory staff portion sections the ovarian cortex (which contains the eggs) into thin tissue slices. The tissue slices are cryopreserved at -196°C using specialized cryoprotectants and controlled-rate freezing equipment.

When the woman and her physicians feel fertility is appropriate, transplantation of the ovarian tissue strips can be attempted. 

In animals and humans, frozen ovarian slices have a high survival rate after thawing. The location for tissue transplantation could be in the abdomen near the fallopian tube to allow natural ovulation and conception. Natural conception occurred in all animal studies. The ovarian tissue began to function within several months after transplantation. The disadvantage of transplantation into the abdominal cavity is limited access, potentially lower viable tissue since ingrowth of blood vessels occurs primarily from only one side of the tissue, and adhesion formation (scar tissue) during the recovery period after surgery.

Recently, transplantation of human ovarian tissue into the forearm resulted in follicle formation and egg retrieval with a needle. Parathyroid tissue transplanted into the forearm routinely functions normally in patients with other medical disorders. The forearm is well-vascularized, easy to access, and is a site with little surgical risk. Consequently, because the ovarian tissue is surrounded with vascularized tissues, it may have a greater probability of short and long-term function. Transplantation of tissue into the forearm precludes natural conception. Assisted reproduction with IVF using eggs retrieved from the arm would necessarily be applied. Risks Surgery is necessary to remove the ovary. Despite routine surgical and anesthetic techniques, complications invariably occur but they are uncommon. The risks are no greater for this procedure than are the risks for any other patient who undergoes ovary removal. If the patient has cancer, the oncologist should address any pre-operative medical needs.

Most cancers do not spread (metastasize) to the ovary. However, if cancer cells are in the ovarian tissue at the time of cryopreservation, they may survive freezing and thawing and they will be transplanted with the normal ovarian tissue. Transplantation of tumor containing ovaries resulted in cancer in the recipient animals. (36) You should ask your doctor for his/her opinion about the likelihood of metastatic cancer cells in the ovary.

Usually, pathology evaluates a sample of the excised ovary. However, the sample is insufficient to confirm a cancer-free ovary. In selected cases, researchers may be able to stain a small portion of the ovarian tissue for cancer markers that to detect tumor cells before transplanting the tissue strips. Other researchers explored the possibility of growing a sample of the ovarian tissue in an immune-deficient mouse to detect occult cancer in the tissue.

Most oncologists believe transmission of cancer cells should be very remote; however, the possibility is real and collaboration between the oncologist and the reproductive surgeon is essential to minimize this risk.

Currently, the process requires removal of all or a part of an ovary and less often both ovaries. The oophorectomy, by definition, will remove 50% of the woman's eggs. It follows that this should increase the probability of menopause from the chemotherapy or radiation to follow if one believes that menopause occurs earlier in women with fewer eggs. Available research suggests that complete removal of an ovary before age 30 accelerates the age of onset for menopause to 44 years, on average. Removing an ovary after age 30 has less effect, incrementally, on menopause.(37-39)

 

Future Directions

Any number of questions remain unanswered, but of critical importance, to bring this technique into mainstream use. For example: How long can the tissue remain frozen and still function after thawing?, Where is the best location to transplant the tissue strips?, How much ovarian tissue is required to provide enough eggs for successful pregnancy?, How long will the tissue function after transplantation?, and many more.

A very interesting avenue of research involves the growth of ovarian tissue from one species in another species (xenograft).(5;6;9;11;15;26) If this technique works and proves safe, several problems become less of an issue.

First, tissue grown in another animal prevents cancer in the human recipient. Even patients with ovarian cancers may be able to use this technique to recover normal eggs without any associated cancer cells. Second, the ovarian tissue contains a limited number of eggs. A xenograft may allow more efficient maturation and retrieval of eggs for IVF. Third, the limited tissue strips might be used more gradually over time for additional children.

Fourth, if only small amounts of tissue prove adequate for IVF, then a small biopsy of tissue in a young woman may be a means of banking eggs if she later finds herself infertile.

Another line of research is egg freezing. Ovarian stimulation similar to IVF allows egg retrieval. The eggs are frozen before they are inseminated and fertilized. Subsequently, when the time is right, the eggs are thawed and inseminated. Embryos derived from cryopreserved unfertilized eggs have yield embryos that developed into normal children. The number of children is limited but growing and the number of successful births clearly exceeds that with ovarian tissue cryopreservation. Only a few centers offer this technique.

 

Questions to ask your doctor and yourself before consulting a reproductive specialist.

Q: What is the likelihood that sterility will occur after treatment? Most patients view their participation in experimental therapies differently when the risk of sterility is 10% versus 90%.

Q: What is the risk of cancer cells in the ovary at the time of ovarian cryopreservation? Clearly, if the risk of metastatic cancer in the ovary is high, this technique is probably not a good idea until methods of extracting the eggs from the tissue without transplantation are available.

Q: How much time do you have before cancer therapy begins? With limited time (less than one month), IVF is impractical but surgery can be performed very quickly - within a few days if necessary. With more time, IVF for production of eggs or embryos is a realistic option.

Q: Are you single or married? Single women have less reason to pursue IVF and embryo cryopreservation unless they have a partner. Embryos formed with donor sperm may be less desirable for producing a family when later a woman finds a partner. Egg freezing may be a better option for single women. Women with a partner should consider IVF and freezing embryos. The woman may want to retain sole control of the embryos once they are frozen. Occasionally, marriages or relationships fail and the former partner could prevent the embryos from being used if the couple agrees to joint control of the embryos.

Q: Do you have a tumor sensitive to reproductive hormones? Women with breast cancer, for example, probably do not want to risk stimulation of their cancer from the high estrogen levels generated during IVF. Nevertheless, many breast cancer survivors can become pregnant safely, so some method of conserving their eggs seems reasonable.

Q: Are you willing to be part of a highly experimental research protocol? Until more experience is available, your participation in ovarian tissue cryopreservation places you on the cutting edge of science. Participation involves risks, known and unknown, and likely expenses that are not covered by insurance. If you are a healthy woman who wants to delay conception and pregnancy for any reason, the experimental and uncertain success of ovarian tissue cryopreservation makes this a very controversial technique for you. In addition to the experimental aspects of participation, the act of removing all or a portion of an ovary may actually increase the probability of an earlier menopause, which is counter-productive to the reason for participating.

Michael Opsahl, M.D. retired from a prestigious career in the United States Navy in 1994 and joined the Genetics & IVF Institute. Dr. Opsahl is board certified in Obstetrics and Gynecology and Reproductive Endocrinology.

 

Selected scientific articles:

1. Gosden RG, Baird DT, Wade JC, Webb R. Restoration of fertility to oophorectomized sheep by ovarian autografts stored at -196 degrees C. Hum Reprod 9[4], 597-603. 1994. 
2. Wang H, Mooney S, Wen Y, Behr B, Polan ML. Follicle development in grafted mouse ovaries after cryopreservation and subcutaneous transplantation. Am J Obstet Gynecol 187[2], 370-374. 2002. 
3. Salle B, Demirci B, Franck M, Rudigoz RC, Guerin JF, Lornage J. Normal pregnancies and live births after autograft of frozen-thawed hemi-ovaries into ewes. Fertil Steril 77[2], 403-408. 2002.
4. Schnorr J, Oehninger S, Toner J, Hsiu J, Lanzendorf S, Williams R, Hodgen G. Functional studies of subcutaneous ovarian transplants in non-human primates: steroidogenesis, endometrial development, ovulation, menstrual patterns and gamete morphology. Hum Reprod 17[3], 612-619. 2002.
5. Snow M, Cox SL, Jenkin G, Trounson A, Shaw J. Generation of live young from xenografted mouse ovaries [In Process Citation]. Science 2002 Sep 27;297[5590], 2227. 2002. 
6. Wolvekamp MC, Cleary ML, Cox SL, Shaw JM, Jenkin G, Trounson AO. Follicular development in cryopreserved Common Wombat ovarian tissue xenografted to Nude rats. Anim Reprod Sci 65[1-2], 135-147. 2001. 
7. Liu J, Van der EJ, Van den BR, Dhont M. Live offspring by in vitro fertilization of oocytes from cryopreserved primordial mouse follicles after sequential in vivo transplantation and in vitro maturation. Biol Reprod 64[1], 171-178. 2001. 
8. Kim SS, Battaglia DE, Soules MR. The future of human ovarian cryopreservation and transplantation: fertility and beyond. Fertil Steril 75[6], 1049-1056. 2001. 
9. Gook DA, McCully BA, Edgar DH, McBain JC. Development of antral follicles in human cryopreserved ovarian tissue following xenografting. Hum Reprod 2001 Mar;16[3], 417-422. 2001.
10. Callejo J, Salvador C, Miralles A, Vilaseca S, Lailla JM, Balasch J. Long-term ovarian function evaluation after autografting by implantation with fresh and frozen-thawed human ovarian tissue. J Clin Endocrinol Metab 86[9], 4489-4494. 2001. 
11. Metcalfe SS, Shaw JM, Gunn IM. Xenografting of canine ovarian tissue to ovariectomized severe combined immunodeficient (SCID) mice. J Reprod Fertil Suppl 2001;57, 323-329. 2001. 
12. Radford JA, Lieberman BA, Brison DR, Smith AR, Critchlow JD, Russell SA, Watson AJ, Clayton JA, Harris M, Gosden RG, Shalet SM. Orthotopic reimplantation of cryopreserved ovarian cortical strips after high-dose chemotherapy for Hodgkin's lymphoma. Lancet 357[9263], 1172-1175. 2001. 
13. Kagabu S, Umezu M. Transplantation of cryopreserved mouse, Chinese hamster, rabbit, Japanese monkey and rat ovaries into rat recipients. Exp Anim 49[1], 17-21. 2000. 
14. Cox S, Shaw J, Jenkin G. Follicular development in transplanted fetal and neonatal mouse ovaries is influenced by the gonadal status of the adult recipient. Fertil Steril 74[2], 366-371. 2000. 
15. Nisolle M, Casanas-Roux F, Qu J, Motta P, Donnez J. Histologic and ultrastructural evaluation of fresh and frozen-thawed human ovarian xenografts in nude mice. Fertil Steril 2000 Jul;74[1], 122-129. 2000. 
16. Oktay K, Newton H, Gosden RG. Transplantation of cryopreserved human ovarian tissue results in follicle growth initiation in SCID mice. Fertil Steril 73[3], 599-603. 2000.
17. Candy CJ, Wood MJ, Whittingham DG. Restoration of a normal reproductive lifespan after grafting of cryopreserved mouse ovaries. Hum Reprod 15[6], 1300-1304. 2000.
18. Imthurn B, Cox SL, Jenkin G, Trounson AO, Shaw JM. Gonadotrophin administration can benefit ovarian tissue grafted to the body wall: implications for human ovarian grafting. Mol Cell Endocrinol 163[1-2], 141-146. 2000. 
19. Shaw JM, Cox SL, Trounson AO, Jenkin G. Evaluation of the long-term function of cryopreserved ovarian grafts in the mouse, implications for human applications. Mol Cell Endocrinol 161[1-2], 103-110. 2000. 
20. Weissman A, Gotlieb L, Colgan T, Jurisicova A, Greenblatt EM, Casper RF. Preliminary experience with subcutaneous human ovarian cortex transplantation in the NOD-SCID mouse. Biol Reprod 60[6], 1462-1467. 1999. 
21. Baird DT, Webb R, Campbell BK, Harkness LM, Gosden RG. Long-term ovarian function in sheep after ovariectomy and transplantation of autografts stored at -196 C. Endocrinology 140[1], 462-471. 1999. 
22. Callejo J, Jauregui MT, Valls C, Fernandez ME, Cabre S, Lailla JM. Heterotopic ovarian transplantation without vascular pedicle in syngeneic Lewis rats: six-month control of estradiol and follicle-stimulating hormone concentrations after intraperitoneal and subcutaneous implants. Fertil Steril 72[3], 513-517. 1999. 
23. Meirow D, Fasouliotis SJ, Nugent D, Schenker JG, Gosden RG, Rutherford AJ. A laparoscopic technique for obtaining ovarian cortical biopsy specimens for fertility conservation in patients with cancer. Fertil Steril 71[5], 948-951. 1999. 
24. Salle B, Lornage J, Demirci B, Vaudoyer F, Poirel MT, Franck M, Rudigoz RC, Guerin JF. Restoration of ovarian steroid secretion and histologic assessment after freezing, thawing, and autograft of a hemi-ovary in sheep. Fertil Steril 72[2], 366-370. 1999. 
25. Aubard Y, Piver P, Cogni Y, Fermeaux V, Poulin N, Driancourt MA. Orthotopic and heterotopic autografts of frozen-thawed ovarian cortex in sheep. Hum Reprod 1999 Aug;14[8], 2149-2154. 1999. 
26. Gunasena KT, Lakey JR, Villines PM, Bush M, Raath C, Critser ES, McGann LE, Critser JK. Antral follicles develop in xenografted cryopreserved African elephant (Loxodonta africana) ovarian tissue. Anim Reprod Sci 53[1-4], 265-275. 1998. 
27. Sztein J, Sweet H, Farley J, Mobraaten L. Cryopreservation and orthotopic transplantation of mouse ovaries: new approach in gamete banking. Biol Reprod 58[4], 1071-1074. 1998.
28. Oktay K, Newton H, Mullan J, Gosden RG. Development of human primordial follicles to antral stages in SCID/hpg mice stimulated with follicle stimulating hormone. Hum Reprod 13[5], 1133-1138. 1998. 
29. Gunasena KT, Lakey JR, Villines PM, Critser ES, Critser JK. Allogeneic and xenogeneic transplantation of cryopreserved ovarian tissue to athymic mice. Biol Reprod 57[2], 226-231. 1997. 
30. Opsahl MS, Fugger EF, Sherins RJ, Schulman JD. Preservation of reproductive function before therapy for cancer: new options involving sperm and ovary cryopreservation. Cancer J Sci Am 3[4], 189-191. 1997. 
31. Marconi G, Quintana R, Rueda-Leverone NG, Vighi S. Accidental ovarian autograft after a laparoscopic surgery: case report. Fertil Steril 68[2], 364-366. 1997. 
32. Oktay K, Nugent D, Newton H, Salha O, Chatterjee P, Gosden RG. Isolation and characterization of primordial follicles from fresh and cryopreserved human ovarian tissue. Fertil Steril 67[3], 481-486. 1997. 
33. Gunasena KT, Villines PM, Critser ES, Critser JK. Live births after autologous transplant of cryopreserved mouse ovaries. Hum Reprod 1997 Jan;12[1], 101-106. 1997. 
34. Nugent D, Meirow D, Brook PF, Aubard Y, Gosden RG. Transplantation in reproductive medicine: previous experience, present knowledge and future prospects. Hum Reprod Update 3[3], 267-280. 1997. 
35. Newton H, Aubard Y, Rutherford A, Sharma V, Gosden R. Low temperature storage and grafting of human ovarian tissue. Hum Reprod 11[7], 1487-1491. 1996. 
36. Shaw JM, Bowles J, Koopman P, Wood EC, Trounson AO. Fresh and cryopreserved ovarian tissue samples from donors with lymphoma transmit the cancer to graft recipients. Hum Reprod 11[8], 1668-1673. 1996. 
37. Melica F, Chiodi S, Cristoforoni PM, Ravera GB. Reductive surgery and ovarian function in the human--can reductive ovarian surgery in reproductive age negatively influence fertility and age at onset of menopause? Int J Fertil Menopausal Stud 40[2], 79-85. 1995. 
38. Gosden RG, Faddy MJ. Ovarian aging, follicular depletion, and steroidogenesis. Exp Gerontol 29[3-4], 265-274. 1994. 
39. Faddy MJ, Gosden RG, Gougeon A, Richardson SJ, Nelson JF. Accelerated disappearance of ovarian follicles in mid-life: implications for forecasting menopause. Hum Reprod 7[10], 1342-1346. 1992. 

 

 

 

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