Category Archives: What’s New
Taken from an article printed in Ob/Gyn News by Dr. E. ALBERT REECE, M.D., PH.D., M.B.A.
DR. REECE, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of its school of medicine. He said he had no relevant financial disclosures.
To help women control weight gain during pregnancy, I try to be both pragmatic and practical.
The latest Institute of Medicine guidelines on weight gain during pregnancy issued in 2009 recommend that women with a body mass index of 18.5-24.9 kg/m2, should gain between 25 and 35 pounds during pregnancy. Those who are underweight (with a BMI of less than 18.5 at the time they conceive) should gain more, between 28 and 40 pounds. However, for women who are already overweight at the beginning of pregnancy (with a BMI of 25–29.9), the weight gain recommendation is between 15 and 25 pounds.
Although I typically recommend that pregnant women gain somewhere in the 20-pound range, many women find gaining so little quite a challenge. This is natural. After all, pregnancy is a time when most women are hungrier than usual and want to eat more often than usual. These new mothers also hear all kinds of “good” advice from their friends and other women in their family such as “You’re eating for two now,” and “You’re growing a baby; this is no time to start on a diet.” It can be very hard for a woman’s physician to counteract such messages from family and friends.
The truth is, the baby is probably going to weigh around 7 pounds or so. Therefore, if a woman is gaining 30 or 40 pounds, such a gain in weight is way in excess of the weight of the baby, the placenta, and all the extra fluid combined. Gaining that much weight makes it that much harder to lose after giving birth.
The group that usually gets the most attention with regard to weight gain is the group of women with diabetes or gestational diabetes. They usually get nutritional counseling, assistance in choosing an appropriate diet, and information about glucose control. The American Diabetes Association recommends that women with gestational diabetes – and women who are just gaining more weight than you’d like – restrict carbohydrate intake to 30%–40% of their daily intake. By doing this they will at least slow the trajectory of weight gain. For those women who are diabetic, restricting carbohydrate intake also will allow them to see a lowering of their blood glucose.
Every pregnant woman needs to eat well. What they may not recognize, however, is that eating well doesn’t mean eating more – it means eating wisely. Furthermore, most women come into pregnancy without healthy eating habits. These habits are already part of their nature, so the best we can do is to try to moderate them.
On the other hand, pregnancy is a very good time to try to improve a woman’s eating habits. Indeed, there are very few other times in a woman’s life when she will be so motivated to change her health habits as when she’s pregnant. Even smokers will quit then – although they may start back up after the baby is born. But during pregnancy, not only the mother, but the entire family is invested in bringing this child into the world as healthy as possible.
When it comes to this issue, I try to be practical. You can’t expect people to change their entire lifestyle immediately. Also, I try to take a pragmatic approach that focuses on changing a few things at a time.
Instead of telling women to “eliminate, eliminate, eliminate,” I encourage them to be thinking all the time about what they do eat. Decreasing carbohydrates in line with the national recommendations of no more than one-third of the daily calories is a good idea for everyone. Protein, on the other hand, is food the body can’t store. So I advise women to increase their protein intake because it has a filling effect and lowers carbohydrate intake as well.
At the same time, they can significantly increase their intake of vegetables and fruits, including salads, while watching the salad dressing. Pregnancy is also a time of slower gastrointestinal motility and constipation. Eating more vegetables – in particular raw vegetables – can cut down on intestinal transit time and help with constipation.
Water is the best drink for a pregnant woman. They may tell you they’re consuming a lot of fruit juice. However, most of these juice drinks are full of carbohydrates in the form of sugar. Even though “naturally” unsweetened juices are a better choice, they still have a lot of calories and carbohydrates in them.
As for soft drinks – the more pregnant women avoid them, the better. They are full of sugar and are really unhealthy for anyone, especially women with diabetes.
Again, if you only counsel women to “eliminate, eliminate, eliminate,” they probably won’t do it. My pragmatic approach is to have women limit, instead of eliminate. So I say, “Try to drink more water, less soda, and unsweetened fruit juice only in moderation.”
Exercise can be beneficial for anyone, and any woman who has been in the habit of exercising can continue. But exercise should not be a new sport you take up when you get pregnant. If pregnant women are new to exercise, it’s better to concentrate on the upper body rather than the lower, because these women don’t have an exercise-related established physiology of improved blood flow. Intense lower body exercise for these women can compromise blood flow to the fetus.
I would say that the average woman with moderate exercise habits can continue to exercise for a moderate duration at a moderate intensity and without excessive fatigue. As far as when to stop as the pregnancy advances, I use my clinical judgment. As long as the baby is growing well and there are no signs of premature labor, exercise can continue. There really is no a priori time that she must stop.
Women who have exercised vigorously much of their life – athletes and dancers, for instance – can usually continue to do so until the time of delivery. If the pregnancy is showing any signs of not progressing well, however, they should stop exercising immediately. On the other end of the spectrum are women who should not be exercising at all during pregnancy. These are the women who have a history of preterm labor or are showing signs of it, as well as those with some underlying disease.
Women with hypertension or some kind of vessel disease – like severe varicose veins or vasculitis – should not be exercising at all. With vessel disease, as the demands on the heart increase during exercise, blood will be shunted way from the fetus and could truly compromise the flow into the placenta. Sometimes these babies will experience decreased heart rates during exercise.
Some mothers have heard that certain exercises during pregnancy will make for an easier labor and delivery. There may be some truth to this, as women who are exercising before they get pregnant tend to have a lower incidence of large-for-gestational-age infants – and in that regard, they may have less difficult deliveries.
The introduction of the da Vinci robot-assisted surgery for use in gynecologic surgery in the past few years has been of great benefit to many patients. It allows the use of a minimally invasive laparoscopic route to cases that would otherwise require an abdominal approach. In the field or reproductive surgery, this benefit most frequently pertains to the removal of uterine fibroids. In the past, the majority of fibroids could only be removed through laparotomy, or a large open incision. But with the use of robotic surgery, the vast majority of these procedures can be performed laparoscopically. This offers the patient a huge benefit. What usually required a 2-3 day hospital stay and 4-6 week recovery is now an outpatient procedure, with the patient going home the same day, and able to return to work in 7 days. There is significantly less blood loss, and less scar tissue formation around the uterus. Surgical outcomes are equal to those performed through an open procedure. With such great benefit, I strive to not perform on open procedure on patients. Even in very difficult settings, nearly all cases can be performed laparoscopically. The only cases which I consider laparotomy instead of a minimally invasive surgery is in those cases with large numbers of fibroids (more than 10), though even with large numbers, select cases may be robotic candidates. Fibroid size is not a limitation.
Another condition that can benefit from the use of robotic assistance is that of severe endometriosis. Particularly in the setting of pelvic pain, it is essential to remove all of the endometriosis. This can be done by standard laparoscopy, but if other organs such as intestines are involved, most surgeons under-treat the disease due to fear of injuring surrounding critical organs. Few surgeons treat it adequately due to the extended amount of time that such a surgery can take. The use of the da Vinci robotic system allows me to more thoroughly treat the disease, and perform a much more careful dissection around critical organs, and do all of this much faster than can be done by standard laparoscopy.
For women facing a hysterectomy, the use of robotic assistance allows for the performance of much more surgically challenging cases. These involve large fibroids, fibroids in difficult locations, endometriosis, and scar tissue. Well more than 90% of abdominal hysterectomies could and should be performed through a minimally invasive route.
You may ask, if this is of such benefit, why isn’t the procedure being done more often? There are several answers to this question. Many times, with general gynecologists, the patients aren’t truly given informed choices of their options. They are usually given the options that their physician can perform, but less often are they given other viable options. Many gynecologists lack the skills and/or training necessary to perform advanced laparoscopic surgery. Unfortunately, they often fail to consider what is in the best interest of the patient, as that may mean referring that patient to an advanced laparoscopic surgeon. Often, the patient may not know all of her options, or be told by the physician that it is not an option. These are situations in which doing your homework or seeking a second opinion can benefit you.
Is the robot necessary for these more difficult cases? No, as most of these above mentioned surgeries can be accomplished by a skilled laparoscopic surgeon. But with increasing complexity, comes the need for more advanced surgical skills, and longer operative times. To a skilled surgeon, the robot does expand what can be “easily” be done laparoscopically, which allows for a faster surgery, improving patient recovery.
If you might be facing a difficult surgery, and question whether the use of robotic assistance may benefit you, please call to arrange a meeting or phone consultation with Dr. Duffy
The following are some of the questions that we received from the audience at our recent Fertility Seminar. Some of these were addressed at that time, but we could not answer all questions. If there are other general questions that you would like to have addressed, please feel free to comment below, and I will answer them. — Dr. Duffy
1. Can you do an HSG (hysterosalpingogram) when a person has an allergy to IVP dye?
Yes, an HSG can still be done. Though the dye usually used is an iodine based dye, the procedure can also be done by using a type of dye normally used for MRIs that contain Gadolinium instead of Iodine.
2. With IVF with ICSI, do you choose any sperm to inject or do you get the best looking one before injecting into the egg?
During the process of ICSI, the embryologist starts by choosing a sperm that is very motile (moving). Most sperm that are significantly deformed aren’t as active. A needle is then used to cut or break the tail of the sperm so that it can be carefully loaded into the needle. This allows a closer look at the sperm as well once the movement stops. Using these techniques, allows us to achieve a very high fertilization rate.
3. In the state of Florida, does a gestational carrier have any legal rights to keep the baby?
One important aspects of third party reproduction, such as using a donor, surrogate, or gestational carrier is having a valid legal contract in place that has been created by lawyers familiar with the process. This routinely addresses the issue of later legal rights, and is clearly laid out in the contract. However, if this part were to be omitted, the carrier could have some legal bearing.
4. How many appointments can we expect for IVF from start to finish?
Once the initial consultation with the physician is performed, the next step is to schedule an appointment in which a “SonoHSG” is performed. This is a special ultrasound which allows us to clearly see that there are not any abnormalities in the uterine cavity that could interfere with the process. A “trial transfer” is also performed at the same time, which takes a measurement of the uterine depth, and ensures that a catheter can be easily placed in to the uterus. On the same day, you will have a consultation with one of our IVF nurses who will lay out the entire process with you, give you a schedule of all the steps, and order your medications. Once you are ready to start the ovarian stimulation, this usually involves between 4-5 ultrasounds to monitor your progress. After that, there is the day of the retrieval, the day of the embryo transfer (3 or 5 days later), and then the scheduled pregnancy test (usually 14-16 days after the retrieval). So in all, there would be about 10 visits for the average IVF cycle.
5. How long does it take from start to finish for an IVF cycle?
Most patients will initiate the IVF process by starting on a birth control pill. This is used to limit any interference that your natural cycle could have on the IVF cycle. This lasts for 3 weeks, at which time the stimulation phase begins, which lasts about 14 days until egg retrieval. A pregnancy test is performed approximately 2 week after egg retrieval. Thus, from starting the birth control pill to a pregnancy test takes approximately 7 weeks.
6. How do you test for ovulation and ovarian reserve in a women who has no uterus who would like to use a gestational carrier?
A woman without a uterus still has a hormonal cycle, and ovulates, but determining this timing is slightly more complicated due to the lack of menses which tells us where she is in her cycle. But with ultrasound monitoring and blood work looking at several hormones, we can still get the information needed. Determining ovarian reserve does not require the uterus to be present and is usually performed with assessments such as an AMH hormone level, and an Antral Follicle Count (AFC), which is determined by ultrasound.
7. How does PCOS affect fertility?
One of the hallmarks of PCOS is the lack of regular ovulation. This can be resolved through the use of medications (oral pills or injectable hormones). However, even once ovuation is established, patients with PCOS still have slightly lower conception rates and slightly higher miscarriage rates than those women without PCOS. The exact cause of this has not been clearly established, though excess androgens or the insulin resistance may play a role. The use of metformin in women who are trying to conceive has been associated with some improvement in pregnancy rates, and decrease in miscarriage rates, though this still does not result in full normalization of pregnancy rates.
8. What monitoring should I have when on a clomid/femara- IUI cycle?
There are several options for monitoring in this situation. Many times, patients may not be regularly ovualating, and in those cases, using an ultrasound to monitor for follicle development is usually the best choice. If a woman has been confirmed to ovulate, and can reliably detect her LH surge with an ovulation predictor kit, then that can be used to time the insemination. However, ovulation predictor kits can be frustrating to use for many women. If they work, then they can be successfully used, however, about 25% or more of women who are known to be ovulating won’t be able to detect the LH surge.
9. How many eggs/follicles do you like to see with a patient on clomid or femara?
The goal of oral ovulation therapy is obviously to induce ovulation. The number of mature follicles seen may vary among patients but usually is 1-2 for most patients. Studies have looked at pregnancy rates in comparison to the number of follicles developed, and with oral medications, it has been found to not be affected by whether there is 1, 2, or 3 follicles developed.
10. How many IUI cycles should you have before considering IVF?
We always try to use our experience and knowledge to help a patient conceive with the easiest, least invasive, and most economical method possible. Doing IUIs (intrauterine inseminations) is recommended for many different reasons as a first line therapy prior to going to IVF. It is difficult to judge exactly when a patient should go to IVF, but we have to take many factors into consideration, such as patient age, prior history, and infertility issues. In most cases, it is felt that most women who will conceive with a given therapy will likely do so in the first 3-4 months. Once a person approaches this time frame, it is logical to start making future plans and weigh options such as continuing with the current therapy vs progressing to IVF. For women who are older, we often encourage this transition earlier, as pregnancy rates continue to decline with age. Younger women have more flexibility in this aspect. There are many more factors to take into consideration, but in general, we will start to bring up the subject on the 2nd or 3rd cycle in order to have a future plan laid out that would best achieve the goal of having a baby.
11. How often can an HSG be performed, and is it recommended to keep the tubes open for conception?
We don’t recommend repeating an HSG unless something has changed recently, such as a pelvic infection, ectopic pregnancy, or other situations which could have caused scar tissue damage to the tubes. Pregnancy rates have been suggested to be slightly higher following an HSG, but there is not any role for repeating the test.
12. How important is sperm morphology in the setting of a good sperm count?
Criteria for what constitutes a “normal” sperm morphology percentage has changed in recent years, with criteria becoming more strict. Isolated cases of low morphology, with otherwise good counts are less troubling than having multiple abnormalities. Trying inseminations is a first line therapy, which may help in these cases, as a lot of the abnormal sperm are washed out in the preparation process, thus likely increasing the percentage of good sperm. With a good overall sperm number, even if the percentage of normal sperm is low, you will ultimately have a reasonable number of good sperm. To summarize, a small percentage of a big number is still a pretty big number. But if overall sperm numbers are low, and morphology is low, then conception rates may not be as good. But the primary numbers that we look at to judge conception chances for inseminations are still the total motile sperm count, which is calculated from the volume, total count, and percent moving. This has always had the highest predictive ability for predicting the chance of conceiving with inseminations.
13. Are egg donors from the same city?
Because of the close monitoring needed for egg donors, nearly all of our anonymous donors come from the greater Jacksonville area. We choose to limit the number of times that one person can donate to a total of four. There are no specific scientific reasons on limits in this area, but we feel that it is a reasonable limit. Many donors are split between two recipients. It is hard to estimate the number of children from each donor, but that number is likely to be a maximum of 6-8 from one donor who has donated the maximum number of foiur times.
14. How is the use of Testosterone (Testim, Androgel, etc) affecting sperm production?
I was asked this question by several people after the seminar in response to my comments during my male fertility lecture. The number of men that are treated with testosterone replacement continues to rise. The physician prescribing this may be a primary care physician or a urologist. Often they do not ask, or do not know to ask on plans for conception. The use of testosterone in any form (patch, gel, or injection) is associated with a rapid shut down of sperm production. This fact may not be known by all primary care physicians, but is known by all urologists. In most cases, this is reversible, but it can be expected to take 4-6 months to fully recover sperm counts. Men who are being treated with testosterone and wish to conceive should be evaluated by a reproductive physician. There are measures that can be taken to help get sperm production started back, but an endocrine evaluation is often necessary to look into reasons as to what may be affecting the normal testosterone production (the reason the medication was started in the first place).
15. Do you recommend an endometrial biopsy before an IVF cycle to theoretically increase the chance of successful implantation of an embryo?
This is a new area of interest in which I have participated in the past. It has been found by small studies that disrupting the endometrium before or during an IVF cycle may help to improve implantation rates. This injury stimulates the production of many chemicals and repairing mechanisms in the endometrium. There are several ways to cause an injury, but most usually would be by endometrial biopsy. I offer this procedure to my patients who have had otherwise unexplained implantation failures. However, because this procedure is painful, and not tolerated well by many patients, I do not think that it is justified in every IVF cycle. Hopefully future studies will help us determine the best way in which to do this procedure and what patients would benefit the most from it.
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.
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.