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a blog by David Kreiner, M.D., F.A.C.O.G., East Coast Fertility, September 14, 2010

September is PCOS Awareness Month. Many women don’t know that PCOS is the most common endocrine disorder of reproductive age women, occurring in over 7 percent of women at some point in their lifetime. It usually develops during the teen years.

Treatment can assist women attempting to conceive, help control the symptoms and prevent long-term health problems. If you think you have PCOS — or are struggling with PCOS — here are some things that you should know:

• Polycystic Ovary Syndrome (PCOS) is a condition in which a woman’s hormones are out of balance. It can cause problems with your periods and make it difficult to get pregnant. PCOS may affect the way you look and can be associated with a variety of health problems including diabetes, hyperlipidemia and hypertension.
• The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels. If a woman does not respond normally to insulin, her blood sugar levels rise triggering the body to produce more insulin. The insulin stimulates your ovaries to produce male sex hormones called androgens. Testosterone is a common androgen and is often elevated in women with PCOS. These androgens block the development and maturation of a woman’s ovarian follicles, preventing ovulation resulting in irregular menses and infertility. Androgens may also trigger development of acne and extra facial and body hair. It will increase lipids in the blood. The elevated blood sugar from insulin resistance can develop into diabetes.
• Symptoms may vary. The most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.
• Ovaries develop numerous small follicles that look like cysts, hence the name polycystic ovary syndrome. These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as Hyperstimulation syndrome. Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs. A woman with Hyperstimulation syndrome may become dehydrated, increasing her risk of developing blood clots. Becoming pregnant adds to the stimulation and exacerbates the condition, leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation. They may also prescribe aspirin to prevent clot formation. These cysts may lead to many eggs maturing in response to fertility treatment also placing patients at a high risk of developing a high order multiple pregnancy. Due to this unique risk it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.
• A diagnosis of PCOS may be made by history and physical examination, including an ultrasound of the ovaries. A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes. Hormone assays will also be helpful in making a differential diagnosis.
• Treatment starts with regular exercise and a diet including healthy foods with a controlled carbohydrate intake. This can help lower blood pressure and cholesterol and reduce the risk of diabetes. It can also help you lose weight if you need to.
• Quitting smoking will help reduce androgen levels and reduce the risk for heart disease. Birth control pills help regulate periods and reduce excess facial hair and acne. Laser hair removal has also been used successfully to reduce excess hair.
• A diabetes medicine called metformin can help control insulin and blood sugar levels. This can help lower androgen levels, regulate menstrual cycles and improve fertility. Fertility medications, in particular clomiphene, are often needed in addition to metformin to get a woman to ovulate and will help many women to conceive. The use of gonadotropin hormone injections without egg removal as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies, and therefore one must be extremely cautious in its use. In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer. Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

  It can be hard to deal with having PCOS. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. Ask your doctor about support groups and for treatment that can help you with your symptoms. Remember, PCOS can be annoying, aggravating and even depressing, but it is fortunately a very treatable disorder.

a blog by David Kreiner, M.D., F.A.C.O.G., East Coast Fertility, May 23, 2011

Many husbands complain that they feel left out of the whole in vitro fertilization (IVF) process, as all of the attention and care is apparently directed toward the woman.

Performance on Demand

If anything, husbands may feel that at best they can show up for the egg retrieval, at which time they are expected to donate their sperm on demand. If you should fail at this, then all the money, time, hope and efforts were wasted — all because you choked when you could not even perform this one “simple” step. I have not witnessed the terror
and horrors of war, but I have seen the devastation resulting from an IVF cycle failed as a result of a husband’s inability to collect a sperm specimen.

Relationships often do not survive in the wake of such a disappointment.

Talk about performing under pressure — there is more at stake in the sperm collection room than there is for pitchers in the World Series. I would recommend that a husband freeze a sperm specimen collected on a previous day when he does not have the intense pressure of having to produce at that moment or else. Having the insurance
of a back up frozen specimen takes much of the pressure off at the time of egg retrieval, making it that much easier to produce a fresh specimen.

In addition, there are strategies that can be planned for special circumstances, including arranging for assistance from your wife and using collection condoms so that the specimen can be collected during sexual intercourse. Depending on the program these alternatives may be available.

Differing Perspectives

Men view IVF from a different perspective than their wives or female partners. The men are not the ones being injected with hormones; commuting to the fertility clinic
frequently over a two-week span for blood tests and vaginal ultrasounds, and undergoing a transvaginal needle aspiration procedure.

Women are involved in the entire IVF process, speak with and see the IVF staff regularly, and understand what they are doing. Women are deeply invested emotionally and physically in this experience.

So what is a husband to do?

Get Involved

The couples that appear to deal best with the stress of IVF are the ones who do it together.

Many husbands learn to give their wives the fertility medication injections. It helps involve them in the efforts and gives them some degree of control over the process. They can relate better to what their wives are doing and take pride that they are contributing toward the common
goal of achieving the baby.

When possible, husbands should accompany their wives to the fertility doctor visits. They can interact with the staff, get questions answered and obtain a better understanding of what is going on. This not only makes women feel like their husbands are supportive, but is helpful in getting accurate information and directions.

Both of these things are so important that in a husband’s absence I would recommend that a surrogate — such as a friend, sister or mother — be there if he cannot be. Support from others helps diminish the level of stress, especially
if it comes from the husband and helps to solidify the couple's relationship.

Husbands should also accompany their wives to the embryo transfer. This can be a highly emotional procedure. Your embryo/s is being placed in the womb, and at least in that moment many women feel as if they are pregnant.

Life may be starting here, and it is wonderful for a husband to share this moment with his wife. Perhaps he may keep the Petri dish as a keepsake as the “baby’s first crib”. It is an experience a couple is not likely to forget as their first time together as a family.

a blog by David Kreiner, M.D., F.A.C.O.G., East Coast Fertility, April 25, 2011

I visited my mom at the nursing home the other day. She has pathologically poor short term memory, a result of a ruptured cerebral aneurysm aggravated by a second hemorrhage at the hands of a fellow learning to place an intracerebral catheter.

"Mom”, I said, “I received this beautiful note from a past patient thanking me for her child." Instantly, mom's face grew a smile so wide with pride and joy soaking in the praise that she shared with her son, and deservedly so.

Families are precious to the Kreiners. Mom grew up in a large close-knit family that grew even closer in the shared beds of her tenement apartment. I was the fourth son, followed eight years later by my sister. Our family was an essential part of my growth and development. I was the first in the family to become a physician, and between my mother and her four sisters, I was groomed to be a physician that families would feel comfortable with.

My first year in medical school, 1977, was when the first baby was born via in vitro fertilization (IVF). Infertile couples previously unable to create a family with their own gametes were now able to have families of their own.

My destiny was clear. I wanted to help others in need build their own families.

Families are so valuable to me that aiding those who cannot create families on their own brings me an inner peace and satisfaction I don't think I could get from any other occupation or service.

I discussed with mom that National Infertility Awareness Week was coming up and told her that I wanted to do something special for couples that were having difficulty conceiving on their own. That's when my mom, sitting in her wheelchair, expressed with pure sincerity and sympathy how infertility is the worst affliction and how badly she felt for those who were unable to have a baby and complete their families. "David," she said, “give them a free IVF and make them a baby."

So, at my mom's suggestion in commemoration of NIAW, we are offering patients an opportunity to win a free Micro IVF. For more information, click here.

My wish is that someday, all who need and wish to do so can do IVF and have that baby of their dreams.

a blog by David Kreiner, M.D., F.A.C.O.G., East Coast Fertility, March 24, 2011

Practicing medicine for the past 30 years, I have developed an enormous respect for those things that happen to people that are beyond our control. Sometimes, the issue of preventability is a gray one and defies definitive blame assignment. Yet, when the dust settles, there remain victims who are harmed for whom we are all sympathetic. It is for this reason that we are compelled to do everything within our power to ensure that tragic errors do not occur.

Elsewhere in society there are potentially devastating outcomes to human error and, like in medicine, it may be difficult to unravel how much fault is from natural calamity and how much we could have avoided with more rigorous human controls.

Gray Areas with Catastrophes

Just about two weeks ago, the world was exposed to perhaps the worst of Mother Nature’s natural disasters: a severe earthquake with multiple aftershocks, followed by a massive Tsunami. Aside from the horrendous devastation that took place in Japan, ongoing danger persists from damage to several nuclear power plants.

These unintentional, uncontrollable catastrophes occur naturally and are arguably nobody’s fault. And although some claim that nuclear power is dangerous because of the history of accidents at places such as Chernobyl and Three Mile Island, nuclear power plants continue to be constructed throughout the world because many perceive that the benefits of this alternate source of energy outweigh the risks. We are assured by those responsible that these plants are safe even in the face of the worst disasters … until we learn they are not.

Potential Disasters with IVF

It is our human condition to speculate how to prevent these complications from occurring. With in vitro fertilization (IVF), perhaps the greatest potential disaster we face is the mixing up of embryos.

In February, 2009, a case of a mix-up of frozen embryos in a Michigan IVF program occurred to a couple who already had a set of twins as a result of a successful IVF. Their embryos were mistakenly transferred into the wrong woman, who then carried the pregnancy, and after delivery handed the baby back to his biological parents. Reports of the mix-up have triggered calls from some to make IVF illegal. This sounds like the recent calls to decommission nuclear power plants and stop production of new facilities.

Mixing up gametes and embryos is tragic, and society must do everything humanly possible to prevent it… except disallow the practice of IVF. As with other societal advances, accidents are rare, but have unfortunately happened in the field of IVF. However, weighed against the benefit of all the babies who otherwise would never have been born, we should strive to improve the safety of IVF, not eliminate it.

Risks and Results

Many of the greatest advances have had tragic results, with unintended accidents that could sometimes have been avoided. Sometimes, like the post-earthquake nuclear disasters in Japan, they are spawned by natural causes. But other times, there is an element of human error that is often preventable with the institution of carefully designed safeguards and a system of checks and balances.

Significant risk, including that of injury or death, is part of nearly everything we do in life today. The construction industry has always been plagued with accidental deaths. Not a bridge or a great high rise has been completed without misfortune. Do we stop construction? No, we ensure that all possible regulations that could protect those involved are in place and followed as strictly as possible to prevent further accidents.

Cardiac bypass surgery and other surgeries save lives and relieve suffering but, occasionally, patients intended to benefit are hurt or even killed accidentally. Rules and regulations are instituted to avoid problems such as performing the wrong operation on the wrong patient, using the wrong medication, operating on the wrong limb. Yet situations do occur rarely, usually because of a human slip. Rules are broken. and mistakes result. When they do, hospitals review the procedures and protocols to better ensure a sufficient system is in place to catch future errors before they effect patient care.

Safeguards

Just as we have safeguards in the operating room, we have them in place for identifying gametes and embryos, with checks and balances that should prevent a mix-up such as the one in Michigan.

In our operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date. As soon as the ovaries are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is double-checked with the patient’s record, which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.

Every attempt is made to confirm the identity of the gametes and embryos repeatedly throughout the IVF process from egg retrieval through embryo transfer. A similar system of double checks of patient and embryo identity exists for frozen embryo transfers as well.

In over 25 years of practicing IVF, my program has not mixed up gametes or embryos.

There are approximately 3 million babies born through IVF and only a few rare mix ups reported. Perhaps we don’t hear … or know … about every mix up. I’d estimate that less than 1/100,000 pregnancies from IVF have occurred with some mix up in the embryo or gamete. When it occurs, it is tragic and requires the attention of our field and a refocus on those checks and balances we have in place to prevent such mishaps.

When it comes to institutions whose impact on society is of such great magnitude, it is essential that governing regulatory agencies ensure that all possible checks and balances are in place to ensure the greatest degree of safety. All involved must work hard to maintain the highest standards, and then we can only pray that we have done everything possible so that such disasters never have such devastating consequences.