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Embryo Banking

Good Day to All,

Today I’d like to talk about embryo banking, which means storing as many embryos as you can for later use. It’s a topic that comes up every day in my practice and on the surface it makes sense, just as egg freezing makes sense for the young and unattached.   The typical scenario is of a woman who is committed to a partner or has identified a donor, who wants to become pregnant now, but is concerned, due to her age, that she will not be able to become pregnant again when she wishes a second or even a third. She may be also concerned that if she does become pregnant and has a miscarriage, she will be similarly be placed at a disadvantage due to the loss of time and the advancement of age.   She therefore packs away as many embryos as she can, possibly after preimplantation genetic screening, and is limited only by her tolerance to the IVF process and, of course, finances.

Does this sound like a good idea? Yes, it’s an outstanding idea; it’s proactive, realistic and optimistic. But, it comes with a number of down sides. Is it really worth the trouble? All of us fertility doctors have charts and graphs blaring out the chances of pregnancy based on age, but those are just averages. We can’t know for sure who will and will not have a baby now or 2 years down the road. And what about all women over 35 who are thinking of becoming pregnant on their own, should I seek them out on First Avenue and scream, “Wait, you’re making a big mistake, come in and bank your embryos!”?

While I consider IVF to be one of the true miracles of modern medicine, its effects on a patients psyche is one of medicine’s scourges. On average, things seem to work out wonderfully for most involved, but individually it can be frustrating, disappointing, exhausting; the list goes on. Some who intend to bank are confronted with low egg production or poor embryo development or genetically abnormal embryos or a combination of these all leaving nothing to save. Granted, some would rather know these things sooner rather than later, and are strong enough to consider other options and move on, but some do not appreciate being thrust into a hole, left with uncertainty in their ability to even naturally conceive.

And then there is the cost; embarking on such a process without insurance coverage is a considerable commitment; having coverage is an enviable luxury.

Summarizing, banking could be a smart play. However for many, the negatives may outweigh the positives.  

Dr. Licciardi

New to Infertility

Hello Everyone,

As the years have gone by, I have very much enjoyed explaining the fertility treatment in a way that is a little more detailed and hopefully more clear than what you might be getting at your doctors office or from other infertility web sites.

The first blogs were more of a “basic training” in infertility, and with time the posts have become more focused on more complex elements of diagnosis and treatment.

The next few blogs will go back to more basic information for those who are new to the infertility world and need a starting point.  Certainly, all of the posts are available for reference.  Here you are with todays entry.

 

Infertility: The Basics

Infertility is a disease, and as with most diseases, nearly all suffers never thought they would be the ones afflicted.  Becoming pregnant is natural, necessary for us all to continue, and it doesn’t make much sense that barriers to conception could exist.  Unfortunately, some if us are indeed sub-fertile or even infertile.  In some cases there have been indications along the way that a woman or man may have trouble conceiving, maybe due to treatment of other medical or surgical conditions, but for most people, finding out that pregnancy has become evasive is troubling news.  The bright side is that significant advances in infertility care have rendered more people fertile than ever before.

I will first establish a few definitions.  I don’t like to spend too much time categorizing patients because it can lead to depersonalization, but you may encounter some of these terms, so here are a few.

 Infertility: the inability to conceive after one year of actively trying. This should be modified in women over the age of 35 to 6 months of trying.  Age is a very sensitive subject: no one wants to be told they are older or not be enthusiastically treated due to age, but age matters, as we will discus in a later blog.

Primary infertility: infertile and never pregnant.

Secondary Infertility: infertile after being pregnant in the past.

So if you have been trying for 6-12 months with no pregnancy, what is your next step?  It’s time to see a doctor. The workup is very simple, and who knows, there may be something discovered that is very easy to remedy that can quickly fix the problem.  Some people are worried about seeing a doctor because they have heard or read misinformation about the diagnosis and treatment options, but you owe it to yourself to at least find out what the problem may be.  Plus a good infertility doctor will explain many things to you about natural and assisted conception; this is valuable information that you should get from an expert.  Alternative educational sources can be excellent (like this website), but having a single experienced resource put everything together will help you make the best decisions.

What does the doctor do to determine what the problem may be?  The testing phase is not very complicated.  There are 3 initial tests.

1)   The hysterogram (the long word is the hysterosalpingogram, also abbreviated HSG). This is an x-ray test to confirm that the fallopian tubes are open. In order for pregnancy to occur, the egg has to make it from the ovary in to the tube, and then pass through the tube into the uterus.  And, the sperm needs to swim up from the uterus into the tube.  Thus, blockage of the tube does not allow for pregnancy to initiate.  The HSG also confirms that the shape of the uterus is normal. Previous uterine surgery can alter the shape. Also, some women are born with an abnormal shape to their uterus, which at times can be corrected.  Some doctors perform alternatives to the HSG, but others believe it is the best test to confirm normal anatomy.

2)   The Semen Analysis.  This is where the sperm is counted and checked for motility (movement) and morphology (sperm shape). If the counts or motility are low, the male partner may be referred to a urologist who can develop a treatment strategy.

3)   Analysis of ovarian reserve. All women lose eggs as they age, and unfortunately, even some very young women are left with a low or absent egg number.  The lower the egg reserve, the more difficult pregnancy becomes. To test for a diminished ovarian reserve you may be asked to have a blood test in day 2 or day 3 of your cycle for the hormones FSH, Estradiol and AMH (more on this in the next blog).

Once all of these tests are performed, your doctor can help you formulate a plan. There are many options available, your doctor will work with you to develop a course of action that is best for you.

Thank you for reading and I look forward to writing again soon,

Dr. Licciardi

New Updated Video: Uterine Septum

Dear Readers,

Yes, it has been quite a while since I’ve written. I hope you all have been well and I am excited to return to the blog sphere. It’s not that I have been slacking; I have been writing extensively in other areas, but I do miss the blog so it’s good to be back.
The attached link is to a patient education piece that I produced on uterine septums, which was accepted and presented at the latest meeting of the American Society of Reproductive Medicine. I am very pleased with this final version and I hope some of you find it helpful.

Patient Education: Uterine Septum Video

More to come!

Frederick Licciardi, M.D.
Professor OGBYN
NYU Langone Medical Center

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AMH (Anti-Mullerian Hormone)

Hello to all. In this blog I will review the usefulness of Anti-Mullerian Hormone, otherwise referred to as AMH.  AMH is one of the hormones, along with estrogen and a few others, produced by the ovary.

Like estrogen, AMH is produced by the granulosa cells. The granulosa cells are the small cells that surround each egg.  These small cells are tightly attached to egg surface whereby they help to vitalize and, when the time is right, mature the egg.   This egg-granulosa cell unit is called the follicle.

No one yet knows what the function of ovarian AMH in females.  AMH is present in males, and we know that it has a very important role in the development of normal male sexual anatomy.  What we do know about AMH in females is that the more healthy follicles one has, the higher the AMH levels.

Measurement of AMH levels can help us predict a woman’s fertility, in a very general way.  We already said that estrogen is also produced by the granulosa cells, so why wouldn’t we just need to measure estrogen levels to find out about ovarian health?  Because estrogen only comes from follicle at a time; the one that is in the process of ovulation. A woman may have 100,000 follicles, but on most cases only one per month gets involved in ovulation and becomes an estrogen producer.   Follicles may make different amount of estrogen each month, so judging fertility based on an estrogen test is not helpful.

Many follicles at one time, however, are producing AMH. Now it’s not every follicle, but it is a large number.  It works like this. The ovary contains different follicles in different stages of maturity.  Here is a microscopic view of the ovary.

 

Some follicles are very immature and have few granulosa cells; just one layer surrounding the egg.   Some follicles are more mature and their granulosa cells have multiplied into more cells in multiple layers.  These are the ones producing the most AMH.  In general, if you have a lot of eggs, you have plenty of follicles in all of the stages of development, giving you higher AMH levels.  Lower AMH levels mean fewer follicles of all types.

Follicles are always making AMH therefore levels can be measured any day in the cycle. In fact, it does not matter if a woman is on oral contraceptives, AMH is still produced and can be measured.

AMH may turn out to be and excellent way to measure a woman’s fertility potential, but we are not quite there yet. We do know that a high AMH is good and a low AMH is bad. What’s a good high level? We are still not sure. We know a little.  Any level over 2 is really not bad at all. Certainly, higher than 2 is better still. We know that undetectable levels, less than 0.16, are bad.  But, we have had women with these low levels become pregnant.  The odds of pregnancy are much worse for women with low levels, but people frequently get pregnant with low odds.  Some women have asked me if the level can be too high.  High levels may indicate the presence of polycystic ovaries (ovaries with an above average number of follicles).  While it is true that some women with polycystic ovaries have trouble conceiving, a high AMH level is not the issue.

Recent studies (one was in the headlines a few weeks ago) have used AMH levels to predict IVF outcome.  But again, really high levels were shown to be good and really low levels bad, but overall, not predictive enough to tell someone they can or can not get pregnant.

What we typically do is to put all of the information we have together to estimate ovarian health.  If we use age, FSH levels, AMH, antral follicle counts, the prognosis becomes a bit more clear, but the system is still not perfect.

AMH testing will become more useful sometime soon. More and more women need to have the test done do we can compare levels to outcomes on a large scale. In addition the laboratories need to get better at the testing.  But once we get better with AMH levels, we may be able to do some very important things.

For instance, some studies have been done comparing AMH levels to the time of menopause. Again, not ready for prime time, but the concept may be very important.  What if we could measure AMH in a young woman and determine at what age she will start losing her fertility? Or at what age will she lose half her fertility? What if we could measure AMH levels in a woman destined for chemotherapy and determine if she should freeze her eggs first?

These would all be wonderful uses of this test and it may be that in the future we could reach these goals.

It’s more likely that newer tests will be developed to improve ability to predict.  As alluded to before, combination tests may be more accurate. For example labs are starting to market “fertility profiles” based on AMH, FSH, inhibin and other hormones.

But in the end, like in all of medicine, the genetic tests will dominate.  Scientists are looking for a gene or groups of genes that control the fertile lifespan of women.  As genetic testing becomes less expensive and as we increase our ability to look at more and more genes at one time, the goal of accurately determining a woman’s ovarian age and potential will be reached.

 

Thanks for reading and please don’t forget to read the disclaimer from 5.17.06

 

Dr. Licciardi

 

Important Final Words on Pre-Implantation Genetic Diagnosis

These past few blogs covering PGD raise a few important issues. There are some well-know fertility centers that are really pushing TE biopsy. The feeling is that the technology has finally become accurate and safe enough.  It may be that doing IVF with PGD leads to a higher pregnancy rate and a lower miscarriage rate.  Plus, if you know you are getting a normal embryo, we can transfer fewer embryos, lowering the rates of twins and triplets.

This all sounds good, however, I think we need just a little more time, but maybe not much more.  In a good center, the pregnancy rate for a woman under 37 years of age is 40-50% without PGD.  PGD adds an invasive procedure. The shell of then embryo has to be opened, usually by a laser beam, then some of the embryo, even if it’s a small piece, has to be chopped away.  We make it sound simple, and so far it seems safe, but no one should promise you all of the safety data is in.  Not to mention the additional costs, which could vary from program to program, but $6,000 is a safe estimate.

In theory, ideally, PGD will be the way to go and everyone doing IVF will have their embryos tested, the pregnancy rates will go up, miscarriage rates will go down and we will say goodbye to IVF twins.   And if the system works really well, in the end this will save money because people will need fewer IVF cycles for success (not to mention the drug cost savings if fewer cycles are needed).

Encouraging news concerning PGD is coming out of the data on miscarriage. Good PGD does decrease the rate of miscarriage. A very high percentage of miscarriages are caused by aneuploidy, which means an abnormality in the number of chromosomes present in the embryo. Just one example of aneuploidy is Down’s syndrome, which is the result of an extra chromosome 21 (also called trisomy 21).  The bulk of PGD is performed looking for aneuploidy.

The reduction of miscarriage rates after PGD has 2 important implications. One is that preventing a woman from having a miscarriage is obviously a welcome idea, as the emotional toll of pregnancy loss is significant. The second is that miscarriage takes time.  While many miscarriages occur early, many women do not suffer their loss until 7-10 weeks, later if the fetus survives to the CVS (10 weeks) or amnio (17 weeks).  When you add in the recovery time of 1-2 months before a woman can try again post-miscarriage, the total time lost could be 2-4 months. This is especially difficult in an older woman whose reproductive time is already limited.

One shortcoming of this technology is that this new method of testing requires a blastocyst. Many IVF programs are still not comfortable growing their embryos to blastocyst; they prefer transferring their embryos on day 3.  These programs will not be able to provide these new services until they become very good a growing embryos out to day 5, which for some clinics could take a very long time.

Lastly, not everyone who wants PGD is a candidate for PGD.  The group that may benefit the best from a PGD cycle is those who are above the average age for reproduction. However in this group, egg production is lower, as is the rate of good (biopsyable) blastocyst formation. So there may be the intention for PGD at cycle start, but if the egg number or embryos quality is low, the option for PGD in that cycle may be lost. Straight IVF may or may not still be a viable option, but at times even those are not possible.  I try to be positive to the end, but it is always necessary to cover all eventualities.

 

Well, that’s quite a bit about PGD. Thanks very much for reading.

Don’t forget to read the disclaimer from 5.17.06.

Dr. Licciardi

References:

  • Braude P. Preimplantation diagnosis for genetic susceptibility. N Engl J Med 2006; 355(6):541-3.
  • Gutiérrez-Mateo C., Colls P., Sánchez-García J., Escudero T., Prates R., Wells D., Munné S. Validation of microarray comparative genomic hybridization for comprehensive chromosome analysis of embryos. Fertil Steril. 2011; 95: 953-958.
  • Twisk M, Mastenbroek S, van Wely M, Heineman MJ, Van der Veen F, Repping S. Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2006; 25(1):CD005291.
  • Munne S, Fischer J, Warner A, Chen S, Zouves C, Cohen J, Referring Centers PGD Group. Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study. Fertil Steril. 2006; 85(2):326-32.

 

 

Trends in Pre-implantation Genetic Diagnosis

So what are the new developments increasing interest in PGD?

 

The first is that there is more laboratory expertise on growing the embryos to blastocysts (see blog on blastocyst). These are embryos that have grown not 3, but 5 days in the lab.  As the embryo grows with time, the total number of cells increases from 6-8 to 30-60. Because the cell number is much higher, we can more safely remove more than on cell, maybe 3-5 cells. All of that extra DNA helps us reach much more accurate results.

 

The second has to do with the way we test the DNA.  The DNA amplification techniques have improved, as have the techniques for identifying important areas in the DNA.

 

An advantage of blastocyst biopsy is that in a good blastocyst, we can tell by looking which cells will be the embryo (the inner cell mass) and which will be the placenta (the trophectoderm- thus the term trophectoderm biopsy, also called TE biopsy for short).  Naturally, at the time of the biopsy, it is the placental cells we take as not to interfere with the fetal cells. Taking a few extra cells from the placenta is much less harmful than taking cells needed for the fetus.

 

Another advantage of performing the biopsy on day 5 is that mosaicism is much less of a problem in a blastocyst. (The last blog explains mosacism), The cells we get on day 5 more accurately reflect the DNA status of the embryo as a whole.   We are not sure why mosacisism is less of a problem on day 5, it may be that it’s common for an embryo to start off with some abnormal cells, but with time the normal cells outgrow the bad ones.

 

One downside to TE biopsy is that in most cases, the results of the biopsy take 1-3 days to process. We do not want a day 5 embryo growing extra days in the lab waiting for the results. Therefore, we usually freeze the blastocysts just after the biopsy, get the results a few days later, and then have the patient come back the next month for a thaw cycle.  This gives the patient a one month delay, which may or not be an important factor, depending on the expectations of the patient.  There are some programs that offer same cycle PGD biopsy and transfer, but usually those women with only the fastest growing and best looking are candidates for the same cycle process.

 

Patients are naturally concerned about embryo freezing, as is it is mostly true that embryos in a frozen cycle have lower pregnancy rates than when the embryos are transferred when fresh.  However, there may be some very explainable reasons why freezing normal blastocysts may not be problematic.  In a standard fresh cycle, the best embryos are transferred. While the extra embryos may look very good, the best ones go back originally, leaving the left overs for the frozen cycle, and this could explain the lower rates.  In a PGD cycle, even the best embryos are frozen, upping the odds for a successful cycle after the thaw.  Also, at least from what I have seen, normal embryos seem to thaw and freeze very well. So if you know you have a good one in the freezer odds are good that it will survive the freeze and thaw and have good potential for success.

 

In addition, freezing techniques have really blossomed in the past few years.  Most programs have moved to vitrification (the fast freezing method), and embryos do have better outcomes when preserved this way.

 

On top of all of this, there are some doctors who believe that all embryos, even without biopsy, should be frozen. There is the revival of an old theory that the endometrium of an IVF cycle is not ideal for implantation, possibly due to excessive estrogen levels caused by the fertility drugs. Others feel that the relationship between the timing of ovulation and embryo transfer is altered with IVF, lowering the ability of the embryo to implant.  I’m not so sure about theses theories, but I am raising the point here to say that a frozen embryo cycle is not necessarily a bad thing.

 

There are still a few more points about PGD that I will go over next time.

 

Thanks for reading, and don’t forget the disclaimer 5.17.06

 

Dr. Licciardi

 

References:

  • Braude P. Preimplantation diagnosis for genetic susceptibility. N Engl J Med 2006; 355(6):541-3.
  • Gutiérrez-Mateo C., Colls P., Sánchez-García J., Escudero T., Prates R., Wells D., Munné S. Validation of microarray comparative genomic hybridization for comprehensive chromosome analysis of embryos. Fertil Steril. 2011; 95: 953-958.
  • Twisk M, Mastenbroek S, van Wely M, Heineman MJ, Van der Veen F, Repping S. Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2006; 25(1):CD005291.
  • Munne S, Fischer J, Warner A, Chen S, Zouves C, Cohen J, Referring Centers PGD Group. Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study. Fertil Steril. 2006; 85(2):326-32.

 

The New Phase of Embryo Biopsy and PGD

Hello to all!

Welcome to this latest blog, which will discuss embryo biopsy and pre-implantation genetic diagnosis (PGD).While many of you may feel that theses processes do not apply to you, the science is progressing to the point that more and more people are becoming candidates. We can’t completely tell yet, but it is possible that in the future almost all IVF cycles will involve PGD. Plus more people may become IVF candidates because of PGD. We’ll see.

In the meantime, I would like to bring you up to speed with some newer information about the treatment. This is the first of a 2 part series. The first will discuss the reasons why PGD took a while to become potentially helpful.

This one is a bit technical, so if you’re really not biased towards technical things, you can wait for the next blog, which has a little more practical information. Here we go. PGD has been around for 2 decades. In fact, one of my partners, Dr. Grifo, was the first doctor in the US to successfully perform the procedure. 20 years is a long time in the world of medicine, but interestingly, the progression of PGD and its usefulness had stalled.

The early techniques were important and useful, however limitations it their reliability kept PGD from being used to it’s potential. The early problems were four-fold. One, the embryos needed to be biopsied on day 3 because we could not at first grow embryos 5 days in the lab. A day 3 embryo has progressed to 8 cells ideally, however, on day 3 many embryos are 5,6,or 7 cells. Of course we do see embryos that are 2-4 cells on day 3, but we usually do not consider them viable enough for a biopsy. The biopsy is performed by opening the shell of the embryo, as is done in hatching, and then plucking off one cell to be tested.

One cell from a 6 cell embryo means that a big percentage (1/6supth/sup, or 17%) of the embryo is removed. Embryos may not like to have a big chunk of them pulled away and may not grow as well as an embryo that is undisturbed. In addition, some of the early cells are destined to be part of the embryo itself and others the placenta. At that stage we can’t tell which cells are which so we just take one at random. If we remove one of the few embryonic cells, the fetus may not develop, we think. These percentage issues led to the second problem, which is that usually only one cell could be removed for testing. If we could routinely take 2 cells we would have get twice as much DNA and therefore be much more accurate with our diagnosis.

There are cases where a second cell has been removed; if for instance, if the first cell was damaged in the extraction process. Some IVF clinics have routinely removed two cells to enhance the accuracy of the testing process, however it was shown that removing 2 cells is too harmful to the embryo. And this leads to the third problem, the biochemistry of the analysis. It’s the DNA of the cell that is tested. I will not go into the gory details of DNA analysis here but I will touch on a couple of things. Early on, a good but flawed method of analyzing the DNA was used. This involved making chemicals that latched on to the single chromosome, and theses chemicals were of different colors. Because each chromosome is very different, you could have one chemical that only stuck to an area on the 21supst supchromosome.

This chemical for instance, would be green. Other chemicals of different colors would stick to the other chromosomes, such that chromosome 15 could be yellow, chromosome 18 could be red, etc. The cell would be treated with these ”probes,” and under the microscope one could look at the cell and count up the colors. Two of the same was the goal. 3 greens, as an example, would indicate the embryo had 3 chromosome 21s, therefore meaning the embryo had trisomy 21, or Down’s syndrome. This technique also worked well, but not well enough to be near perfect, and in medicine, near perfect is the minimally acceptable result. Here is a picture (Munne).

You can see that the colors are sometimes faint. One problem occurred when 2 color spots were very close to each other making accurate reading difficult. One shortcoming of this technology was that only 14 probes were available (fewer earlier on), and we have 23 pairs of chromosomes. Therefore, if an embryo had an extra chromosome 20 and there were no probes for chromosome 20, we would have to say it’s probably normal and do the transfer and hope for the best. This could lead to pregnancy failure or miscarriage. This probe technique is sometimes still used, however newer tests are better for most things.Other tests, which are sometimes still used, do not use colors and probes. They involve instead making millions of copies of a small specific area in the cell’s DNA. This test is more used when looking for subtle genetic defects, as in sickle cell disease. Having millions of copies lets us confirm that our results are correct. We can actually see the piece of DNA we are looking for. Here is a picture. Don’t try to figure it out, it’s just an example. Each dark line is millions of copies of DNA (Girardet et al).

In an attempt to make al of those copies, things can go wrong, resulting in the wrong diagnosis or no diagnosis at all. This system is actually a good system, but when using a single cell, the amount of starting material is so small, problems and errors can occur.The fourth problem was mosaicism. We were all taught that after the egg divides, all of the new cells have the same DNA and are identical. What we have learned from embryo DNA testing is that some cells are different than others. In about 30% of the cases, the embryo is made up of 2 cell types. This is called mosiacism. This is problem when trying to get a picture of the whole embryo based on the DNA extracted from only one cell. If we take off cell that we test as normal, but the rest of the embryo is abnormal, we will transfer that abnormal embryo leading to no pregnancy or miscarriage. The opposite issue of discarding and “abnormal” embryo that is really mostly normal also can happen.Next time we will talk about the newer developments that may make PGD more acceptable.

Thanks for reading and don’t forget the disclaimer 5.17.06. Dr. Licciardi

References:

  • Braude P. Preimplantation diagnosis for genetic susceptibility. N Engl J Med 2006; 355(6):541-3.
  • Gutiérrez-Mateo C., Colls P., Sánchez-García J., Escudero T., Prates R., Wells D., Munné S. Validation of microarray comparative genomic hybridization for comprehensive chromosome analysis of embryos. Fertil Steril. 2011; 95: 953-958.
  • Twisk M, Mastenbroek S, van Wely M, Heineman MJ, Van der Veen F, Repping S. Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database Syst Rev 2006; 25(1):CD005291.
  • Munne S, Fischer J, Warner A, Chen S, Zouves C, Cohen J, Referring Centers PGD Group. Preimplantation genetic diagnosis significantly reduces pregnancy loss in infertile couples: a multicenter study. Fertil Steril. 2006; 85(2):326-32.

So Who Really Needs Infertility Surgery?

Today we will talk about trying to figure out who needs infertility surgery and who does not. Some cases are obvious, and some are very borderline.

This blog will discuss the case of the fibroid uterus, another blog will follow concerning other problems.

I’ll start with a little story. Cathy was a 40-year-old woman who had been trying to become pregnant for years. Before I examined her she said that doctors have told her she has a fibroid, but she did not think it was causing her any problems.

When I got to her exam, I found a huge fibroid growing all the way to her navel. On ultrasound she had a fibroid larger than a grapefruit distorting her entire uterus making it impossible to become pregnant. In addition, she was anemic because the fibroid was causing her to have super heavy periods. Upon further questioning, she revealed that she had been told about this problem years ago, but figured she would just try on her own just in case.

So here is a woman who absolutely needed surgery to become pregnant, and for some reason did not want get it done. I gently explained her that she could not get pregnant without an operation, and she told me she was really going to consider it this time, but never returned.

I can’t explain her behavior; maybe fear, or maybe a family member was giving her advice. But the point here is that from my end, this was easy advice to give, it was clear, she needed surgery. Very few cases are as clear as this. In fact in most cases of infertility surgery, non-surgery is a real option.
Lets go through a few more scenarios.Here is another easy fibroid case, the case of the submucus myoma (myoma=fibroid). Submucus means right in the cavity itself, it grows among the glands that are necessary to hold an embryo.
A submucus myoma even as small as a half of an inch can be a problem because it can disrupt the uterine lining (the endometrium), interfering with implantation. Plus they can cause heavy bleeding.
While pregnancy is possible with these myomas, we usually recommend removal because the surgery is relatively easy and the results are favorable. Rarely, scar tissue can be a complication and sometimes the cases need to be repeated if it’s hard to get every little bit out at the first case.
Most doctors recommend the removal of submucus myomas, even if small.
Here is another easy one. What if you have one 3 centimeter (cm) (3 cms is a bit bigger than one inch) fibroid that is not growing near the lining, and it’s your only fibroid.
In this case, you do not need surgery.
Every doctor has his or her own size cutoff, but for almost all of us, 3 cm is just too small to operate.
Yes they can grow during pregnancy, but many do not.
Most doctors do not recommend surgery for 3 cm fibroids, as long as they are not in the cavity (submucus).
Now it’s going to be a bit harder.
What if you have 3 fibroids that are 3 cm each?
Or one fibroid that is 6 cms, or 7 fibroids all less than 2 cms?
These are the cases where the real answers are hard to come by.
Maybe you need surgery, maybe you don’t. And what does need mean?
Does it mean you can’t get pregnant without surgery? Does it mean you could get pregnant but then have an early miscarriage? Or does it mean that all will be well until the 28thweek of pregnancy when you prematurely deliver?
This is all impossible to predict. Every fibroid is different and every uterus is different. In addition, there are so many causes (not all known) of infertility, miscarriage and premature delivery that blaming the fibroids on bad outcomes is at times futile.
Many doctors have just a firm size cutoff, which could vary from 4, 5, 6, or 7 cms depending on the doctor. Some doctors, don’t use a cutoff, they use many multiple factors including size, location and history. Either way, we never really know, except in the most obvious cases, if the surgery we did made the difference.

I realize this can be a difficult part, and here is where the broken record comes in, get different opinions.
In the case of fibroids, opinions from high-risk obstetricians are very helpful. These are the doctors who take care of women with problem pregnancies, and they have a good understanding of the possible risks associated with fibroids.
I have found that these types of doctors are more comfortable with taking care of women with fibroids, but see that your doctors say.Next time we will talk about other conditions such as polyps and endometriosis.Of course any real opinions of you condition and options will have to come from your doctors. Dr. Licciardi

 

References:

  • Fibroids:
    • American Association of Gynecologic Laparoscopists (AAGL): Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol. 2012 Mar-Apr;19(2):152-71.
    • Giatras K, Berkeley AS, Noyes N, Licciardi F, Lolis D, Grifo JA. Fertility after hysteroscopic resection of submucous myomas. J Am Assoc Gynecol Laparosc 1999 May;6(2):155-8.
    • Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008 Apr;198(4):357-66.
    • Munro MG. Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management. Obstet Gynecol Clin North Am. 2011 Dec;38(4):703-31.
  • Endometriosis:
    • Marcoux S, Maheux R, Berube S, et al. Canadian Collaboration Group on Endometriosis. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Eng J Med. 1997; 377:212-22.
    • Jacobson TZ, Duffy JMN, Barlow D, Koninckx PR, Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database of Systematic Reviews: 4, 2009.
    • Fayez JA, Vogel MF. Comparison of Different Treatment Methods of Endometriomas by Laparoscopy. Obstet Gynecol. 1991; 78: 660.
    • Gruppo Italiano per lo Studio dell’Endometriosi. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Hum Reprod. 1999; 14(5): 1332.
    • Vercellini P, Chapron, C, Di Giorgi, O, Consonni, C, Frontino, G, Crosignani, PG. Coagulation or excision of ovarian endometriomas. Am J Obstet Gynecol 2003; 188(3):606-10.
  • Polyps:
    • American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol. 2012 Jan-Feb;19(1):3-10.
    • Rackow BW, Jorgensen E, Taylor HS. Endometrial polyps affect uterine receptivity. Fertil Steril. 2011 Jun 30;95(8):2690-2.
    • Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol BW, Mathieu C, D’Hooghe T. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update. 2010 Jan-Feb;16(1):1-11.
    • Varasteh NN, Neuwirth RS, Levin B, Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol. 1999 Aug;94(2):168-71.

Fred’s Face Part 2

Hello everyone, in today’s blog you will see that I had to make decisions about my health. Yes, I am a practicing physician, but injuries of the face are not my forte. I received very different opinions from different doctors and I had to put it all together, which was not an easy task.

I am sure that many of you have been or are in the process of making a serious decision based on the information you receive from doctors. One main point here will be you always need to get another opinion. In addition, just because a doctor is well known doesn’t mean he/she will do the best thing for you.

The CAT scan revealed that I indeed had multiple fractures of my face, the most prominent being the zygomatic arch, which is the bone between your ear and nose right under the eye. It’s the one that gives your cheekbone a nice round shape. After notifying me of my results, the ER doctor, who was very nice and competent, told me I was probably looking at surgery with plates and pins.

By the way, a word about nausea. I have always been taught that when treating patients, nausea is worse for them than pain, and from this experience I can fully attest to that. As the blood filled my sinuses, I had tremendous nausea. When the doctor offered me pain medications I refused. I told him it really hurts but if the Percocet will make me even more nauseous I will not take it, I’d rather be in pain. He gave me something for the nausea, and I began to feel human, then I took the pain medication. I can also say from personal experience that the only time this concept may not apply is in the case of a kidney stone, which involves pain and nausea, but the pain is so insanely severe, pain meds first please.

Anyway, I was discharged from the ER, CAT Scan and drugs in hand, and off I went to seek professional help. I called a plastic surgeon friend who told me nothing needed to be done right away, so that gave me reassurance that I had some time to get to the right person. You should take your time too.

I did a bit of research and made appointments to see to 2 prominent facial surgeons, each at different institutions. Teaching point: I didn’t see one then decide to see another, I went for 2 opinions from the start.

Doctor One. Asshole. Typical NY office: all of the NY’s best this and best that plaques. Alright, I seem to be in the right place. Plus he was highly recommended, so let’s see where this takes us. He seemed nice, thoroughly examined my CAT scan, and then told me what I absolutely needed, no question about it. I needed to have the bones put back in their right place with pins and plates. Because some of the broken bones were part of my upper jaw, he said that if I did not have the surgery I would never be able to eat properly again. To get to the bones, he would need to make a long incision right across the front of my face. Not a word about the resulting scar. He was so interested in doing the surgery, he called the hospital and resident right in front of me and scheduled me for Sunday. Who does surgery on Sunday? Who rushes to get the thing booked right away? Someone desperate to operate, that’s who. He already knew I was getting other opinions, so after hearing this I said I would get back to him. I did not totally dismiss his suggestion, but I left his office running. And he was the most prominent surgeon at a very fancy New York Hospital.

Doctor Two. Better, but, well you’ll see. Same thing, the good recommendation, plaque city. He was a very nice man, who seemed much more competent that doctor one. He reviewed my films and told me that I had the option of surgery or no surgery. If I had surgery he could do it from the inside of my cheek. Wow what a difference; imagine how angry I became at doctor one who had no problem at all slicing my face right open. I am still mad at him. Doctor 2 was not worried about the eating thing, getting me even madder at Doctor 1. Doctor 2 did however say that he was in favor of surgery. Why? “Because afterwards I would be more beautiful.” More beautiful? Is he kidding? Here I was 50 years old, married 24 years and he is telling me I should have the surgery to be more beautiful? I think he must have dosed off during our conversation and he forgot I was not coming in for a facelift. Then when I asked him again about a scar he did say that some time after the original surgery he would need to make a tiny incision on my face to remove a wire. Oh.

Two doctors 2 very different opinions. At least I felt safe with Doctor 2, so if I thought I should have the surgery, I was fine with him doing it.

So as it turns out I have a friend through a friend who is also a prominent facial surgeon, Steven Denenberg. He practices in Omaha, but with the internet and phones, I was able to send him my films and talk about my options. With Steve, things were starting to make sense. The key approach: think about what you have now, and how that might be changed with surgery. What did I have? A depressed face, pushed in about 2-3 millimeters, enough to see if you looked carefully, but to most people, not noticeable. What would surgery do? It would give me a risk of bleeding, infection, big or small scar, and may or may not be able to make a big difference in the way I looked. What if in the quest for perfection, the doctor raised the bone 2 mm too much? This is a real possibility because it’s hard to get it exactly right with such small distances. What if in healing it only really elevated one millimeter? Then it was kind of a waste to have the surgery in the first place.

So in the end, I did not have the surgery. When I look in the mirror, I see the dent, but I’d rather see the dent than a massive scar or some other bump or new dent from surgery that was supposed to make me better. And years later I am still eating, no one has ever noticed my slightly asymmetric face, and I have not missed out on any movie roles for being less beautiful.

Has a doctor recommended surgery to you? Do you have fibroids, endometriosis or uterine scaring? Next time I will do my best to discuss which surgeries may be necessary and which are not.

Thanks for reading, I’ll write again soon,

Dr. Licciardi

Fred’s Face Part 1

Hello everyone. I will start today with a story that at first is not related to infertility, but in the end will provide a discussion that will be relevant. Here we go.

Well here you see it, the spoils of a surfing accident that in 2007 changed my face just a bit just forever.
I really had to force the smile here because I was in pain and sleepless. Surfing accidents are usually quite embarrassing. They are frequently caused by human error.
This could mean 2 crashing into each other, in which case one party was in the wrong, but even here the person in the right may have avoided injury if he was paying more attention to his surroundings. In most other cases, the surfer gets into trouble for not properly thinking about the task at hand ie. trying to catch too big a wave. Commonly, it’s just a matter of improperly judging the break of the wave or improperly timing the standup and turn. Sometimes poor judgment relating to local conditions ie. reefs, shallow bottoms, currents etc., can get surfers into big trouble.
The point is surfing accidents are never glamorous.

It’s not like saying “I broke my arm running with the bulls”. Skiing accidents are more suitable for putting the blame on something other than stupidity. “There was this huge patch of ice”, “they did not groom well” and “my binding never released” are common statements lifting the blame for injury away from the operator.
When you get hurt surfing, you usually know what you did wrong, and it’s not a good feeling.My main problem was inexperience.
I grew up spending a fair amount of time in the ocean and frequently body surfed and boogie boarded, so I was at least familiar with wave shapes, currents and tides. But I did not start surfing till much later and without lessons I was just out there waiting for trouble. Learners tend to start on larger boards, and mine is a monster.
9 feet 6 inches of very thick glass, making it one of the heavier boards in its class, quite a torpedo. Perfect for learning and for getting up on small waves, but dangerous under the wrong circumstances.

So this is where the non-glamour comes in.

I wasn’t even trying to catch a wave.
I paddled out on a rough day with wave that were closing out, meaning that the wave instead of starting to break on one side, the wave just broke all at once, not leaving any place to catch and ride. After a while I recognized this and realized I should head in: good thinking. What I did not appreciate is that you need really watch the waves as you come in, because if you get caught at the wrong spot, a large heavy wave can crash right on top of you sending you and your board, separately of course, into the underwater equivalent of outer space.

You go down and around and around and around.

So that’s what happened to me.

Knowing my board was not far from me, I covered my face with my hands (I have since learned arms are better) and I waited for the rough water to calm. Just as moved my hands away, while still well underwater, the nose of the board rammed into the side of my face, hard.Why am I telling you this? Because I want to tell you of my experience with the doctors I ran into in seeking treatment. My interactions were probably very similar to yours, especially when faced with the prospect of surgery. And believe me; I was very surprised by what I found.

All to come in the next blog.