Question:
What is my fertility physician looking for in conducting an antral follicle count?

Answer:
Women are born with all of the eggs (oocytes) that they will ever have. This is a set number, which is determined before birth. This pool of eggs is never replenished. A female fetus will have the greatest number of eggs around 16-20 weeks of pregnancy (6-7 million); at birth this number decreases to about 2 million; and by puberty to about 300,000. This constant and dynamic process of decline continues until menopause and is not interrupted by birth control pills, pregnancy, or ovulation. From this reservoir of eggs, fewer than 500 eggs will ovulate during a woman’s reproductive life.

There is a continuous process occurring in the ovaries, where eggs are constantly being prepared for the maturation process. It takes 3-6 months for eggs to develop and mature. As the eggs are developing, they transition from a primordial, to preantral, to then antral follicle. Antral follicles are visible by vaginal ultrasound. Antral follicles therefore represent the reserve of eggs in our ovaries and those that are candidates for selection and growth by fertility stimulation medications (gonadotropins).

When assessing one’s ovarian reserve (potential for a successful pregnancy), a number of parameters are evaluated. One of these is called the “antral follicle count” (AFC). An antral follicle count is typically done during the 2nd-4th days of menstrual flow, though it can probably be as accurately done during other times of the menstrual cycle. Studies show that the AFC is predictive of the expected ovarian response to gonadotropins. An AFC less than 6 total (between both ovaries), predicts a poor stimulation response. For those undergoing IVF, a similarly low AFC will be associated with a higher cancellation rate. As women approach their 40s, and as day-3 FSH results rise above 10 mIU/ml, this typically correlates with fewer eggs overall in our ovaries, and therefore a low AFC. Indirectly, a low AFC can correlate with diminished ovarian reserve.

In the same way that there can be monthly variability in day-3 FSH test results, there can be monthly variability in the AFC. More variability is observed in the AFC of young infertile women than in older women. However, overall a single AFC is still quite predictive of ovarian response under gonadotropin stimulation, and there is fairly good agreement between repeated AFC over consecutive cycles. In conclusion, doing an AFC is an adjunct to the day 3-FSH test to predict ovarian reserve and ovarian response to fertility medications.

– Isabelle Ryan, MD

Many people who get pregnant easily but have experienced recurrent miscarriages may not realize that they may actually have an “infertility” problem. The rubric of infertility includes not only helping couples establish a pregnancy but also achieving a viable pregnancy, which will grow to full term. So the diagnosis and treatment of recurrent miscarriages is indeed an area that is managed by infertility experts.

Recurrent Miscarriages, also called recurrent pregnancy loss (RPL), is diagnosed after at least 2 or 3, or more, consecutive pregnancy losses in the first or early second trimester (less than 15 weeks gestation). It is one of the most common clinical problems in reproduction, yet a definite cause can be established in only about 50% of the cases, often leaving patients distraught and frustrated. Consequently, some patients will turn to alternative therapies of unproven benefit. Medically known causes and treatments are described in this article.

Egg Quality Factor
The normal biological aging process of the egg causes the egg to function less accurately during the fertilization process at the critical time of chromosomal duplication and pairing. The resulting chromosomally abnormal embryos have a lower chance of implanting in the uterine lining. If implantation does occur, these embryos have a higher chance of leading to a first trimester miscarriage. We test for egg quality by performing a blood test for the FSH and Estradiol hormones on menstrual cycle day 2 or 3. For some patients we may recommend a more extensive test called a Clomid Challenge Test.

Other Hormonal Factors
Other hormonal abnormalities that result in miscarriage must be very subtle because the cycle is normal enough to allow egg development, ovulation, fertilization, and implantation, yet the pregnancy is lost at a later time. The amount of progesterone produced by the follicle after ovulation and the effect of that progesterone on the lining of the uterus may be of importance. A low progesterone level or an inadequate maturation of the uterine lining is called a luteal phase defect.

Abnormalities of other metabolic hormones can cause a luteal phase defect. If the prolactin level is elevated, it is important to evaluate for prolactin-elevating drugs, hypothyroidism (check the TSH), and pituitary tumors. The prolactin level can be lowered to a normal range with medications.

Women who have polycystic ovary syndrome (PCOS) are at higher risk of miscarriages because of an intraovarian hormonal imbalance. If PCOS is suspected, checking for LH, androgens and insulin resistance can be helpful in discussing treatment with insulin-sensitizing agents (metformin).

Anatomical factors
The anatomical factors are a variety of structural abnormalities of the cervix and uterus that are found in about 15% of women with recurrent pregnancy loss. These factors are diagnosed by performing a hysterosalpingogram (HSG), mid-cycle ultrasound or saline hysterogram, with attention directed to the shape or contour of the uterine cavity.

Potential abnormalities that may be found and associated with recurrent miscarriages are polyps, fibroids, and uterine septums. These anatomical abnormalities can lead to an unfavorable uterine environment for the embryo at the time of implantation and early embryo development. These can lead to early pregnancy loss. All of these abnormalities can usually be corrected with minor surgery.

Chromosomal Factor
There are 2 types of chromosomal factors. One is a random event; the other is genetically inherited by the fetus. At least 60% of all miscarriages are chromosomally abnormal embryos that arose from sporadic, random genetic defects in the sperm or the egg. These are defects that would not have been detected by analysis of the couple’s chromosomes (karyotype). However, these defects become more common as the woman ages. The miscarriage risk increases from about 15% of pregnancies before age 35, to 35% by age 40 and to 50% by age 45. About 99% of the time a chromosomally abnormal embryo will be miscarried. Because perhaps 1% will continue to develop, amniocentesis or chorionic villus sampling, which determine the genetic makeup of the fetus, is suggested for women over 35. When the genetic makeup of the fertilized egg is very abnormal, no embryo forms. On ultrasound examination an empty sac or a “blighted ovum” is seen in the uterus.

Some patients have chromosomal abnormalities in each cell, including eggs and sperm, which place them at greater risk of making a larger proportion of abnormal embryos. The fetus then genetically inherits this abnormality. Every cell in our body other than eggs and sperm has 46 chromosomes arranged in 23 pairs. It is possible that between the two chromosomes of a designated pair there could be a mix-up in the sequence of genes that make up these chromosomes, but the total number of genes is still normal. This mix-up is called a “balanced translocation” and causes no symptoms, diseases, or abnormalities in the patient or partner. However, if this genetic rearrangement occurs in a sperm or egg, the embryo will be chromosomally abnormal, and a miscarriage will follow. Balanced translocations can be detected by performing a chromosomal analysis. Chromosomal analysis requires a blood sample from both partners. The white blood cells are cultured to produce an analysis, or karyotype, of the chromosome pairs. The karyotype will be abnormal in about 5% of cases of couples that have suffered from three or more miscarriages. It is difficult to say what the risk of repeated miscarriages will be with a balanced translocation, however a normal full term pregnancy is still possible.

Immunologic factors
The immune system protects our bodies against foreign micro-organisms by recognizing any cells that are different from our own and making antibodies that attack and destroy those cells. Some women with recurrent pregnancy loss have autoantibodies. These are antibodies in their blood vessels that are made to attack their own tissues (e.g., antiphospholipid (anticardiolipin), antinuclear, or antithyroid antibodies). Antiphospholipid antibodies, along with lupus anticoagulant, may interfere with the formation of a normal placenta early in pregnancy and increase the risk of abnormal blood clotting in the placenta later in the pregnancy. This compromised placenta will lead to compromised growth of the fetus and an eventual miscarriage. If one has a positive antibody test, the test should be repeated 6-8 weeks later. If both sets of tests are positive, the recommended treatment may include one “baby” aspirin tablet per day, and sometimes the addition of daily heparin.

Thrombophilia Factors
Various enzymes regulate effective flow and clotting of blood. If there is a deficiency in some of the clotting enzymes, then small blood vessels of the placenta may be at greater risk of forming clots. Clots of the placenta will compromise blood flow to the growing embryo, placing the pregnancy at greater risk of a miscarriage. There are now a number of clotting enzymes that are recommended to be tested for in patients with recurrent miscarriages. If specific combinations of these enzymes are found to be in an abnormal range, then recommended treatment is a “Baby” aspirin per day with the possible addition of heparin.

Most miscarriages are the result of a random genetic defect leading to abnormal chromosomes for that particular fetus. This random event is unlikely to recur. For patients who have had three consecutive first-trimester miscarriages, and normal results after full evaluation, the chance of the next pregnancy leading to the delivery of a child is approximately 65%. Therefore, despite having had three recurrent miscarriages, the odds are still in favor of the next pregnancy being a normal pregnancy. While it can be incredibly frustrating both for patient and physician, to face repetitive failed pregnancies, it is still important to understand that the odds are still in the patient’s favor of eventual success. This may require fertility treatment, from low-tech intervention such as Clomid to high tech intervention such as IVF with preimplantation genetic screening (PGS), but in general, success is in our favor. If you are, or know someone who is experiencing recurrent miscarriages, please discuss this with a fertility specialist who may be able to recommend treatment options.

– Isabelle Ryan MD

Some patients might have noticed claims that an Inhibin B blood test can better help determine her egg quality. We at Pacific Fertility Center have examined this topic carefully and have chosen not to incorporate this test as a routine procedure.

Currently we use a number of parameters to determine egg quality, or ovarian reserve. For most patients this includes review of:

1. The female partner’s age,
2. Results of cycle day 3 FSH and
3. Estradiol (estrogen) testing or
4. A complete clomid challenge test (CCCT), and
5. Ultrasound to determine basal antral follicle count (AFC).

With these parameters we can help determine chances of success with each treatment modality.

We are constantly looking for ways to better determine ovarian reserve. One proposed adjunct is a blood test for Inhibin B. Inhibin B is a protein secreted by the resting antral follicles in the ovary, and is responsible for inhibiting the secretion of FSH in the early part (follicular phase) of the menstrual cycle. There is also a second inhibin called Inhibin A. This inhibin is secreted by the selected and growing follicle in the second (luteal phase) part of the menstrual cycle.

Inhibin B is secreted by the group of small, resting follicles in the ovary and indicates a woman’s ovarian reserve. The higher the Inhibin B level, the more ovarian follicles are present in the ovary, the greater the chance of growing a number of follicles with stimulation medications, the greater the chance of achieving a pregnancy. Most studies indicate that an Inhibin B level = 45 pg/ml would indicate adequate ovarian reserve. Inhibin B levels decrease as women age and total follicle numbers decline. Women with very low Inhibin B levels (<20 pg/ml) have such poor ovarian reserve that they have a very high chance of cancellation in an IVF cycle.

Inhibin B is a direct measurement of the hormonal dynamics of the ovarian follicles. FSH testing is an indirect measure of ovarian reserve, but the FSH test is readily available at most reference laboratories. Inhibin B testing is more laborious, and few labs offer this test. Additionally, numerous studies have shown that doing an Inhibin B test alone does not provide more accurate information nor better predict one’s ovarian reserve, compared to an FSH test alone. Therefore, these 2 limitations have not allowed for the incorporation of routine Inhibin B testing in a fertility evaluation.

– Isabelle Ryan, MD

Q.
I sought our physician’s opinion about how my fibroids might impact our desire to get pregnant. Eight doctor opinions later, we are no closer to a decision. About half of the experts advise surgical removal; and the other half tell us to try to get pregnant despite them. Why is the medical community divided on this?

A.
Fibroid(s) of the uterus, also known as leiomyomas or just myomas, are benign growths that may be located on the exterior of or within the muscle layer of the uterus, or may be growing within the lining of the uterus. For the vast majority of women, fibroids do not cause significant health problems.

A few women who desire pregnancy may need to have their fibroids removed (myomectomy) prior to conceiving if the fibroids are very large (greater than 6 cm) and/or if they impinge upon and distort the uterine cavity.

Various surgical approaches to removal are further described on PFC’s web site, along with a more in depth summary of the factors that our physicians consider when counseling a patient to undergo a myomectomy.

You probably received different opinions because the impact of fibroids as related to pregnancy chances depends on the size and location of the fibroids. Other issues to consider are that fibroids are dependent on estrogen to grow, and high levels of estrogen produced during pregnancy can lead to rapid growth of the fibroid(s). If the fibroid is on the outer surface of the uterus, this may present little problem. If the fibroid is located within the uterus muscle wall or nearer the uterine cavity where the fetus is growing, a patient may be at higher risk for various pregnancy complications (miscarriage, preterm labor…).

In rare cases, the fibroid may grow so rapidly during pregnancy that it outgrows its blood supply and starts degenerating, which can be painful and sometimes lead to pregnancy complications. Also uncommon but of significance is the fact that some fibroids may block the lower portion of the uterus, prohibiting the baby’s head to descend into the birth canal, making cesarean delivery necessary. However, it is important to keep in mind that the majority of patients with fibroids experience no problems during pregnancy.

What is the impact of fibroids on pregnancy chances? It is unclear that there is any negative impact, if the fibroids are small and not growing within or distorting the uterine cavity.

You may have heard about Preimplantation Genetic Screening as a technique provided in the IVF laboratory, and may have wondered if this technology is one you should consider incorporating in your IVF cycle. When considering various technologies in your IVF cycle, it is always important to clearly define what information you wish to gather with this technology, and also understand the pitfalls of the technology.

We have two methods of screening embryos. The first is called Preimplantation Genetic Diagnosis, for couples that have a known and defined genetic disease (e.g. Cystic fibrosis, Huntington’s disease, thalassemia), or are carriers of a single chromosome abnormality (chromosomal translocation). In this case we screen the embryo(s) for that particular genetic disorder, and transfer appropriate embryos. For this type of genetic screening, the aim is to conceive a healthy, unaffected child.

The other type of genetic screening is called Preimplantation Genetic Screening, where we screen the embryos for abnormalities in chromosome number. We all have 23 pairs of chromosomes. Embryos that have extra or missing chromosome(s) (aneuploid embryos) are much more likely to not implant, or to produce a miscarriage. The incidence of implantation failure, or of miscarriage, depends on which chromosome(s) are missing or duplicated. We therefore can screen an embryo with a “five or nine chromosome panel.” At PFC we utilize the nine chromosome panel. We look at the nine chromosomes that have been identified as most commonly being associated with implantation failures or miscarriages to see if that particular embryo has the correct number of those nine chromosomes. If so, this embryo is deemed “normal”, and can be transferred back to the uterus.

So who might consider PGS? Patients who have had a number of failed IVF cycles (documented failed implantations), those with a poor response to ovarian stimulation or those with poor embryo development (poor responders), those with recurrent miscarriages (>2 first-trimester miscarriages), those with a prior aneuploid pregnancy, those who are at least 35 years old are all candidates for PGS. The chances of improved pregnancy rates with PGS are dependent on the indication for PGS.

When we started doing PGS for various indications, we expected a dramatic improvement in implantation rates, and therefore pregnancy rates, as we were transferring pre-selected embryos. As it turns out, we have not necessarily seen those expected improvements in all patient groups. Patients who are younger than 35 yeas of age have a better chance at improved implantation and pregnancy rates using PGS. Improvements can still be obtained for older patients, if the 9 chromosome probe set is used (some centers use a 5 chromosome panel). Studies now indicate that patients who have at least 6 fertilized eggs to screen will also have a better prognosis than those with 5 or fewer. For those patients who have five or fewer fertilized eggs in their IVF cycle, we may actually recommend not proceeding with the PGS. In this case less manipulation of embryos may provide the patient with the best overall chance at pregnancy. Patients who have had less than 3 failed IVF cycles may have greater benefit from PGS than those with > 3 failed cycles. Patients with a prior aneuploid pregnancy or with recurrent pregnancy losses can also expect an improvement.

For patients who have had repetitive IVF cycle failures, or repetitive pregnancy losses, a PGS cycle may be diagnostic (explain if those failures/losses are from a high number of abnormal embryos), and in that sense may provide important information that explains those fertility failures. With those answers, the patient can then decide about pursuing similar treatment cycles, or choosing other options (using a donor egg, pursuing adoption, or choosing to live child-free). Studies indicate that results from one PGS cycle are indeed predictive of probable results in subsequent PGS cycles. In other words, if we have a cycle with a higher than expected percentage of abnormal embryos, we have to anticipate that we will probably have a similar result in subsequent PGS cycles.

There are many proposed reasons to explain why we are not achieving a higher implantation/ pregnancy rate in PGS cycles. There clearly is added stress placed on the embryo(s) when one cell is biopsied out, and when the embryo is kept in culture for an extra day or two while waiting for the results of the genetic testing. We currently can only test for 9 chromosomes, and it is possible that there may be undiagnosed abnormalities on one of the untested chromosome pairs. There is also a small possibility that an embryo we deem “normal” may actually not be normal (false negative result). It also may be that simply looking at chromosomes is not the final answer. Most likely the integrity and health of the cytoplasmic structures, and other important structures of the egg are also critical in the ability of the embryo to develop into a viable and healthy pregnancy.

Who Benefits Most?

• Patients with < 3 failed cycles, and > 5 fertilized eggs
• Patients 35 year and older (if using a 9 chromosome panel)
• Patients with a history of recurrent pregnancy losses
• Patients with a previous aneuploid pregnancy
• Patients using PGS as a Diagnostic Tool for:
  - Repeated IVF failure
  - Non-obstructive Azospermia

So, while PGS is a wonderful tool that can be incorporated into the various techniques of your IVF cycle, you need to be aware of the strengths and limitations of PGS testing. Your physician can help guide you in terms of the appropriate use of PGS and whether you may benefit from incorporating PGS in your IVF cycle.

As fertility care providers, a frequent question we are asked is “Does stress affect my chances of a successful outcome?” This is a difficult question to answer, because few substantial studies have been conducted. However, some viable data is starting to trickle in.

Researchers from the UC San Diego Dept. of Family and Preventive Medicine, working with a number of IVF centers, tried to assess the impact of patient worries on their IVF outcomes Konoff-Cohen et al, Fert Ster: Vol 81, No 4, 982-988). In this prospective study, 151 women completed questionnaires pre and post IVF or GIFT treatment regarding their concerns about medical aspects of their treatment (not achieving desired results, side effects, surgery, anesthesia, not enough information, pain, recovery) and financial aspects (missing work, finances). It is important to note that only the questionnaires completed pre-treatment provided data for this study, since not enough post-treatment questionnaires were returned.

Women who were concerned about the medical aspect of the procedures had 20% fewer eggs retrieved and 19% fewer fertilized, than women who were less inclined to worry about it. Women who were concerned about missing work had 30% fewer eggs fertilized. Those who were very concerned about the financial implications of their treatment cycle had a greater risk of not achieving a live birth. These results were adjusted for different variables that could also affect success rates such as age, race, smoking, type of infertility, previous treatment attempts, and prior live births. However, other important predictors of outcome were not adjusted for, such as FSH and antral follicle count.

While these findings may appear to show dramatic differences, it is important to note that these differences (20-30% fewer eggs, 19% fewer fertilized) clinically represented a decrease of only ONE fewer embryo transferred. The greatest decrease was seen in women > 35 yrs old, and those who had already done a treatment cycle.

This study represents an interesting look at the issues of personal concerns and IVF/GIFT outcomes, and calls for further studies to understand the potential physiological effects that may mediate these outcomes. Other related studies are also worth noting.

For instance, a well-done study (Domar), which we described in the November/December 2003 issue of Fertility Flash, has shown that women participating in support groups while in IVF treatment seem to have increased pregnancy rates. A recently published study (Facchinetti) has looked at changes in physiological markers (heart rate, blood pressure, cortisol levels) in women undergoing IVF treatment and participating in support groups, showing evidence of physiological changes for those in support groups. These physiological changes are consistent with those seem in lower stress situations.

These collective studies suggest that one can best prepare for IVF by being as informed as possible about expectations of one’s treatment cycle (treatment procedures and financial impact). It may also be helpful to consider joining a support group. Fertility clinics can help patients by trying to alleviate patient’s concerns and making the IVF experience as smooth as possible.

More and more patients undergoing fertility treatment ask about incorporating acupuncture and Chinese herbal medicine treatment with their IVF cycle. Some patients are especially inquisitive after reading Lifang Liang’s recently published book Acupuncture and IVF: Increase IVF Success by 40-60%. For most patients going through the struggle of infertility, this title proposes a provocative and enticing claim.

While acupuncture is based on an ancient medical tradition, current studies are trying to clarify the physiological basis for treatment results. Some indicate that the benefits of acupuncture may be mediated by opioid-types of proteins in the central nervous system. Some of the proteins affect gonadotropin secretion from the pituitary (brain), and therefore could impact menstrual cyclicity to help regulate ovulation. Others propose that blood flow to the pelvic organs may be improved through mechanisms other than the central nervous system therefore improving fertility. And yet others propose there might be a psychosomatic benefit.

While all these theories are intriguing, a true understanding of the benefit of acupuncture and its impact on fertility will not be elucidated until the execution of several well designed studies (large numbers of patients, randomized controlled trials).

To date, there is only one such study (Paulus et al, Fertil Steril. 2002 Apr;77(4):721-4), which was conducted in Germany. While this study revealed an improvement in pregnancy rates, there are a number of issues with the study itself, which calls for cautious interpretation of the final results (an improvement in pregnancy rates from 26% to 42% – 61.5% improvement rate). For instance, the study was weakened by a low baseline pregnancy rate (26.3%) in a young patient population (early 30yo). Statistically, it is much easier to show an improvement in pregnancy rate, when the baseline pregnancy rate is so low. This finding may not hold true if this study was performed in an IVF center where the pregnancy rates in young patients was closer to 50% (which is what we expect for patients in their early 30s). More importantly, when studying such complex questions, a clear understanding will not be obtained, and claims of improvement cannot be made, until a number of well designed studies are performed and the majority of results echo a similar theme (either positive or negative).

In her book, Lifang Liang presents a nice overview of the theories behind Chinese Medicine, as well as various herbal treatments available for fertility patients, and their proposed effects. She then presents a number of “Case Histories”, illustrating the use of both herbal therapies and acupuncture. While these are quite interesting, they are anecdotal stories, and do not represent a scientific study to evaluate the role of acupuncture and infertility. The above study by Paulus et al is mentioned in the book, and seems to be the basis for the claim of a 40-60% increase in IVF success rates. As mentioned, this claim should be taken with caution.

All of us who serve patients with fertility treatment, whether trained in Western or Chinese medicine, are looking for the best possible outcome for our patients. It would be wonderful if indeed there was a combination of various treatment approaches which, when practiced together, could provide the best “cocktail”. However, the exact role that acupuncture plays is currently an unanswered question, until more well-designed studies are performed. We look forward to such studies, to better define the role of acupuncture and herbal remedies in the treatment of infertility.

Q:
Can vaginal Viagra increase my odds of having a successful IVF cycle?

A:
Some fertility physicians turn to vaginal Viagra as a tool to improve uterine function. However, there is a great deal of skepticism about the use of Viagra for fertility patients.

One of the key parameters we monitor during a fertility treatment cycle is the development of the endometrial lining: both thickness and pattern. Our aim is to achieve a lining with a minimum thickness of >=7mm, and a trilaminar (or triple) pattern of the endometrial layers, by the day of HCG administration. For some patients, we cannot obtain this type of a lining, despite various hormonal manipulations.

For these patients, and even many without endometrial lining issues, we will typically recommend that she take a baby aspirin per day (81 mg) starting with gonadotropin stimulation. The rational for the use of baby aspirin is that on a micro-vascular level, vasodilation and decreased blood platelet aggregation occurs and therefore improves blood flow to the uterine lining, providing a lining with functional improvement. Blood platelets are the blood cells, which promote blood clotting. Two well designed studies confirm the benefit of baby aspirin use in improving pregnancy rates for patients with endometrial linings <8mm. It is important to note that the lining does not necessarily thicken with the use of baby aspirin – this is a qualitative improvement. It is also important to take only a baby aspirin, NOT a full dose aspirin.

Some fertility practitioners have suggested that Viagra vaginal suppositories for women, which are also a vasodilator, may provide improvements in pregnancy rates in the same way baby aspirin does. It needs to be noted however, that Viagra as a vasodilator works via a different mechanism compared to aspirin. While these claims have been made, well designed studies have yet to prove this. In the interim, Viagra should be used with caution.

Stress reduction through mindful well being… while this may sound like a new age mantra, the medical community is growing in consensus about a mind/body connection that can positively impact a patient’s health. No other physician has probed the mind/body infertility correlation deeper than Alice D. Domar, Ph.D., who has written extensively on health and stress, conducted research and designed a comprehensive workshop series. Included in these mind/body and mindfulness health and wellness programs are relaxation techniques involving controlled breathing and posture awareness; yoga, meditation, journaling, neuro-linguistic programming, and joining a support network. Dr. Domar’s techniques are designed to help women treat their own stress responses so their bodies might have a higher chance of conceiving. Pacific Fertility Center’s team has examined the scientific, medical and anecdotal information surrounding the topic of stress and infertility. And because various relaxation inducing/stress reducing techniques are likely to have an overall positive impact on a patients’ general health, PFC is offering classes modeled around Dr. Domar’s mind/body practice (see Mind/Body@PFC) Indeed, infertility clinics all over the country are offering similar programs despite the lack of scientific consensus about how stress affects fertility. Skeptics point out that millions of people under extremely stressful circumstances, even kidnap and rape victims, regularly get pregnant. But some facts are clear: Ongoing chronic stress can affect menstrual function; change hormone levels; alter blood sugar; increase heart rate and change a person’s immune response. Mind/body therapies are frequently initiated for groups with serious medical conditions, from lupus to multiple sclerosis to major heart disease. It is only natural that the more serious an illness, the more anxiety it can induce in a patient, thus potentially bringing on accelerated and aggravated symptoms. This vicious stress/body cycle, when broken through stress reduction techniques, can provide overall improvement in health. Dr. Domar’s initiated one of the few controlled studies funded by the National Institute of Mental Health on this topic. Results of the research showed an improvement in pregnancy rates using either relaxation techniques or though the psychological support of joining a group. With so much growing attention into the mind/body stress reduction methodologies, there is bound to be a greater body of critical scientific knowledge gathered. Meanwhile, take a deep breath and consider your own stress response strategy.

– Carolyn Givens, M.D. and Isabelle Ryan, M.D. contributed to this article

Q:
Hi – I have severe painful endometriosis, am 34, otherwise healthy and fit with one failed fresh IVF cycle and one failed frozen transfer. Is there anyway I can help the process of implantation? And could the endometriosis be preventing the implantation? Many thanks for your help.

A:
Endometriosis is the condition where tissue that forms the uterine cavity lining each month (and is shed as menstrual flow is now growing outside of the uterine cavity. This extra-uterine tissue is most commonly found around the ovaries, fallopian tubes, and outer layer of the uterus. In general, the negative affects of endometriosis are due to processes occurring in the pelvis. These negative affects make the pelvic fluid more hostile to eggs and sperm. Therefore, the negative pregnancy affects are limited to the processes that are occurring in this pelvic environment (egg bathed by pelvic fluid as they are ovulated, fallopian tubes bathed by pelvic fluid and impacting fertilization and early embryo development). The uterine cavity itself seems to be protected from these negative affects. For patients who need to proceed to IVF, we bypass the “pelvic environment” and all steps which would be occurring in the pelvis are now occurring in the laboratory (egg recovery, fertilization, early embryo development). The uterus is protected from the negative pelvic affects, so pregnancy rates are the same for endometriosis patients, as they are for other patients who need IVF. Exceptions to this would be patients with adenomyosis. Adenomyosis is a benign condition characterized by the endometrium lining growing INTO the muscular layer of the uterus, instead of just staying confined to the uterine cavity. The other exception is for patients who have endometriomas (endometriosis ovarian cysts filled with thick, dark brown blood). These can impact egg quality, so it is not uncommon that if you have endometriomas, it might take a few more IVF cycles than the average to achieve a successful pregnancy.

Isabelle Ryan, MD  and Joe Conaghan, Ph.D contributed to this post