Category Archives: Blogs
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.
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.
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
Miscarriages are pregnancies that stop developing. Development stops at different times and for different reasons. The great majority of miscarriages are early occurring before 10 weeks due to a genetically/chromosomally abnormal conceptus – the result of an abnormal egg or sperm fertilization. Most often it is an abnormal egg because the egg is much older than sperm. Women are born with a certain number of eggs, they never make any more eggs their entire life. Eggs accumulate genetic/chromosomal errors as a function of time. Continue reading
Fertility preservation offers couples or individuals the opportunity to preserve their ability to have children in the future. For some women a medical reason, such as cancer treatment, may lead them to seek fertility preservation. For others, the reason is personal such as to defer childbearing or to pursue a chosen career path. Continue reading
Throughout recorded history, there have been many superstitious beliefs with regards to menstruation. If a woman does not have a regular, monthly period there are typically a handful of reasons why. The focus of this blog is to help patients understand the normal menstrual cycle.
A normal menstrual cycle typically occurs every 24-35 days. It is divided into two phases, the follicular phase when an egg grows inside a follicle and the luteal phase when the follicle becomes a corpus luteum and makes progesterone. The end of the follicular phase and beginning of the luteal phase is marked by ovulation. Continue reading
There are thousands of cryopreserved embryos being stored at IVF clinics throughout the world. These embryos are for the most part leftover from successful cycles. Couples may come back to use these embryos, continue to store them, discard them or put them up for adoption. At the Florida Institute for Reproductive Medicine we strongly encourage couples who have completed their family to consider adoption. Embryo adoption is an ideal option for many couples, particularly those with severe egg or sperm factors. Costs to do donor embryo IVF are typically much less than donor egg in vitro fertilization and can be comparable to donor sperm insemination given the differences in fecundity. Continue reading
Women are born with a certain number of eggs, they never make any more eggs their entire life. At the time of puberty when women start menstruating they have lost over 90% of their eggs having a few hundred thousand remaining. Each month with menses a group of eggs start to develop, only one of which goes on to ovulate. If multiple eggs develop a multiple pregnancy can occur. The remaining eggs that do not mature form scars in the ovary. The whole cohort of eggs is lost each month. Being on birth control pills does not prevent this programmed loss of eggs. As the eggs get older they accumulate genetic/chromosomal errors in response to different environmental insults, i.e., free radicals, alcohol, caffeine, tobacco, chemotherapeutic drugs and other toxins. As a result of the decreased number and quality of eggs fertility rates decrease over time. At age 35 fertility rates drop significantly, by age 40 rates drop drastically. The great majority of women older than 42 will require donor eggs to achieve healthy ongoing pregnancies.
Since the very first IVF pregnancy there have been countless different stimulation protocols to try and get women to produce more and better quality eggs. In my reproductive medicine career spanning almost 30 years, I have reviewed at least 30 different protocols none of which have ever been shown to significantly improve the number and quality of eggs. The only medication that has some evidence supporting a benefit to egg quality has been growth hormone, and this is questionable. Because we have not been able to significantly improve egg number and quality in the low response patient, the stimulation strategy has changed over the last several years to stimulating patients with the least costly option, i.e. low dose gonadotropin protocols or even oral medications. While there is a cost rational for this, in these patients it is critical to get as many eggs as possible. For that reason, in most cases, I will stimulate the patient with a high dose protocol to try and get every egg that is coming along to develop. In the case of repeated IVF failures in the low response patient, the only real solution is that of either donor egg or donor embryo IVF whereby younger, healthier eggs are used.
Kevin L. Winslow, M.D.
Director for Florida Institute for Reproductive Medicine
In terms of evaluating the endometrial cavity, the site of embryo implantation, direct inspection via a hysteroscope offers the most precise information. It also allows us to treat any pathology, i.e., adhesions, polyps, fibroids or a uterine septum. Hysteroscopy gives us information regarding the opening of the fallopian tubes, but does not give us any information regarding the remainder of the tubes.
Hysterosalpingogram (HSG) performed by the injection of a contrast dye into the uterine cavity will detect filling defects, but does not tell us what the pathology is. Hysterosalpingogram also allows us to assess whether the fallopian tubes are patent, as contrast dye can be seen filling and exiting the tubes. By examining the course of the fallopian tube we can get an idea as to whether there may be paratubal adhesions, i.e. the tube is often convoluted with poor dispersion of the dye throughout the pelvis. When the fallopian tube is not a concern sono-hysterosalpingogram can be performed, an office procedure whereby sterile saline is injected into the endometrial cavity and an ultrasound is performed. This technique is more sensitive in detecting endometrial pathology than a regular hysterosalpingogram, but again does not tell us what the pathology is and does not allow for corrections. Sono-HSG is often the screening procedure of choice when the fallopian tubes are known to be patent or have been removed. Will all three diagnostic procedures there is a low chance of infection. The risk of this is significantly higher if the fallopian tubes are blocked. Prophylactic antibiotics are often recommended if tube status is unknown.
Kevin L. Winslow, M.D.
Director for Florida Institute for Reproductive Medicine