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a blog by Eric Levens, M.D., Shady Grove Fertility Center, May 16, 2011

Last week was National Nurses Week, but the indispensable role nursing staff play in caring for patients is something that should be honored year-round.

Infertility nurses come from a variety of training backgrounds, but the vast majority have previous experience in women’s health care. Infertility nurses work diligently to help execute treatment plans and play an important role in supporting patients through the complex journey of infertility — from infertility diagnosis to fertility treatment to pregnancy.

What can you expect from your infertility nurse? As described in a previous blog, the initial visit to an infertility specialist often involves several essential tests including ovarian reserve testing, a hysterosalpingogram (HSG), and scheduling a semen analysis. The fertility nurses in my office work to aid patients in scheduling these appointments and to ensure that these test results return promptly. Unique to reproductive endocrinology and infertility, fertility testing and treatment involves specific timing around the menstrual cycle. For some patients, this may be unpredictable — requiring efficient and effective attention. To be an infertility nurse requires exquisite organization to care for the many patients that my team cares for on a daily basis.

Fertility nurses work tirelessly to execute treatment plans that fertility doctors formulate with couples starting at the initial visit. Frequently, infertility nurses instruct patients on how to administer the fertility medications. This is certainly true in my office where my nursing team provides outstanding teaching to couples, including how to administer subcutaneous and intramuscular injections. For many patients, this is the first time they have had to give injections to themselves. Understandably, this can create a certain level of anxiety, which nurses will skillfully help to reduce.

Scheduling treatment plans is more involved and complicated than many patients realize. At Shady Grove Fertility nurses also perform that important role. Again, not only is reproductive endocrinology and infertility a complicated subject, but the complexity of cycle timing adds another dimension that must be managed. Our nurses do such an outstanding job at making sure that treatment plans are effectively delivered.

The diagnosis and treatment of infertility involves significant stress that in several studies has been shown to be comparable to being diagnosed with cancer. Added to this stress is the cost of treatment, which all too frequently is not covered by insurance plans. In the end, an empathetic nursing team will work under stressful conditions to ensure that patients are compassionately and effectively cared for.

To this end, I want to recognize all infertility nursing staff for a job exceptionally well done and I hope each and every one had a wonderful Nurses Week and that we continue to work together to provide you a Fertile Future.

a blog by Eric Levens, M.D., Shady Grove Fertility Center, November 16, 2010

I cannot stress enough the negative impact of female aging on reproductive outcomes. Every day that I see patients in the clinic, I discuss the importance of the age-related decline in female fertility. I typically describe this as a case of "cruel biology," because for women, unlike for men, the passage of time is a treacherous adversary in terms of achieving a pregnancy and building a family.

For many men, sperm production sufficient to achieve a pregnancy occurs throughout their entire lives, and men have produced pregnancies in their 70s or 80s. A notable example is Charlie Chaplin who fathered five children from the age of 62 to 73. While aging in men does result in a lower number of moving sperm, it does not seem to result in a reduced capacity to fertilize an egg and produce a pregnancy. In a recent study, pregnancy outcomes in donor egg cycles were not reduced with increasing male age (1).

For women, however, the story could not be more different. Many women are surprised to learn that fertility begins to decline in their early 30s and declines even more rapidly after age 37. This fact has been observed across the last four to five centuries (2) and is reflected in the success with IVF at our clinic today.

One of the reasons for this is the decline in the number of eggs resting within the ovaries. Prior to birth, there are approximately 6-7 million eggs in the ovaries. However, at the time of birth, there are only 1 million. By the time of puberty this number has been reduced to 300,000 to 500,000, and by 37 years of age, only 25,000 eggs remain! The natural age-related decline in fertility is accompanied by a significant decrease in the quality of the eggs, resulting in an increased risk of miscarriage.

Not only does reproductive aging affect egg quality, but as age increases, there is a greater risk of other disorders that may have an adverse impact on fertility: fibroids, damage to the Fallopian tubes and endometriosis. Because of the age-related decline in fertility, the increase in the incidence of disorders that impair fertility and the greater risk of pregnancy loss, women older than 35 should undergo evaluation and treatment after six months of failed attempts to conceive.

In the end, the reproductive aging is not an ally in the quest of achieving a pregnancy, and being keenly aware of this will make it more likely that you, too, will achieve a fertile future.

References:

a blog by Eric Levens, M.D., Shady Grove Fertility Center, July 16, 2010

Claims abound that nutritional supplements will improve our health, gaining headlines in the media and in the popular press. While nutritional supplements may provide some health benefits including pregnancy-related outcomes, nutritional supplements may not be as safe as they would seem, especially when considering early fetal development.

I frequently get asked about vitamins with respect to fertility. Many patients are surprised to learn that excessive vitamin intake may result in serious medical conditions and have been associated with fetal malformations. This is especially the case for fat-soluble vitamins (A, D, E and K). In general, additional nutritional supplementation outside of a standard prenatal vitamin is not necessary. A typical prenatal vitamin will provide sufficient vitamins and minerals for a healthy early pregnancy. The amount of vitamin A, for example, in standard prenatal vitamins (4,000 to 5,000 IU) is considered the maximum recommended dose before and during pregnancy.1

Another concern with nutritional supplements is that numerous supplements have been found to contain contaminants such as toxic plant materials, heavy metals and even prescription medications, to name a few. These compounds pose serious potential consequences for a developing fetus. Prior to 1994, dietary supplements (vitamins, minerals, amino acids, and botanicals) were considered food additives and thus were required to demonstrate safety prior to product marketing. Since the passage of the Dietary Supplement Health and Education Act, supplements are now presumed to be safe until shown otherwise. Relaxed Federal regulation, largely unknown by consumers and physicians alike, has created an environment in which hazardous supplements may be produced with little product liability. To date, more than 140 contaminated products have been identified, but this likely represents only a small proportion of the total contaminated products available today. 2

To date there has been little conclusive research demonstrating a benefit of nutritional supplements for fertility or early fetal development. A notable exception is folic acid. Folic acid has been shown to reduce the incidence of a specific birth defect known as neural tube defects by as much as 36 percent.1 As a result, the Centers for Disease Control and Prevention and my former agency, the US Public Health Service, recommend that women of reproductive age take 0.4 mg of folic acid daily before conception and during the first trimester. For women with a prior history of a pregnancy affected by a neural tube defect and for women taking anti-seizure medications, 4 mg (10 times the amount) of folic acid in the months in which conception is attempted and for the first trimester is expected to reduce this risk by a remarkable 80 percent.

Nutrition is an essential component of preconception care for all patients. The combination of a well-balanced, varied diet that is consistent with a woman’s food preferences and a standard prenatal vitamin should be sufficient to meet the dietary needs of a developing pregnancy.

Please feel free to write comments on this blog or on my Facebook page which can be found through our ,a href=http://www.shadygrovefertility.com/social-networking>web site As always, I wish you the best in your pursuit of a fertile future.

References:
1. American College of Obstetricians and Gynecologists. (2007). Guidelines for perinatal care. Elk Grove Village, IL
2. Cohen, P. A. (2009). "American roulette — contaminated dietary supplements." N Engl J Med 361(16): 1523-1525.

a blog by Eric Levens, M.D., Shady Grove Fertility Center, May 19, 2010

Ready for a fertility fact? Forty percent of women who present with fertility problems aren't regularly producing an egg that can be fertilized (anovulation).

The vast majority of problems with ovulation are accounted for by a condition known as polycystic ovary syndrome (PCOS). Other fertility problems resulting in irregular menstrual cycles include ovarian failure or inadequate signals from the brain that control the menstrual cycle (hypothalamic dysfunction).

To get a better sense of potential underlying fertility problems, at my initial fertility evaluations I often ask “Are your periods regular?” and “How far apart are your cycles?” I want to get a sense of how frequently ovulation is occurring.

The typical menstrual cycle is between 24 and 35 days. When menstrual cycles are irregular in duration or outside this normal range, this frequently indicates a problem regularly producing an egg.

Today, there are many high-tech devices lining pharmacy aisles, all designed to predict ovulation (some even have digital smiley faces). Nevertheless, few tests are as important and as simple as a thorough menstrual history.

In a 2003 study by Malcolm in the journal Obstetrics and Gynecology, the authors reported that a normal menstrual cycle predicted ovulation 99 percent of the time.

While I frequently use high-tech solutions to solve many fertility problems, it's just as important today as ever to remember to listen to a patient's history. It may tell more about the underlying problem than any test.

Once again, I want to thank you for reading my blog and best of luck achieving a Fertile Future.