Posts

21
Jan

IUI with Clomiphene, a First Line Treatment for Infertility

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This information is provided for couples who may just be starting out in fertility treatments and are trying to conceive using IUI with clomiphene. CNY Fertility Centers provide infertility services including low cost IVF (In Vitro Fertilization) for couples who are starting or continuing their families in Albany, New York, Rochester New York and Syracuse, NY. In addition to our local services we work with patients from across the country and world offering affordable IVF and fertility treatments.

Unexplained infertility is when a couple can’t conceive although the woman is ovulating, and her fallopian tubes, uterus and partner’s semen results come back normal after testing. Some of the women have had endometriosis diagnosed and treated, thus are not truly unexplained, but do fit into this category in terms of an approach for treatment.

Clomiphene is inexpensive, and acts in women who already ovulate to stimulate production of several eggs during a treatment cycle. Clomiphene causes the brain to misinterpret blood estrogen levels. This induces the pituitary gland to produce a surge of the follicle stimulating hormone or FSH. The result is the production of more than usual numbers of follicles, each with one egg.  Intrauterine insemination (IUI) places more sperm into the uterus and then the fallopian tubes than could ever reach through intercourse. Thus more bullets are shooting at more targets.

The combined use of clomiphene and IUI has been shown to nearly double the results compared to using clomiphene alone to improve pregnancy likelihood (Guzick, 1998). The master student of IUI, Dr Richard Dickey and colleagues in 2002 compiled a large series in New Orleans and reported almost 10% success per cycle.

The distinguished Boston IVF group in a study led by Dr. Alan Penzias recently confirmed a cycle success rate of 11.5% (Dovey, 2008) from over 4000 cycles of treatment. The patients were ovulatory and some of the men had low sperm counts.  The success of treatments cumulatively over up to four cycles, was successful in 24% of patients under age 35. Age specific pregnancy rates per cycle ranges from 12% under age 35 to 4% over age 40. Corresponding decreases in overall success were seen according to age. Only one patient was successful (1.8%) of the 55 women treated over 43 years of age.

The study verified findings by others who found that 90% of success is found in three or four cycles. Those who are not pregnant by then should move to gonadotropin and IUI or IVF therapy.

At RBA in Atlanta, Dr Massey and colleagues found that the addition of a chemical called PAF to the sperm wash dramatically improved success rates (Roudebush 2004) to nearly double those without it. This is a reasonably simple method which more clinicians might use.

Those who are concerned with cost effective treatment for infertility continue to believe that clomiphene and IUI are a good treatment for younger patients who are trying to conceive, and fit the criteria outlined.

Selected References
Dovey S et al Fertil Steril 2008:90:2281-86
Guzick, DS et al Fertil Steril 1998;70:207-13
Dickey RP et al Fertil Steril 2002;78:1088-95
Roudebush WE et al Fertil Steril 2004;82:52-56

25
Nov

The high cost of increasing age and FSH in IVF treatment

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This article is provided for patients who are trying to conceive and have concerns regarding the potential cost- effectiveness of IVF. It is written for patients who have an understanding of the basic concepts being discussed. For explanation of the significance of FSH values, please see articles on this website on IVF and prognosis, and low response. At CNY Fertility Centers, access to care is a concern addressed by offering low cost IVF options in Syracuse, New York, Rochester NY and Albany NY.

The age of a woman who is trying to get pregnant with IVF and her ovarian reserve as reflected in day 3 FSH values are good predictors of IVF outcomes. Henne and colleagues at Walter Reed Hospital and the NIH evaluated 1238 first IVF cycles of women between age 26 and 42 years and an FSH level of <13 miu/ml.  A cost analysis was applied and focused on these patients who by normal standard were good prognosis. Patients need to understand that statistics for overall success even with a specific age group may not apply if the FSH is higher than 12 as results would be even worse. At a cost of $10,803 per cycle costs soared to over $100,000 per baby born as FSH and age of the patient increased over age 38-39.
This is not surprising as Voorhis had estimated cost per baby of $89,981 for patients over 38. Trad calculated the cost to be about $75,000. Neumann, who used very low success rates estimated that in low prognosis patients, costs per baby could be as high as $800,000.

For comparison and for patients concerned about the high cost of donor egg treatment the delivery rates of the alternative must be considered. At a cost of $25,000 per cycle, and delivery rate of 51%, the cost per baby is $49,000. These costs will be dropping rapidly as egg banking becomes widely available. As a woman’s predicted delivery rate falls below 10%, the donor egg option becomes favored treatment economically. CNY Fertility Center offers multiple options to make IVF and donor eggs more affordable including a refund program for IVF and donor egg IVF, 0% financing, six cycle discount program, and Fall IVF specials.

References:
Henne, MB et al The combined effect of age and basal FSH on the cost of live birth at assisted reproductive technology Fertil Steril 2008; 89:104-10.
Neumann, PJ Johanesson M The willingness to pay for in vitro fertilization: a pilot study using contingent valuation. Med Care 1994; 32: 686-99.
Trad, FS et al In vitro fertilization: a cost effective alternative for infertile couples? J Assist Reprod Genet 1995; 12 418-21.
Van Voorhis BJ et al. Cost effectiveness of infertility treatments. Fertil Steril 1997; 67:830-6

12
Nov

IVF and Antral Follicle Count

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This information is provided for patients interested in their prognosis for infertility treatment. CNY Fertility Center in Syracuse NY, Albany, NY and Rochester, NY provide consultations, and treatments for couples trying to conceive.
The number of follicles, each containing one egg, which are available in the ovarian pool relates to the chance of success of In Vitro Fertilization (IVF). These numbers decline with age, and in some women decline abnormally fast. For couples who are trying to conceive and their care givers, methods of predicting the potential outcome of IVF can be important in making medical decisions.

One important tool for measuring the ovarian pool is a direct measure of the follicles as they emerge in a given month. The number of small follicles in the ovary during a menstrual period are observed using ultrasound. At this point there are no large follicles, and the pool of follicles which will emerge that month are beginning to grow. As the fluid accumulates, even a few milliliters (a teaspoonful is 5 ml) of fluid in the antral follicle can produce a measurable echo on the highly sensitive ultrasound machines used for transvaginal evaluation of the ovaries. Follicles between 2 and 5 mm can be visualized and counted. The antral follicle count (AFC) must be done when the follicles have not begun to grow. Thus it is scheduled day 2, 3 or 4 of the cycle prior to considering IUI or IVF therapy. Since there is not a huge variation from month to month, this test can give a good idea of the prognosis for the future.
antral follicle
Antral Follicle from www.DKImages.com
antral follicle ultrasound
Ultrasound image of antral follicles from www.healthline.com
Because not all of the follicles can be visualized , after stimulation by clomiphene or injectable gonadotropins, the number of follicles which eventually develop may be higher that the number of antral follicles in that particular cycle.

In a review of studies, Verkagen has concluded that the AFC is as good as any of the biochemical tests to determine ovarian reserve. In IVF treatment, if the AFC is less than 4, there is a much lower rate of successful pregnancies. Since this cut off is so low, this limits the value of the test. How high can it go? Egg donors or young infertility patients might have an antral follicle count of 17 or more. The typical mid-30 year old infertility patient will have 5-10 antral follicles. Sometimes in women with low ovarian reserve it is tempting to try to find a cycle with more antral follicles in order to get a slightly better result. However, there is low variability of the AFC from month to month (Jayaprakasan 2008) so waiting for another month is not likely to change much.

More indirect biomarkers of ovarian reserve include serum FSH, day 3 estradiol levels, inhibin B and anti-Mullarian hormone. These tests of ovarian reserve are covered in the section on IVF prognosis on this web site. In practice all available information is used for prognosis. Thus, the AFC is used in conjunction with the indirect tests of ovarian reserve.
For additional information and opportunities to get involved in infertility chat rooms, visit CNY Fertility Center’s patient discussion forums for medical questions or support.

Selected References
Verkagen et al Fertil Steril 2008
Jayaprakasan, K et al. Establishing the intercycle variability of ultrasonographic predictors of ovarian reserve. Fertil Steril 2008;90:2126-2151.
Edited by JBM on 9-26-09

IVF and antral follicle count.

This information is provided for patients interested in their prognosis for infertility treatment. CNY Fertility Center in Syracuse NY, Albany, NY and Rochester, NY provide consultations, and treatments for couples trying to conceive. For a glossary of terms please refer to www.fertilitylifelines.com

The number of follicles, each containing one egg, which are available in the ovarian pool relates to the chance of success of in vitro fertilization (IVF). These numbers decline with age, and in some women decline abnormally fast. For couples who are trying to conceive and their care givers, methods of predicting the potential outcome of IVF can be important in making medical decisions.

One important tool for measuring the ovarian pool is a direct measure of the follicles as they emerge in a given month. The number of small follicles in the ovary during a menstrual period are observed using ultrasound. At this point there are no large follicles, and the pool of follicles which will emerge that month are beginning to grow. As the fluid accumulates, even a few milliliters (a teaspoonful is 5 ml) of fluid in the antral follicle can produce a measurable echo on the highly sensitive ultrasound machines used for transvaginal evaluation of the ovaries. Follicles between 2 and 5 mm can be visualized and counted. The antral follicle count (AFC) must be done when the follicles have not begun to grow. Thus it is scheduled day 2, 3 or 4 of the cycle prior to considering IUI or IVF therapy. Since there is not a huge variation from month to month, this test can give a good idea of the prognosis for the future.

secondaryFollicle-thumb.jpg

Antral Follicle from www.DKImages.com

antral healthline .com

Ultrasound image of antral follicles from www.healthline.com

Because not all of the follicles can be visualized , after stimulation by clomiphene or injectable gonadotropins, the number of follicles which eventually develop may be higher that the number of antral follicles in that particular cycle.

In a review of studies, Verkagen has concluded that the AFC is as good as any of the biochemical tests to determine ovarian reserve. In IVF treatment, if the AFC is less than 4, there is a much lower rate of successful pregnancies. Since this cut off is so low, this limits the value of the test. How high can it go? Egg donors or young infertility patients might have an antral follicle count of 17 or more. The typical mid-30 year old infertility patient will have 5-10 antral follicles. Sometimes in women with low ovarian reserve it is tempting to try to find a cycle with more antral follicles in order to get a slightly better result. However there is low variability of the AFC from month to month (Jayaprakasan 2008) so waiting for another month is not likely to change much.

More indirect biomarkers of ovarian reserve include serum FSH, day 3 estradiol levels, inhibin B and anti-Mullarian hormone. These tests of ovarian reserve are covered in the section on IVF prognosis on this web site. In practice all available information is used for prognosis. Thus, the AFC is used in conjunction with the indirect tests of ovarian reserve.

For additional information and opportunities to get involved in infertility chat rooms, visit CNY Fertility Center’s patient discussion forums for medical questions or support.

Selected References

Verkagen et al Fertil Steril 2008

Jayaprakasan, K et al. Establishing the intercycle variability of ultrasonographic predictors of ovarian reserve. Fertil Steril 2008;90:2126-2151.

Edited by JBM on 9-26-09

23
Jun

April's journey to fertility: Week five

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Fertility SymbolApril is a CNY Fertility Center patient and has been on her journey to fertility for approximately two years. April will share candid stories and a unique perspective on the fertility challenges many women and couples face.

Week five: The right path for us

In examining our approach to becoming parents, we knew that making an appointment with another fertility specialist was an absolute necessity. After unsuccessfully going through multiple IUI cycles, we were at a loss as to what the next best step was, but felt that consulting with CNY Fertility Center might offer a different perspective.  Fortunately, our consultation with Dr. Kiltz was helpful and refreshing. During the hour long visit, Dr. Kiltz did not focus solely on my cycle or my husband’s sperm count. Instead, he focused on the fact that the possibility of our becoming parents was far more likely to happen than not and that our journey to parenthood had to involve what was best for us. We left the appointment feeling relieved for numerous reasons. First, we had a doctor who was listening to us and trying to thoroughly address our emotional and physical needs. Secondly, we left with a short term plan which included a series of different blood tests, continuing alternative treatments (acupuncture, massage, herbal remedies, etc.), initiating lifestyle changes (daily gratitude lists, meditating, yoga, etc.) and my undergoing a laparoscopy and hysteroscopy surgery.
I remember believing that surgery was the next best step. When there is no explanation for what is wrong with you, when your husband’s “numbers” are fantastic, and you have failed many assisted cycles, all you want is an answer (other than a baby, that is!). I felt that the surgery might offer some explanation. I knew it would be an invasive procedure, but that it only required small incisions (as long as there were no significant issues with my reproductive organs) and that this exploratory operation could be productive, depending on what the doctor found. The closer surgery date became, the more I knew that the doctor was going to find something that would provide an explanation for us. I do not know how I knew – call it intuition or call it coincidence, but I just knew.  The first question I asked when I awoke from surgery was, “Did he find anything?” The nurse, who was phenomenal in terms of meeting my post-surgery needs, stated that I had a “spattering of things going on,” and explained that the doctor removed endometriosis, scar tissue and a fibroid. I remember silently thanking God and smiling because I felt as if we now had several more puzzle pieces to lay into place.
I feel so much more hopeful now that we are working with a fertility center that meets our needs a bit more personally. My post-surgery follow-up visit was about 45 minutes and we discussed the likelihood of achieving pregnancy and exactly what my chances of conception look like at this point (not too bad, I might add!).  After discussing how my husband and I could continue to stay positive and spiritually “intact,” we decided to simply relax until my two month follow-up, at which point we would discuss our overall “fertility plan” with the doctor. As of today, our plan is in rough draft form and developing our plan has been an emotional process, but I am determined to become a mother, and I have to be able to ask the tough questions and seek out the necessary answers.
My intention for you this week is that you would begin to ask yourself some of the tough questions and consider what resources you have that will assist you in best developing your own plan. I promise to discuss our plan more elaborately next week. Until then, keep persevering.
Miracles and blessings,
April all Year
Below are links to April’s past articles in case you missed any of them:
Week four: Our fertility treatment “break”
Week three: Deliberate choices
Week two: This moment
Week one: My story

16
Jun

April's journey to fertility: Week four

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Fertility SymbolApril is a CNY Fertility Center patient and has been on her journey to fertility for approximately two years. April will share candid stories and a unique perspective on the fertility challenges many women and couples face.
Week four:  Our fertility treatment “break”
We take a break from different aspects of our lives because something is not working. After our multiple IUI attempts and a discussion about moving onto IVF, I knew that our approach to becoming parents was simply not working. As a result, we decided to take a break from western fertility treatments. I spoke with my acupuncturist about naturally increasing my fertility, and she recommended that I take a series of vitamins and put me on two different types of herbal formulas – one for my follicular phase and one for my  luteal phase. She also recommended I increase my acupuncture treatments from two times a cycle to three times a cycle. During the first month of taking herbal remedies, I ovulated in the middle of my cycle. This was HUGE for me. I had always seemed to ovulate much earlier in my cycle. I was so excited to see progress!
As Heather continued to treat me, we came up with two more additions to my fertility plan: weekly yoga and regular fertility massages. I have to admit I am consistent with my acupuncture and herbs but am not as consistent with yoga classes or massage treatments. Part of the reason for my inconsistency is lack of time and the other is lack of money since fertility treatment can become expensive. Fortunately, CNY offers a package (buy three treatments and the next one is free) that has made paying for treatments more affordable. After pre-paying for a six week session of yoga I decided to pay per class; then if I have to miss a class, I don’t feel as though I have wasted any money.  After tweaking my financial approach, paying for my appointments/classes has become more manageable. Not to mention, I often compare what I pay per month at CNY to what I will be paying for daycare as a working mom and I consistently realize that we just need to carefully budget and deliberately spend money. (Hopefully you realize the connection to last week’s discussion on deliberate choices and thinking.) Read more

9
Jun

April's journey to fertility: Week three

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Fertility SymbolApril is a CNY Fertility Center patient and has been on her journey to fertility for approximately two years. April will share candid stories and a unique perspective on the fertility challenges many women and couples face.
Week three: Deliberate choices
I felt the pressure of an infertility diagnosis creeping upon us long before the one year mark. Our first unsuccessful attempt at conception was such a disappointment; I truly (and perhaps naively) believed I was pregnant after only one attempt at conception. The second month of trying to conceive, I found out my best friend was pregnant with her first child. I was happy for her, but tearfully sad we were not both pregnant. By the third month of trying to conceive, I was in the midst of a major medical work up because I was exhibiting what would quickly be diagnosed as Multiple Sclerosis. As a result of our rather disheartening initial three attempts at conception, I felt that I had to become pregnant sooner rather than later.
I used my recent diagnosis as a means to justify moving more quickly than the average couple through fertility testing. Fear quickly became the driving force behind my decisions. (What if I had a disease flare up that left me disabled? What if one of us was sterile? What if I had already waited too long to conceive? What if we never had a baby?) We put little forethought into what we were doing; instead I simply followed doctors’ orders and allowed myself to mechanically move through the fertility treatment process. I have to admit I never really thought any of the IUIs would work. I wanted them to, but somehow I just knew that we were going to have a long road ahead of us.
Following my sixth and last IUI cycle (it might even have been my seventh – I lost count!), I had a car accident after leaving the doctor’s office. The accident was minor, but the reality check was major. I remember thinking that I just could not run around like that anymore Read more

8
Jun

Creating Your Eastern Medical Team

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art_lotus_A few months ago I felt a lot of pain on my right side.  It felt like every movement made it worse.  I had an ultrasound done at CNY Fertility and they found a large cyst on my right ovary.  Due to the size of the cyst I had the option to have it aspirated, but I was unsure that an aspiration was exactly what I wanted.  Instead I decided to walk over to CNY Healing Arts (www.cnyhealingarts.com) to try and take care of it a bit more naturally.
I gathered my Eastern Medical team as I call them, and went to work on the cyst.  It started with a TON of fluids, took all of my herbs and vitamins from Heather in Rochester, and a bit of a change in my diet, as my Qi (chi) was off.  I also had a couple acupuncture sessions with Donald (he is wonderful!) and yoga with Kim (she is wonderful too!) both from Syracuse.  While this journey was a bit longer and more intensive than having the cyst drained, it was completely fulfilling and satisfying the moment we did another ultrasound and discovered that the cyst was almost completely gone within two weeks.
I’m happy to say my little experiment worked, and the pain was gone.  It took a bit of work, meditation, and some good attention from my favorite practitioners, but it worked.  This is just one of the many stories out there about the benefits of Eastern Medicine and wisdom. Read more

2
Jun

April's journey to fertility: Week two

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Fertility SymbolApril is a CNY Fertility Center patient and has been on her journey to fertility for approximately two years. April will share candid stories and a unique perspective on the fertility challenges many women and couples face.
Week Two: This moment
At some point over the last two years, I have begun to steer away from the drama and fear of infertility. If anyone asked me to pinpoint when I began to embrace all motherhood rather than run from the pregnant women at the grocery store or have a meltdown at the beginning of each menstrual cycle, I would have to attempt articulating how this attitude is a result of my own ability to experience each moment as it is versus how I would rather it be. Somewhere in the past two years, I realized that the amount of time I spend worrying about future events is simply a waste. I cannot afford to fret about those experiences over which I have no control. And, friends, I have no control over when I will become pregnant. That, however, does not mean I am powerless, which is the key difference between envisioning the miracle and trying to plan the miracle. Within me lies the power to be happy, not to necessarily create an opportunity for happiness but to experience happiness within this moment.
However, the question from last week’s blog still remains, how did I get to the point where I was able to help my friend throw the baby shower? I think the answer is this; I have learned too many tough lessons in the last two years not to realize how much I actually do have and to appreciate my many blessings. For example, I have an exceptional husband and, on most days, I am happy and healthy. I live in a time where both infertility and MS have so many possible treatments that success on both fronts is far more likely than not. I have this moment to embrace and in the midst of every moment is an opportunity to simply be happy – whether it is a rainy or sunny day, whether I am pregnant or not. I have often heard that happiness is a choice, a state of mind. I used to think “whatever, try being me.” But with a great deal of emotional work, I have realized that enjoying what is happens to be far more rewarding than wishing about what could be. And although there is no baby yet, she is coming. Somehow, I just know a baby is in my future.  I have to remember that the overall goal isn’t when I become pregnant, or how I become pregnant, but that I become a mother (and I will!). Read more

27
May

Maya Abdominal Massage Case Studies

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Dr. Rob Kiltz’s CNY Healing Arts Center location in Syracuse, NY is currently looking for applicants to participate in Maya Abominal Massage Case Studies. These Massage Sessions are offered at no charge to the participant. Our Maya Abdominal Massage Practitioners, John Capozzi and Erika Lutwin will be running the Case Studies.
Click here to learn what Maya Abdominal Massage is all about and how you can participate in the case studies. Or just call CNY Healing Arts Center at 315.671.5755.

26
May

April's journey to fertility: Week one

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Fertility SymbolApril is a CNY Fertility Center patient and has been on her journey to fertility for approximately two years. April will share candid stories and a unique perspective on the fertility challenges many women and couples face.
My Story:
Patience has never been one of my virtues, but rather a skill I have been learning and re-learning over the years. In my journey to becoming a mother, I have had to readjust my initial plans. Fellow mothers-to-be, I decided that in April of 2007 we would begin trying to conceive so I would have my baby sometime in the spring of 2008. Then I would be able to take the rest of the school year off. (By the way, I am a high school English teacher.) In my head, the plan was perfect. Then the universe, or in my case, God, decided that I still had a few lessons to learn. In June of 2007, I was diagnosed with Multiple Sclerosis.
There were two questions I had for the doctor when he told me I had MS. 1.) Was I going to die early? and 2.) was I going to be able to have children? Here I was, being diagnosed with what can be a disabling and debilitating disease, and the second question out of my mouth was if I could still have children. (The neurologist happily informed me I was not going to die early and that I could safely conceive children.) Oh, friends, once we yearn for a baby there is little else that we are able to consider. In telling you about my initial reactions to my MS diagnosis, I simply want to let you know, that I get it – the feeling that maybe I am not meant to be a mother (what a sad thought), that choked up emotion that surfaces when I hear yet another one of my colleagues is pregnant, the tears that well when I begin another cycle. I have been trying to conceive for a bit over two years and my journey has been a challenging, frightening, and enlightening experience.
Before I finish this week’s blog, I have an intention for you. Is there anything you can do to embrace motherhood –not simply your motherhood, but motherhood in general? For example, I helped my best friend throw a baby shower yesterday. When I was telling my mom, she said that must have been hard for me; but for the first time in approximately two years, attending someone else’s baby shower was not an anxiety inducing event. I did not have to lock myself in the bathroom for any moments of escape nor did I have to give myself a pep talk before the event. Instead, I asked the mother-to-be to rub up against me as many times as she could before she left in hopes that her fertile hormones would rub off on my nearly fertile hormones. I sat with a table full of mothers who were discussing their childbirth stories and did not flinch when another woman asked me if I had any kids. Nor did I begin to tell her all about my fertility woes. A year ago, my response to this question would have been a 20 minute life story synopsis. Instead, I just moved on and focused on their stories because, ladies, one day it is going to be me in that birthing room. How did I get to the point where I am able to embrace others’ fertility? That is a topic for next week. I hope you will continue to follow my story!
Envision the outcome and embrace all motherhood. We will be mothers!
Baby Dust Blessings,
April all Year