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Monthly Archives: December 2010

New study puts to rest fears that IVF linked to cancer

In the wake of Elizabeth Edwards’ death, many women are wondering whether the fertility treatments the former Senator’s wife underwent to bear children late in life could have contributed to the breast cancer that killed her. Previous data have suggested that these fertility drugs may be associated with increased risk for breast, uterine and ovarian cancers.

It’s a plausible concern, given that fertility treatment exposes women to unnaturally high levels of hormones, including estrogen and progesterone — often repeatedly, and sometimes at an age when those hormones would normally be declining.

But a large new study set to be published in the January 2011 edition of the journal Human Reproduction suggests that women who undergo in-vitro fertilization (IVF) do not put themselves at a higher-than-usual risk of cancer. The study examined data on all IVF births in Sweden between 1982 and 2006, comparing the rate of cancer in 24,058 women who conceived via IVF with that of nearly 1.4 million Swedish mothers who did not require fertility treatment.

The study found that the risk for any cancer was actually 26% lower in women after they had children through IVF, compared with those who had conceived the old-fashioned way. Breast cancer risk was reduced 24% and cervical cancer risk 39%, over the eight-year follow-up period.

However, women who underwent IVF started out with higher rates of cancer than those in the general population; the fact that these women were more likely to have been treated for cancer, which causes infertility, is probably why they sought IVF. This risk was especially elevated for ovarian cancer: in women seeking IVF the risk of ovarian cancer was nearly four times greater than in other mothers before conception. That is likely because the same problems that contribute to ovarian cancer may also produce infertility. “If you have an ovary that has a tendency to develop into cancer, it might also be poorly functioning reproductively,” said Dr. Bengt Kallen, professor emeritus at the University of Lund and lead author of the study.

However, the study found that the risk of ovarian cancer in women who were able to conceive and give birth to a baby through IVF was only twice as high as in mothers who conceived naturally. The effect was not because IVF reduces the odds of developing ovarian cancer, the authors say; instead, it’s more likely that women who are able to conceive and successfully carry a pregnancy by IVF are probably healthier than other women, and are more likely to undergo regular screening for cancer. The same phenomenon is likely to explain the lower risk of breast and cervical cancers in the same group.

The new study is consistent with most previous research, says Kallen, noting that while some studies have found a small increased risk in cancer for some subgroups of women using fertility treatment, others cannot find any risk.

The study also did not find any increased risk of cancer in women undergoing IVF over age 30, compared with younger women. However, it could not determine whether repeated cycles of IVF affected cancer risk, nor could it provide data on the risk in women who underwent fertility treatment but did not conceive. The average age at which participants underwent treatment was 32, and the average follow-up period was eight years, which means that the study would not have captured cancers that occurred later in life.

“One should have the caveat that these women are not very old yet; they’re mainly premenopausal. What happens at a higher age, we don’t know yet,” Kallen concedes. “Common sense says that if you increase a woman’s risk because of hormonal treatment, then that should appear rather quickly, within 10 years. You wouldn’t expect to see it 20, 30, 40 years later.”

This study reaffirms that ultimately, there is no increase in cancer risk associated with IVF.

All pregnant women (and those trying) should get the flu vaccine

Washington, DC – All pregnant women, regardless of trimester, should get the influenza vaccination during the flu season, according to new recommendations issued by The American College of Obstetricians and Gynecologists and published in the October issue of Obstetrics & Gynecology. The College emphasizes that preventing the flu during pregnancy is an essential element of prenatal care and that it is imperative that physicians, healthcare organizations, and public health officials improve their efforts to increase immunization rates among pregnant women.

Last week, the CDC, along with The College and other medical organizations, encouraged all physicians and health care providers to urge their pregnant and postpartum patients to get vaccinated against the seasonal flu.

Annual flu vaccination is crucial for pregnant women because the immune system changes during pregnancy, which results in women being at increased risk of serious complications if they get the flu. Flu vaccination performs double duty by protecting both pregnant women and their babies. Babies cannot be vaccinated against the flu until they are six months old, but they receive antibodies from their mother which help protect them until they can be vaccinated.

The flu is a highly infectious virus and can be especially serious for the very young, those with certain medical conditions, and pregnant women,” said Richard N. Waldman, MD, president of The College. “Pregnant women were disproportionately affected by flu complications last year—some went into premature labor, some developed pneumonia, and unfortunately, some died.”

Vaccination early in the flu season is optimal, but can be given at any time during this period, regardless of the stage of pregnancy. The College advises that all women who are or become pregnant during the annual flu season (October through May) get the inactivated flu vaccine. Women can also receive the flu vaccine postpartum and while they are breastfeeding if they missed it during pregnancy. The live attenuated version of the flu vaccine (the nasal mist) should not be given to pregnant women.

According to the CDC, the seasonal flu vaccine is made the same way each year. “The only difference from year to year is that new strains of virus are used to make the vaccine based on which are predicted to be most prevalent,” said William M. Callaghan, MD, the Centers for Disease Control and Prevention (CDC) liaison to The College’s Committee on Obstetric Practice. There have been no studies showing adverse effects of the inactivated flu vaccine for pregnant women or their children, according to The College. “Millions of pregnant women have received the flu vaccine over the past 45 years, and no studies have shown harm to them or their babies,” said Dr. Callaghan.

Despite concerns about thimerosal, a mercury-containing preservative used in some vaccines, there is no scientific evidence that it causes harm to women or their infants. The only side effect is the occasional local skin reaction at the injection site. “There are seasonal flu vaccines that don’t contain thimerosal, so people who remain concerned can ask for those,” said Dr. Callaghan.

Dr. Callaghan notes that The College’s recommendation to increase the vaccination rate among pregnant women dovetails with the CDC’s push for physicians to offer the flu vaccine to every patient age six months and older at every opportunity.

What is involved in an IVF Cycle?

Many patients have heard of IVF (In vitro fertilization), and may even be facing IVF in their effort to conceive.  However, many do not know exactly what is involved.  This will hopefully give a quick overview of a typical IVF cycle.

General

The basic idea in IVF is to give the patient a large amount of gonadotropins (the hormones from the brain that stimulate egg development) to cause the development of many follicles (the ovarian cysts that each contain an egg).  The hormones used must all be given as injections, as they do not come in pill form.  The injections are given just under the skin like an insulin injection that a diabetic person might take.  Once the follicles are fully developed, which usually takes 10-12 days of medication, the eggs are retrieved through an in-office procedure.  The eggs are given to the embryology lab where they are fertilized with sperm, and allowed to grow for 3-5 days.  At that point, the embryo(s) are transferred back into her uterus through a small catheter (tube).

Stimulation Protocols

There are several basic plans (protocols) for performing ovarian stimulation for IVF.  There have been numerous variations reported over the years, but primarily two or three basic standard types have proven to be the most successful.  The differences between any of the protocols are subtle.  It is usually only through the judgment of the physician that it can be determined which protocol will be most suitable for a particular patient.

The two protocols that have been time-tested and most often used are termed “Agonist Protocols” and “Antagonist Protocols”.   These terms refer to the type of medication that serves to prevent your body from trying to prematurely ovulate or release the developing eggs.   In both protocols, the stimulation medication (FSH and LH) are used for a total of 10-12 days.

Though it may sound counterproductive, it is helpful to use a birth control pill for at least one cycle before starting the IVF medications.  This serves to keep the ovaries quiet and prevent any cyst formation that may later interfere with the IVF cycle.

In an Agonist Protocol, a hormone (called a GnRH-agonist) is used to prevent the brain from trying to prematurely ovulating the developing follicles.   This is usually started during the last week of the birth control pills, and continued daily up until the point of egg retrieval.  The stimulation medications (FSH and LH) are started after being on the GnRH Agonist for approximately one week.

In an Antagonist Protocol, the stimulation medication is started once the menses following the birth control pill cycle occurs.  After 4-6 days of stimulation medication, another hormone is started (a GnRH-antagonist), which prevents premature ovulation of the developing follicles.  This is also continued until the point of egg retrieval.

Cycle Monitoring

The initial dose of medication is chosen by the physician based on several factors, including the patient’s age, previous IVF experience, and hormone levels.  Usually the dosages of stimulation medications will be adjusted during the stimulation phase based on the results of close monitoring which includes a pelvic ultrasound and hormone measurements.   This monitoring is performed at baseline before starting stimulation, and after the first 3-5 days of stimulation medications.  From that point on, an ultrasound and estrogen blood level is usually performed every 2-3 days until the time of retrieval, for a total of 4-5 monitoring visits.

Once the majority of the ovarian follicles reach the proper size (usually 17-19 mm in diameter), a separate medication is given (hCG- human chorionic gonadotropin).  This serves to “trigger” the eggs, causing the eggs to genetically awaken from their idle state, continue development, and become “mature” or able to be fertilized and develop into an embryo.

Egg Retrieval

The hCG medication is given with specific timing.  If the eggs are not retrieved, they would be ovulated and released.  This timing is such that the egg retrieval occurs just several hours before the eggs would be released.  The egg retrieval occurs in our certified operating room located within our office.  Anesthesia medication is administered through an IV placed in an arm vein.  This allows the patient to be fully relaxed and comfortable during the procedure.  A pelvic ultrasound is performed as usual, and ultrasound guidance is used to guide a needle into each ovary allowing the fluid (containing the egg)  in every follicle to be removed.  After the eggs are carefully removed, they are given to the embryologist (the laboratory scientist specially trained in handling eggs and embryos).  The entire retrieval usually takes about 15-30 minutes, and the patient goes home once fully recovered from the anesthesia (about 45 minutes later).

Fertilization and Embryo Culture

Once the eggs are retrieved, they are fertilized several hours later.  This is usually done by mixing the eggs with the sperm.  In cases of male fertility issues, an individual sperm may be directly injected into each egg.  The fertilized eggs then start the process of dividing.  They are grown (cultured) in a very closely monitored and controlled setting which allows for the optimal environment for the early embryos.  They are assessed on the second day after retrieval, and depending on several factors, a decision will be made by the physician to either transfer the embryos on the following day (Day 3), or allow them to grow for an additional two days and transfer them on Day 5.

Embryo Transfer

When the day comes for the embryo transfer, you will return to the office.  The transfer will take place in another room specifically used for this purpose which is located next to the embryology lab.  The transfer is a simple and painless procedure that does not require any type of anesthesia.  It is very similar to having a pap smear performed.  During the transfer procedure, a small catheter (tube) containing the embryos is carefully inserted through the cervix and into the uterine cavity.  This is guided with an ultrasound to ensure that they are gently placed in the proper location.    After the transfer, the patient relaxes for approximately 15 minutes then is able to go home.  Once placed in the uterus, the embryos cannot “fall” out or dislodge.

After the Embryo Transfer

After the retrieval and transfer, hormone supplementation (using progesterone) is continued to provide extra support for the pregnancy.  Progesterone is available in several forms including injection, vaginal tablets, and vaginal creams. A blood pregnancy test is performed about 14-16 days after the egg retrieval.  Once a pregnancy test is positive, an ultrasound is performed approximately 3 weeks later, at which time we should be able to detect a heartbeat in the embryo.  Progesterone is continued for an additional 2-3 weeks after the detection of a heartbeat.

Summary

At first glance, the steps of IVF appear very complicated.  However, our entire team of physicians, nurses, and staff will work to guide you step-by-step through the entire process.  Having a dedicated team available and on call 24-hours a day ensures that you have a continuous support network at your fingertips.  The entire time-frame from the start of a birth control pill until the pregnancy test is approximately 7 weeks, during which specific IVF medications are used for 4 weeks.  IVF is not necessary for every couple, but it is always the fastest route to a pregnancy.

What treatments are available for uterine fibroids?

I previously discussed the impact that fibroids can have in a woman’s life, primarily that of irregular bleeding, pelvic pain, and infertility.  There are various options for the treatment of fibroids depending on the future fertility plans of the woman.  The guiding question should be whether or not there is or may be any future plans to conceive.   If so, then the only treatment that should really be considered is a myomectomy, a surgical procedure in which the fibroids are removed, leaving the uterus in place.  If childbearing is complete, then there are several other routes which may be chosen.  These could include a myomectomy, hysterectomy, uterine artery embolization, endometrial ablation, or MRI guided focused ultrasound.

Medical (Non-Surgical) Management of Fibroids

I did not mention the use of medications in the above paragraph due to the fact that this is not a good long term option for fibroid treatment, and is only used in a few circumstances.  The medications that are used work by shutting down the ovary temporarily.   This induces a temporary reversible menopause-like situation.  This can be used to reduce bleeding due to fibroids, and help to shrink them by about 30%.  However, this effect only lasts as long as the medication is used, with fibroids returning to their normal size soon after stopping the medication.  Due to the menopause-like situation, this treatment should only be used for short term treatment (<1 year duration) with ultimate definitive therapy.   This is most frequently used in women who are having heavy bleeding, allowing the bleeding to slow or stop down so that her body can recover before ultimately having surgery.

Myomectomy

In a myomectomy, uterine fibroids are surgically removed, leaving the uterus in place.  If fibroids are located primarily within the uterine cavity (submucosal type), then they may be able to be removed with a hysteroscope (small camera) by entering the uterus through the cervical opening.  In most cases, they are removed by making an incision on the outside of the uterus, removing the fibroids, and suturing (sewing) the uterus back together.  In the past, myomectomies were performed through large open incisions in the abdomen, often going side-to-side, but sometimes vertically.  This type of “open” myomectomy has significant drawbacks, including a 2-3 day hospital stay, extended recovery, adhesion (scar tissue) formation, and significant blood loss.  In recent years, there has been a large shift towards performing myomectomies by laparoscopy (through small incisions using cameras).  This “minimally invasive” route offers significant advantages, including less pain, a more cosmetic result with smaller incisions, usually no overnight hospitalization, less bleeding and scar formation, and a much faster recovery.   Before a few years ago, only some selected cases were performed laparoscopically due to the significant increase in difficulty in performing myomectomies laparoscopically.  The introduction of the da Vinci Robotic System for laparoscopic assistance has made a tremendous improvement, allowing nearly any myomectomy to be performed laparoscopically, regardless of size or difficulty.    Our practice specializes in myomectomies and is able to repair and reconstruct the most severely distorted uterus due to fibroids.

Hysterectomy

For some women, they may choose to have a hysterectomy (removal of the uterus) as a treatment for fibroids.  It is for this reason that a hysterectomy has become one of the most common surgeries that a woman may face during her lifetime.  Most hysterectomies can be accomplished by a minimally invasive route, either removing it through the vagina, or laparoscopically through the use of small cameras, or in difficult cases, using Robotic assistance to perform it through a camera.  Rarely is an open incision needed for a hysterectomy.

Uterine Artery Embolization

A uterine artery embolization (UAE) procedure performed by a specially trained radiologist which involves injecting small particles (about the size of a small grain of sand) into the uterine blood vessels. These particles clog the small blood vessels that supply the fibroids, cutting down the blood supply and causing the fibroids to die and degenerate. Fibroid volume shrinks by 40% to 50%, and the majority of patients experience symptomatic relief.  However, patients generally experience several days of pain after the procedure and are usually hospitalized for 1-2 days. Women who are older may at risk of developing early ovarian failure.  Due to the effect on uterine blood flow, this technique is not recommended for women who would like to conceive in the future, and for those who do, there is a slightly higher rate of pregnancy complications.

Endometrial Ablation

An endometrial ablation is a procedure that is intended to treat heavy uterine bleeding in general.  This could be due to fibroids or to other causes.  In this procedure, one of several techniques are used to basically burn or cut out the endometrium (lining of the uterus).  This significantly limits the amount of bleeding that occurs.  An ablation may be effective in treating bleeding due to fibroids, but may often provide only effective treatment for a limited time (perhaps 1-3 years).  Bleeding may return as fibroids continue to grow and enlarge.

 

MRI Guided focused ultrasound

This is a newer approved technique which uses powerful ultrasound waves to destroy the fibroid.  It has only limited availability, and only small studies available with long term follow up.  It is likely most effective for someone with a small number of larger fibroids.  However, due to the lack of long term follow-up results it is not widely recommended and cannot be recommended for anyone wishing to retain their fertility.

In summary, if fertility is still desired, then a myomectomy is the procedure of choice.  Other forms of fibroid treatment should not be undertaken due to known problems with subsequent pregnancies.  If childbearing is not desired, then the woman can make an informed decision with her physician regarding her desires, knowing that each of the above option has both benefits and drawbacks.

Can uterine fibroids affect my fertility?

Uterine fibroids, also called myomas or leiomyomas, are benign (non-cancerous) tumors that arise from the muscle of the uterus.  They are extremely common, with most women developing them at some point in time during their life.  One study found that by the age of 50, that 70% of Caucasians and 80% of African-Americans will have developed fibroids.   There appears to be a genetic link to the development of fibroids, often arising earlier and growing faster in African-Americans.  Fibroids often appear to begin when a woman is in her 20s, and usually grow at a slow rate, only reaching a size large enough to cause symptoms when she is in her 30s-40s.  Because of this, problematic fibroids are the most common indication for a hysterectomy in women.

 

When they reach a large enough size, they can cause symptoms such as heavy or irregular bleeding, infertility, pain, or symptoms of “pressure” by pressing on other pelvic organs.  However, many fibroids can be totally asymptomatic, with the woman not having any problems until they are incidentally seen by an ultrasound or CT scan. 

We classify the location of fibroids as primarily four different types:  1) subserosal- located in the outer-most portion of the wall of the uterus, just underneath the outer surface (the serosa); 2) pedunculated- a type of subserosal fibroid that lies mostly outside of the uterus and only connected by a small stalk of tissue; 3) intramural- found within the main body of uterus; 4) submucosal- In the inner-most portion of the uterus and protruding into the cavity of the uterus. About 55% of fibroids are subserosal or pedunculated; 40% are intramural; and 5% are submucosal.    As fibroids increase in size, they may come to span two or more of these categories.   Typically, submucosal and larger intramural fibroids are responsible for heavy menstrual bleeding.

So do they affect your chance of conceiving?  In short, likely yes, possibly no.   This depends on the location and size of fibroids.   Many studies have tried to determine the right answers to this question, with some progress being made.  Some of the results are still somewhat debated.  Many women with fibroids conceive on their own and they may only be discovered during routine pregnancy ultrasounds.  However, for many women they can play a role in hindering fertility.  It is estimated that fibroids play a role in approximately 5-10% of infertility cases.

There is very good data and it is clear that submucosal fibroids can decrease pregnancy rates by about 35%, and increase miscarriage rates by over 65%.   On the other hand, fibroids that are only of the pedunculated or subserosal type appear to have no effect on fertility or miscarriage.  Fibroids that are intramural do appear to decrease fertility though the scientific data is less clear.  With all categories, however, there likely is an effect of fibroid size and fertility impact.  Subserosal fibroids can enlarge to the point that they become predominantly intramural or even submucosal.  Once this size, they may also impact fertility.

Both the lowered pregnancy rate and increased miscarriage rate is likely due to altered blood flow within the uterus.  The fibroids may serve to divert necessary blood flow away from the uterine cavity where an embryo could implant.

We’ll discuss the treatment options for fibroids in an upcoming blog topic.

A Caring Doctor and Staff

Dear Dr. Winslow,

We would like to start out by thanking you for being a wonderful doctor. In a time when couples are beaten down, disappointed, and at times feel hopeless you are a sign of hope. The first time we walked into your office, not knowing what to expect, we were greeted by a wonderful staff of smiling faces and sweet words. As we met you hope of becoming parents started to return and by the time we were having our first IUI done we felt as if you were a blessing from God himself. A few weeks later we were so excited to learn that we were pregnant and a few months later devastated at the loss of a much anticipated baby. When we returned to repeat the process you were so kind and hopeful that it would happen for us again and it did. We prayed for those 3 years for a sign and blessing and little did we know that you were a part of that plan. You have been given a gift and you use it to bless other couples with precious babies they thought would never be a part of their lives. The Lord uses you in a miraculous way. You take time to make every patient feel comfortable and valued. Most doctors would have done the procedures and not taken the time to get to know the patient, you don’t. We thank Him for leading us to you and every day when I look at our Miracle baby boy I think of how wonderful our experience was at your clinic through the ups and downs. God is working through you and all of the wonderful people at the FIRM. We will definitely return when we are planning on baby number 2. Parenthood is a dream come true and a gift we don’t take for granted. Thanks for helping our dreams come true!

Truly Blessed,

The Johnsons

Florida Institute for Reproductive Medicine proudly serving patients in North Florida and South Georgia including Savannah, Columbus, Jacksonville, Jacksonville Beach, Orange Park, St. Marys, Palm Coast, St. Augustine, Palatka, Lake City, Tallahassee, Daytona, Ponte Vedra, Gainesville, Orlando, Melbourne, Ormond Beach, New Smyrna, Port Orange, Brunswick, St. Simons Island, Thomasville, Tifton, Albany, Brunswick, Valdosta and Dothan Alabama.

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