Category Archives: Blogs
Blogs about infertility by the experts at F.I.R.M. or Florida Institute for Reproductive Medicine cover female infertility, male infertility, and IVF treatments based in Jacksonville, FL
Given current Florida law, the Florida Institute for Reproductive Medicine (FIRM) does not anticipate the recent overturn of Roe vs. Wade to pose any changes to treatment options regarding your cryopreserved embryos, pre-embryos, eggs or sperm. If in the future treatment rights are in any way affected, FIRM will facilitate the transfer of your reproductive materials to the state and program of your choice.
Kevin L. Winslow, MD
Director
This June marks the 30th anniversary of the Florida Institute for Reproductive Medicine (FIRM). This time period has been very exciting with some monumental advancements in reproductive medicine technologies. Intracytoplasmic sperm injection (ICSI), whereby a single sperm can be injected into an egg producing a healthy ongoing pregnancy – has largely eliminated male factor infertility. Egg cryopreservation, whereby women faced with potential sterilizing therapies or delayed child bearing can freeze their eggs and have a family at the time of their choosing. Pre-embryo genetic testing, whereby embryos created in the lab can be checked for potentially life-threatening genetic diseases has been a major advance in preventing birth defects and recurrent pregnancy loss. Over the last 30 years the Florida Institute for Reproductive Medicine has been on the forefront of all these technologies. We have grown from a practice of one to a practice of six board certified physicians providing the most comprehensive reproductive medicine to North Florida/South Georgia.
FIRM comprehensive care includes:
- In-house surgical sperm extraction – a huge advantage in terms of using non-frozen sperm to fertilize eggs.
- Performing in-house pre-embryo genetic testing.
- A staff of three PhD embryologists and one masters level embryologist allow us to perform IVF year round, i.e., on the patient’s schedule.
- In-house egg, embryo, sperm storage eliminating the need to constantly mail eggs, sperm, embryos to and from a storage facility – expensive and potentially dangerous.
- An egg bank as well as embryo bank.
- Gestational surrogate IVF.
- Physician highly experienced in robotic surgery.
Apart from our technologic expertise what I believe most distinguishes FIRM is our personalized care. When you come to the Florida Institute for Reproductive Medicine you will see a board certified reproductive medicine specialist who will provide essentially all your care. We have a team of 12 RNs averaging over 6 years of experience in reproductive medicine.
This high tech, high touch philosophy of care combined with some of the most competitive pricing in the Southeast has made the Florida Institute for Reproductive Medicine the largest program in North Florida/South Georgia. We continue to strive to stay on the forefront of new reproductive technology advances and to provide the most personal care possible.
Regular menstrual cycles each month are the result of regular ovulation. If a female is having irregular cycles, out of the range of every 21-35 days, or not having cycles at all, her ovulation is either irregular or not happening at all. In a normal cycle, at the start of each month, there is a group of eggs that are ready to be chosen from. In women who are ovulating regularly, one egg is chosen from that group and all of the others die off. If one is not chosen from that group because the patient is not ovulating, that group of eggs still dies off.
Ovulation induction is the process by which medications are given in order to help a women ovulate or to regulate her ovulation. This is done so that patients know when to time intercourse in an effort to conceive. In patients with irregular or no ovulation, depending on the cause of the irregularity, we can use lifestyle modifications, medications, either oral pills like clomiphene citrate or letrozole, or injections, called gonadotropins, to stimulate the development of a single follicle and subsequent ovulation of a single egg. We are not depleting a woman’s supply of eggs more rapidly, we are just growing one from that group that would have died off anyway.
Depending upon the particular patient, one of several treatments may be recommended. In women who do not ovulate, oral medications, rather than injection medications, are often recommended as the initial treatment. Some of the advantages of oral medications compared to injections include the ease of oral administration, fewer side effects, lower cost (of the medication itself, as well as the monitoring), lower risk of multiple pregnancies, and a reduced time commitment (related to monitoring during treatment). If the woman has tried oral medications or if oral medications are unlikely to be helpful, the next step is often to try ovulation induction with injection medications. Oral or injection medications may be used along with timed intercourse (TIC), intrauterine insemination (IUI), and/or in vitro fertilization.
When initiating treatment for ovulation induction, in most cases, one will have a baseline ultrasound to assess the ovaries at their “resting” state. If the ovaries look as they should, the patient will take the oral medication or give an injection once per day, for a number of days. The pill is taken by mouth and the injection can typically be given under the skin. After taking the medication for an allotted time period, the patient may be asked to have a pelvic ultrasound to measure follicle growth, and possibly a blood test to measure hormone levels. Depending upon the results of these tests, the dose of the medication may be increased or decreased. Blood testing and pelvic ultrasound may be repeated more times during a cycle. For women who do not ovulate on their own, the goal is to have one follicle that is at least 18 mm in size. If more than one follicle develops, depending on the number, the cycle may be cancelled due to a higher risk of becoming pregnant with twins, triplets, or more. In rare cases, the cycle may be converted to an in vitro fertilization cycle, so that the clinician can ultimately control the number of embryos that are transferred in the uterus.
The side effects of both oral and injection medications are usually minimal. With oral medications, there are side effects of hot flashes and night sweats as well as headaches to name a few. While these side effects are less likely with injection medications, patients can feel more emotional on all of the medications. Because the ovaries grow during treatment, a patient can have abdominal discomfort, and in more severe cases, nausea and vomiting. The most serious risks of oral and injection medication therapy are the development of ovarian hyperstimulation syndrome (OHSS) and conceiving a multiple pregnancy. OHSS is a condition in which the ovaries become enlarged and in severe cases, the woman may develop severe abdominal pain, vomiting, and blood clots. However, severe OHSS occurs in less than 2 percent of women undergoing treatment with injections and less than 1 percent of women undergoing treatment with oral medications.
The take home point is that if your menstrual cycles are irregular or you are not having a menstrual cycle at all, ovulation induction is the process that can help to regulate ovulation! Once ovulation is regulated, one can understand when to time either intercourse or an intrauterine insemination so they have a better chance of conceiving!
– Kari von Goeben, M.D.
By: Melinda B. Henne, M.D.
Going to the fertility clinic is scary enough even when you understand all the terms. It’s even harder when it feels like you are reading alphabet soup. Here is a list of common abbreviations used in the clinic.
ART—Assisted Reproductive Technology include advanced fertility techniques such as in vitro fertilization where an embryology lab is required to help fertilize an egg
ECS—Expanded Carrier Screening may be offered to couples planning to have a baby. There are many illnesses that have a genetic cause and require genes from both parents. If a person is a carrier of any of these conditions, they won’t be affected but if they conceive with someone who also is a carrier of these genes, there is a ¼ chance their child could have the condition.
FET—Frozen Embryo Transfer is when an embryo grown in the lab is transferred into the woman’s uterus after having been cryogenically preserved (frozen) for some period of time.
HSG—A HysteroSalpingoGram is a procedure where fluid is placed into the uterus and x-ray is taken of the uterus and tubes to see the shape of the uterus and/or to see if the tubes are open
ICSI—Sometimes, advanced techniques are needed to fertilize an egg. IntraCytoplasmic Sperm Injection is where a single sperm is placed directly into an egg to increase fertilization
IUI—IntraUterine Insemination is the process where sperm is concentrated and placed into the woman’s uterus.
IVF—In Vitro Fertilization is the process where eggs are retrieved from a woman’s body and fertilized in the laboratory with a man’s sperm to create an embryo. Embryos are then placed in the woman’s uterus.
OHSS—Ovarian Hyperstimulation Syndrome is a condition that sometimes happens when ovaries have been stimulated to make more than one egg. Sometimes it is serious and requires medical intervention.
PCOS—PolyCystic Ovarian Syndrome is a condition where women don’t ovulate (release eggs) regularly. The ovaries have a particular appearance on ultrasound and some women have higher than normal levels of androgens (masculine hormones). There are other conditions that may cause these symptoms that should be evaluated and ruled out before the diagnosis is made.
PGT—Preimpantation Diagnostic Testing is a laboratory procedure where cells are removed from the developing embryo and tested for genetic conditions
SET—Single Embryo Transfer is when one embryo is placed into a woman’s uterus. eSET is an elective SET and means there was more than one embryo available and the woman chose to have only one embryo transferred. Other embryos may be stored for later.
SIS—Saline Infusion Sonography is a procedure where salt water is placed into the uterus while ultrasound is being performed. This gives a very detailed look at the inside shape and lining of the uterus
TVOR—Transvaginal Oocyte Retrieval is the procedure where eggs are removed from a woman’s ovaries with ultrasound guidance. This is done by a needle attached to an internal (vaginal) ultrasound probe. Women are often sedated for this procedure.
A more contemporary way to perform a cryo (frozen) embryo transfer is the modified natural embryo transfer protocol. The concept behind this is to simply perform a frozen embryo transfer at the proper time point during a natural ovulatory menstrual cycle to allow for embryo implantation and development. During such a treatment cycle, the patient’s natural follicle development is followed by ultrasound and blood work. At the time that it is expected that the woman would ovulate, a trigger shot of hCG is typically given to cause ovulation and promote good corpus luteal function, thereby maintaining proper progesterone levels. The day following the follicular trigger shot, a minimal form of Progesterone administration is typically begun. During the natural cycle no supplemental Estrogen is typically required. The advantage to such a cycle is that there is little need for hormonal support and implantation is ultimately allowed to occur in an environment very closely replicating a natural ovulation. Disadvantages to such a transfer cycle mainly focus on our inability to time the cycle to possibly desired calendar days for transfer, as we are simply following along the natural follicle development. Not all women will be candidates for a modified natural embryo transfer cycle. Those patients would include women with irregular menstrual cycles, history of recurrent pregnancy loss, gestational carrier cycles, and others. Better suited candidates are women who have had prior spontaneous successful pregnancies and now have infertility issues due to tubal factor or severe male factor. If such a frozen embryo transfer cycle interests you, please consider discussing this with your physician at the F.I.R.M.
By Michael L. Freeman, M.D.
By Teresa M. Erb, M.D.
What does transgender mean?
Most people are assigned a sex at birth (boy vs. girl) based on their external genitalia. For some people, that “boy” or “girl” label may not feel right. For example, someone born and labeled female may feel that they are really a male. Conversely, someone born and labeled male may feel that they are really a female. Transgender is a term used to describe people who may feel this way.
Others may feel that they belong to neither gender or to both genders. Terms used to describe this setting may include “gender fluid,” “gender queer,” “gender neutral,” and “gender nonconforming.”
Members of the transgender or queer community may decide to change how they dress, change their name and change their preferred pronouns. Some may even choose to take hormones or to have surgery so that their bodies more closely match their gender identity. Others do not. There is no “correct” way to be a transgender person.
Do I need permission for a medical transition?
In most places in the United States, you will need permission from your parent or guardian to do a hormonal or surgical transition before you are 18 years old. You also will need to talk with a mental health professional and get a letter of support before starting treatment. This may involve multiple counseling sessions.
How do hormonal treatments work?
Hormonal treatments are usually managed by a pediatric or medical endocrinologist.
One way that hormones can be used for a medical transition is to block or delay puberty. These medications can stop menstrual periods, breast growth, facial hair growth and deepening of the voice. You may need to wait until you have started the early stages of puberty before taking puberty blockers. Most effects of puberty blockers are reversible.
Another way that hormones can be used is to help you look or sound more masculine or feminine. This also may be called gender-affirming hormone therapy. Depending on the treatment, these medications can help you develop desired characteristics, such as: deepening your voice, growing facial hair, developing breasts, changing your body shape. Most of these changes cannot be reversed.
What fertility treatments are available for transgender patients?
Some kinds of hormone treatments may make it harder for you to have a baby in the future. Some kinds of surgery may make it impossible. Talk about this with your doctor before you have treatment. Prior to initiating any hormonal or surgical treatment, it is advisable to meet with a reproductive endocrinologist to review future reproductive treatment options which may include:
- Freezing your eggs or sperm
- Intrauterine Insemination
- In Vitro Fertilization
- Freezing Embryo(s)
- Using donated eggs or donated sperm to achieve a family
- Using the help of a gestational carrier to help you achieve a family
- Adoption
If you have questions about your gender identity:
If you have questions about your gender identity it may be helpful to talk with your parents, a teacher, counselor, doctor, or other health care professional. It’s a good idea to ask about what can be kept private before you talk with an adult.
There are websites and hotlines where you can be anonymous if you need information. These websites also can help you educate your parents, family, and friends about the transgender community.
Resources
- Centerlink
(954) 765-6024
www.lgbtcenters.org
Directory of community centers for LGBT people. - Transgender Care Listings
www.transcaresite.org
Directory of trans-friendly health care professionals. - Trans Youth Equality Foundation
www.transyouthequality.org
Resources for transgender teens and young adults. - Campus Pride
www.campuspride.org
Resources for LGBTQ college students. - PFLAG
(202) 467-8180
www.pflag.org
Network of communities for LGBTQ people, parents, and friends. - Gender Spectrum
510-788-4412
www.genderspectrum.org
Organization that supports gender expansive children, teens, and their families.
Hotlines
- Trevor Lifeline
Toll-free: 866-4-U-TREVOR (866-488-7386)
Hours: 7 days a week, 24 hours a day
www.thetrevorproject.org
Confidential suicide and crisis counseling for LGBTQ teens and young adults. Text and instant messaging options are
available on the website. - Trans Lifeline
Toll-free: 877-565-8860
Hours: 7 am–1 am PST / 9 am–3 am CST / 10 am–4 am EST
www.translifeline.org
Peer support hotline that is run by and for trans people. - LGBT National Youth Talkline
800-246-PRIDE (800-246-7743)
Hours: Monday–Friday 1 pm–9 pm PST / 4 pm–12 am EST, Saturday 9 am–2 pm PST / 12 pm–5 pm EST
[email protected]
www.glbthotline.org/youth-talkline.html
Peer support and resources for LGBTQ teens and young adults.
More and more babies are being born after using assisted reproductive technologies (ART). This mainly includes babies being born after in vitro fertilization (IVF) when a woman’s eggs are fertilized with a man’s sperm inside a dish in a laboratory. However other techniques that are under the umbrella of ART are procedures like egg donation, surrogacy and egg freezing. At our annual meeting in the fall of 2016, an estimated 5 million children were born after ART technologies in the previous six years! This increase is thought to be due to increasing access in developing countries and increasing insurance coverage in many locations. According to the Centers for Disease Control and Prevention, about 1% of babies born in the United States each year, so about 60,000, are conceived through ART.
Kari Sproul von Goeben, M.D.
Men with low libido, chronic fatigue are getting checked for low testosterone levels. There is no agreement what constitutes a normal testosterone level – in most reference labs values range from 300 – 1200. Men complaining of decreased libido, chronic fatigue are being treated with a variety of different testosterone preparations. What is not being made clear to these individuals is that exogenous testosterone in any form suppresses sperm production. The higher the dose and the longer the duration of administration, the greater the suppressive effect. If sufficient doses are given for long enough atrophy of the cells that make sperm occur resulting in permanent sterility.
Continue reading →
Pre-embryo genetic testing (PGT) is an exceptionally powerful tool increasing in vitro fertilization pregnancy rates, decreasing the risk of a multiple pregnancy, miscarriage and minimizing the number of babies born with genetic anomalies. To understand this technology it is important to understand how the process is performed. Blastocyst (day 5, 6 and 7) embryos derived from IVF typically contain anywhere from 200-400 cells. The embryo consists of an outer trophoblastic layer destined to develop into the placenta as well as an inner cell mass destined to develop into the fetus. Biopsying the inner cell mass would give us the most direct information about the fetus, but poses a risk of injury. For that reason the outer cell mass is sampled. Biopsy of the outer cell mass is limited to 4-10 cells to minimize the chance of embryo damage – herein lies one of the sources of potential sampling error, i.e., only a small percentage of the total cells are tested. The cells of the outer cell mass have a high degree of concordance with the inner cell mass, but not 100% – a second potential source of sampling error. It is believed that often subsets of abnormal cells are destroyed by healthier more rapidly replicating normal cells – a third potential source of sampling error.
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Day 0 – FIRM physicians refer to retrieval day as day O of embryo development. Before leaving the recovery area, your FIRM doctor will give you the final egg count. Several hours later an embryologist in the IVF lab will inseminate the eggs. Insemination can be accomplished by standard insemination or by ICSI (shown below). Standard insemination involves placing washed sperm with an egg into the culture dish. ICSI, a more involved process, requires that the embryologist insert the sperm into the egg using a specialized needle and a microscope. After insemination, the eggs are placed back into the incubator to allow time for fertilization to occur. Your FIRM doctor will review with you the method to be used for insemination prior to your IVF cycle. However, on occasion, the results of the semen analysis on the day of the retrieval may necessitate ICSI be done, which your FIRM physician would discuss with you in that event. Continue reading →