Posts

18
Jul

Video: The Process and Role of Embryo Grading

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Dr. Rob Kiltz shares the concept of embryo grading and how the quality has to do with maximizing the outcome for implantation and conception. It’s important to keep in mind that embryos can always change and at one moment an embryo may not look great but that can change several hours later. We continue to develop the best system to provide the best outcomes for our clients at CNY Fertility Center.

If you are interested in an initial fertility consultation either over the phone (if you live out of the NY State region) or in-office, please call our toll-free number at 800.539.9870 or request a consult here.

5
Oct

Endometrial Biopsy MAY Improve Embryo Implantation and IVF Pregnancy Rates

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It’s never easy to reverse a long held opinion. But in order to keep improving what we do, we must be open-minded to change. I remind myself of this perspective whenever I encounter a new study that contradicts a long held belief. Recently, I started reconsidering my skepticism on “scratching” or taking an endometrial biopsy in order to better prepare a woman’s uterus for embryo implantation.
The way I was trained, it was imperative that we perform an embryo transfer without causing any trauma to the endometrial lining. Oftentimes we worked through difficult transfers in order to minimize the risk of getting a spot of blood on the catheter as it was felt to be an ominous sign. Blood on the catheter tip was believed to reduce the chance for successful implantation. Recent studies suggest that in some cases the opposite may be true. Let’s first consider the theory behind this potential benefit.
Following any damage to the endometrial lining, chemicals called cytokines are released which promote healing of the injury. This healing process promotes what is called decidualization which also encourages implantation. Decidualization can also help slow the changes that are occurring in the endometrium—another benefit since the hormone levels associated with IVF can accelerate endometrial growth and therefore make the uterine lining out of synch with the actual embryo development. Whether some or all of these changes are responsible there have been a few studies now that have looked at the impact that inducing an endometrial injury can have upon embryo implantation.
A recent review [r1] of the five published studies on the effects of performing an endometrial biopsy prior to or during and IVF cycle was even more revealing. They found that four of these studies demonstrated that endometrial biopsy significantly improved implantation—suggesting that in some patients it may even double success rates. They also found that the timing of the biopsy was critical. In the one study[r2] that involved performing the biopsy on the day of the egg retrieval, they found a dramatic reduction in the implantation and on-going pregnancy rate; an observation that validates my previous doubts about “scratching” the endometrium. So before you request this treatment consider the following:
*Discuss with your doctor whether you may have had an implantation problem or if your previous unsuccessful cycles were due to poor embryo quality.
*Request this procedure be performed before the menstrual cycle of the month you wish to proceed with IVF (prior to starting ovarian stimulation meds)
*Endometrial biopsy can be uncomfortable so consider the use of an anti-inflammatory about an hour or so before your procedure
[r1]Link to http://www.medscape.com/viewarticle/769316?src=mp
[r2]Link to http://www.medscape.com/medline/abstract/19568761

Robert Greene, MD, FACOG
CNY Fertility Center
e-mail me at rgreene@cnyfertility.com
Call our toll-free number at 800.539.9870 or request a consult here.

11
Aug

Progesterone: Answers to the most frequently asked questions and concerns

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CNY Fertility Center, founded and directed by Dr. Robert J. Kiltz, with offices in Albany, Latham, Syracuse and Rochester, NY offers several different protocols for the treatment of infertility.  All treatments include the administration of a vaginal progesterone for luteal phase support.  Progesterone is necessary to prepare the uterus for implantation of an embryo.  Progesterone is produced by the cells in a follicle after ovulation.  If the embryo does not implant into the uterus, your level of progesterone drops and menstruation begins.  If implantation is successful and pregnancy occurs, about 10-12 weeks into your pregnancy, your placenta takes over and produces high levels of progesterone and continues until your baby is born.  There are many reasons why a client may not produce enough progesterone to support a pregnancy.  Certain medications as well as the aspiration of follicles minimizes the number of progesterone-producing cells, therefore, the supplementation of progesterone is indicated in all types of protocols when assisting reproduction.
At CNY Fertility Center, we use three different types of vaginal progesterone, all which provide support to the endometrial lining and a pregnancy.  Crinone Gel, Endometrin and Prometrium are the commonly used progesterones.  All offer common levels of support and have similar side effects.  Shortly after ovulation/egg retrieval, progesterone support is initiated.  The vaginal progesterones cause very similar side effects and are similar to the effects of premenstrual syndrome (PMS).  Breast tenderness, bloating, nausea, occasional vomiting, mood swings, depressive feelings, and cramping are common side effects.  Many of our clients will look for signs and symptoms of an impending positive pregnancy test and the progesterone support often gives the same symptoms of an early pregnancy.  Vaginal progesterone can also irritate the vagina, much like a yeast infection.  Clients may complain of vaginal itching and discharge.  These are very common side effects and does not necessarily indicate infection.  Some clients may also experience bleeding prior to their pregnancy test.  It is IMPERITIVE that our clients remain on their progesterone support until their pregnancy test.  Often a client who is pregnant may have bleeding early on in pregnancy so it is very important to remain on progesterone support until a blood pregnancy test confirms the outcome.
Once a pregnancy is established, many clients experience cervical irritation from the vaginal progesterone and thus experience bleeding.  This bleeding typically presents as a “gush” of watery blood which, over a period of a few hours to one day, tapers off to a brown spotting.  We encourage our clients to call the office with any bleeding and we will evaluate you in the office, however, be reassured, that in most cases, this is cervical irritation and has no affect on your baby growing in your uterus.  Oral progesterones are available, however, at CNY Fertility Center, we have found that the vaginal route is more effective.  Vaginal progesterone support is a very important step in reaching the goal of a successful pregnancy.
Justine Taylor, RN, BSN
Nurse Manager and IVF Coordinator
jtaylor@cnyfertility.com

11
Sep

Reproductive Dysfunction

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Hi this is Dr. Rob talking about reproductive dysfunction, infertility, the inability to conceive and recurrent pregnancy loss. All these things affect our ability to conceive and deliver a healthy baby.

A 20% delivery rate per month is normal. After one year it may drop down to the 5-10% per month range and after two years it may drop to 1-5% per month range, but it doesn’t drop to zero! Keeping at it, I’m finding, is the key to all of this and I believe that stress, anxiety and fear are some of the major causes of reproductive dysfunction.

I believe in treating the patient as a whole entity, not just treating their reproductive organs. The mind, body and spirit play a huge role in each person’s day to day wellness and quality of life. Incorporating things like yoga, meditation, acupuncture, and maya abdominal massage are some steps from eastern treatments which work toward healing and normal reproductive function. Certainly it’s also important to look at western medical treatments for things such ovulation failure, pelvic adhesions, endometriosis, tubal factors, uterine factors such as uterine fibroids or intrauterine adhesions and diminished ovarian reserve from age factor infertility. All these can all affect egg function and implantation.

Let us not forget the male and sperm factors. There are two important halves to healthy reproductive function, and sexual dysfunction for many of us, can begin with the very basic inability to come together at the right time. There may be an inability to deposit sperm in the right place. There is also the question that if the sperm is properly placed, is the semen of normal count, motility and function?

In reality it all comes down to function, even though everything looks normal, regular cycles every 28 days, a normal hysterosalpingogram that documents that the fallopian tubes are open and the uterus is normal. A semen analysis that documents that there are at least 20 million sperm with 50% motility and the morphology is fantastic and normal. It’s all about the function of our organs (including the brain!), and the gametes. With unexplained factor (idiopathic) infertility there are unknown components preventing conception. It could be a genetic or chromosomal issue, a immunologic factor or a hormonal issue. We can treat these all with eastern and western treatments. We should start with the mind in all of these. With visualizing exactly what we want, we want – a baby, a family. There is an instinctual natural drive for these things. We do harbor fear, anxiety, worry, regret, guilt and judgment. Through yoga, meditation, acupuncture, massage, herbs, support group, connecting positively with other women and sharing stories, often sharing our pain, we can let it go.

I believe that journaling each and every day, a simple five minute journal entry, is helpful. Just write down how you are feeling. Then continue with working on the positive mantras of the day with meditation, which is really important. It can help. Studies by Ali Domar, of the mind body institute at Boston IVF have shown an increased success for patients who included a mind-body-spirit regimen with fertility treatments. Randine Lewis has shown with eastern treatments, significant improvements in outcomes that often do not require shots or pills or surgeries, both for the male and the female.

The fertility evaluation should start with sharing your story with your practitioner, whether it’s a Reproductive Endocrinologist, an OBGYN, family doctor or a Traditional Chinese practitioner. Share your story, or even if it’s with your partner or friend, share your story. There is guidance, there is assistance there.

Some blood work may be important for both the male and female. Patients may benefit from testing hormone levels, looking at immunologic factors, karyotyping and chromosomal factors. Performing a hysterosalpingogram to look at the fallopian tubes and uterine patency can add to the diagnostic picture. A pelvic ultrasound can be performed to look at the uterus, ovaries, ovarian reserve and fibroids. Additionally a laparoscopy and hysteroscopy could be recommended. These are operative procedures to look into the woman’s pelvic organs and uterine cavity. Through these procedures we are able to look for adhesions which may affect the transport of the egg and sperm. Both hysteroscopy and laparoscopy are out patient procedures, often done in the office.
Endometriosis is an infertility factor which we believe is the implantation of the glands from the endometrial cavity, either coming directly out of the fallopian tube or just spontaneously growing on the reproductive organs, causing inflammation and scar tissue and sometimes diminishing ovarian reserve. Via the laparoscopy, endometriosis and adhesions can be removed and increase a couple’s odds of delivering a baby.

It may be that the cycles are regular, the fallopian tubes are open and the semen analysis is normal. It may be as simple as trying a few timed clomiphene citrate cycles with intrauterine insemination, which will bump your delivery rate from about 1-5% per cycle to 5-10% per cycle. There are some side effects from medications. Clomid has an anti-estrogenic effect and can often cause some emotional upheaval, some depression, anxiety, PMS type symptoms, or premenstrual syndrome.

There are many options available to couples experiencing infertility, both invasive and non-invasive, Eastern and Western, and each offers some benefit to the patient guiding them closer to parenthood. I believe that doing something is always better than doing nothing, especially when trying to create a family. For more information about any of our services you can call CNY Fertility Center and CNY Healing Arts and speak with our highly knowledgeable staff.
Have a spectacular day!
Dr. Rob