Pacific Fertility Center and The Fertility Flash would like to invite you to a special Valentine’s Day event.
Do You Love Your Genes? Tweetup/Meetup (a Valentine’s Day event)
Thursday February 11, 2010 at 5:30pm
Pacific Fertility Center’s Education Center
55 Francisco St., Suite 550
San Francisco, California 94133 Get Directions

Please join us for genes, love, award-winning wine, chocolate, and tasty, healthy appetizers!

To view the invitation, click here

This is an in-person and virtual event for all who would like to participate and learn about the leading edge of genetics and fertility. We will also be tweeting live during the event to communicate with and connect tweeters.

Genes are an important part of life, especially for those who are struggling to conceive a child.  At this event we will celebrate these building blocks of life in all forms, whether they come from biological parents, birth parents, or donors.

We will also be joined by representatives from Counsyl and the Gene Security Network (GSN) to speak about their cutting edge genetic testing technologies.

For more details on our presenters see:

Pacific Fertility Center: http://pacificfertilitycenter.com
Counsyl: http://counsyl.com
GSN: http://genesecurity.net

**

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—Best regards from all of us at Pacific Fertility Center.

This year’s flu season is certainly not your standard flu season. 2010 brings not only the current seasonal flu variety, but also the pandemic H1N1 virus, commonly known as Swine Flu. These are two separate viruses. H1N1 is not only of great concern for all members of the population, but also of particularly serious concern for pregnant women.

The single most important action, strongly recommended by the Centers for Disease Control (CDC), is for pregnant women to be vaccinated against both the seasonal flu and, most importantly, H1N1. Both the seasonal flu vaccine and the H1N1 vaccine can be administered at the same time, at separate injection sites. There are two methods of dispensing the flu vaccine; either by injection or by a nasal spray (Flu Mist).

For immunization of pregnant women, only the injectable vaccine should be administered. Ob/Gyn practices will be the first to receive the vaccine. Patients should plan to be vaccinated at their Ob office.

Above: Tis the season to be conscious about germs

In addition to the flu vaccines, there is medication available to treat those with symptoms of the flu or those who have been exposed to someone with the flu. Symptoms of the flu can include: cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, and sometimes diarrhea and vomiting. Fever is common, but it is important to note that not everyone with flu will have a fever. If you have symptoms or if you have been exposed to someone who has the flu, call your doctor right away.

Pregnant women with suspected influenza, or experiencing more severe symptoms such as evidence of lower respiratory tract infection or clinical deterioration should receive prompt empiric antiviral therapy, regardless of previous health or age. Most healthy persons who develop an illness consistent with uncomplicated influenza, or persons who appear to be recovering from influenza, do not need antiviral medications for treatment or prophylaxis.

Pregnant women exposed to someone with influenza should consider antiviral chemoprophylaxis. Chemoprophylaxis should generally be reserved for persons at higher risk for influenza-related complications who have had contact with someone likely to have been infected with influenza. However, early treatment is an emphasized alternative to chemoprophylaxis after a suspected exposure. Household or close contacts (with risk factors for influenza complications) of confirmed or suspected cases can be counseled about the early signs and symptoms of influenza, and advised to immediately contact their healthcare provider for evaluation and possible early treatment if clinical signs or symptoms develop. Early recognition of illness and treatment when indicated is preferred to chemoprophylaxis for vaccinated persons after a suspected exposure.

Go to the emergency room immediately if you have difficulty breathing, or shortness of breath, pain or pressure in your chest or abdomen, sudden dizziness or severe or persistent vomiting. Prevention is certainly the best defense–and there are a number of things we can all do to minimize the spread of flu this season.

Wash your hands! Frequent hand washing or use of alcohol-based hand sanitizers is a major preventative measure. Carry a hand sanitizer in your purse, in the car, even a small bottle in your pocket. You can use them just about anywhere at any time.

Cough into your elbow! This helps to keep your germs to yourself.

Keep your hands away from your face! You will not be infected with the flu by touching a contaminated surface — unless you then touch your eyes, nose, or mouth.

Stay away from sick people if you are healthy and from healthy people if you are sick! You do not want to knowingly expose yourself, but remember, if it does happen, call your doctor straight away.

You do not want to spread the flu if you have it. Stay home and stay away from other family members as much as possible and make sure to call your doctor as soon as you have symptoms.

The CDC will continue to update their website as there is new information:

For general information on 2009 H1N1 flu go to:
cdc.gov/h1n1flu/qa.htm

For more information on flu shots go to:
cdc.gov/h1n1flu/vaccination

Assisted reproductive technology (ART) has been a part of modern medicine now for over 30 years and in the US alone over 132,000 IVF cycles were performed in 2007. All birth outcomes are reported to the Centers for Diseases Control but there is no mechanism for long-term follow-up of IVF births.

Well over a million babies have been born world wide through IVF and new data are emerging about reproductive birth outcomes after conception. Some countries, particularly the Scandinavian countries, do an excellent job on gathering data for all births, including IVF-conceived births. One of the greatest risks of ART is prematurity from multiple gestation. From several of these databases, it has become apparent that even singleton IVF births are statistically associated with poorer birth outcomes. Lower birth weights, pre-term delivery and infants small for gestational age (i.e. lower weight than expected for number of weeks in utero) are some of the findings from follow up of IVF babies.

These findings beg the question: is it something about IVF, namely the culture of the early embryo in a lab for the first three to five days of life, that results in these poorer outcomes, or is it something about the couples that need IVF to conceive that is associated with them? This can be a difficult issue to sort out because relatively few people undergo IVF who are not infertile.

A recent study from Norway was published in the British medical journal Lancet that tried to address this question by comparing IVF babies with their spontaneously-conceived siblings. The study compared 1,200,922 spontaneously-conceived live births and compared them with 8,229 live births after ART between January 1984 and June 2006. Of those women who had given birth to a singleton infant after ART, 2,456 also delivered a singleton infant after spontaneous conception. In 56% of the cases, the ART baby was born first and in 44% the ART baby was conceived after the birth of the spontaneously-conceived infant. The researchers looked at birth weight, gestational age as well as a number of other factors.

Compared with women in the general population that delivered a spontaneously-conceived birth, the women that delivered after IVF were older, less likely to smoke and had fewer previous births. Induced labor and cesarean section were more common in the IVF moms. The difference in birth weight between ART and non-ART babies was 131 grams (4.6 ounces). That is, the ART babies weighed, on average, 4.6 ounces, or about 3/4 pound less than the spontaneously-conceived babies. After statistical adjustment for gestational age, maternal age, prior births, year of birth, the difference in birth weight between ART and non-ART babies was 25 grams (0.88 ounces). The ART babies were born, on average, 3.7 days earlier than the controls. After statistical adjustment, the number of days of total gestation was 2 fewer days. Because of the large sample size, these were statistically significant differences but realistically, they were probably not clinically significant.

In comparing the sibling relationship ART vs. non-ART births, the differences were even smaller. The difference in birth weight was only 87 grams (about 3 ounces) for the ART babies as compared to their spontaneously-conceived siblings. The gestational age differences at birth were 1.3 days less for ART. After adjustment, these differences were only 9 grams and 0.6 days. These differences were not even statistically significant.

From these data, we can see that ART births do show statistical differences in some birth outcomes as compared to spontaneously conceived births. However, none of the differences seem are to an extent that would have any real clinical meaning. These differences tend to disappear to a large extent when comparing siblings from both spontaneous and IVF conception, suggesting that it is something about the families that utilize ART, rather than the technique itself that may be associated with the outcome differences.

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 critical an illness, the more anxiety it can induce, thus potentially inducing accelerated and aggravated symptoms. Breaking this vicious stress/body cycle through the use of stress reduction techniques can provide an overall improvement in health. For those experiencing infertility, the hope is that breaking this cycle would lead to an improved ability to conceive.

Skeptics point out that millions of people, under extremely stressful circumstances, 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.

Pacific Fertility Center’s team has examined the scientific, medical and anecdotal information surrounding the topic of stress and infertility. We have found that various stress reducing techniques are likely to have an overall positive impact on a patients’ general health. For this reason, PFC continues to offer classes modeled around Dr. Alice Domar’s mind/body practice (see PacificFertilityCenter.com for more information on Dr. Domar and Mind/Body@PFC Workshops).

Alice Domar, PhD has extensively probed the mind/body infertility correlation. She 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 through the use of either relaxation techniques or the psychological support of joining a group. Based on the results of her research, Dr. Domar’s mind/body programs include instruction on relaxation techniques, controlled breathing and posture awareness; yoga, meditation, journaling, neuro-linguistic programming, and the joining of a support network. These techniques are designed to help women adjust their stress responses so their bodies might have a higher chance of conceiving.

It is our hope that the growing attention to the mind/body stress reduction methodologies will lead to the development of more critical scientific knowledge on the topic. Meanwhile, take a deep breath and review Peggy Orlin’s tips on relieving stress during this holiday season.  Carolyn Givens, MD and Isabelle Ryan, MD

Coping is developing the ability to manage in a difficult situation.
Excited children, crowded stores, decorations, and holiday parties are descending upon us. Yet because the winter holidays tend to celebrate families and children, these usually joyous occasions can bring up painful feelings when you are struggling to create and celebrate with a family of your own. In order to feel as good as possible during the holidays, you will need to develop some good holiday coping skills. Use whichever of these suggestions seem helpful to you. Do what feels right for you.

DO: Give up any and all guilt for how you are feeling. There is no right or wrong way to experience infertility. Your feelings may run the gamut from indifference to intense anger and despair and everywhere in between.

DO: Reach out to childfree friends. Their parties will be adult-focused.

DO: Choose the gatherings you attend carefully. If being around children upsets you, gracefully decline invitations to events where they are likely to be present. Know your limits and stick with them.

DO: Think of non-child centered holiday rituals. Take a vacation. Eat at a fancy restaurant.

DO: Continue to exercise moderately, eat healthy foods and get plenty of rest. You will feel better if you treat your body with care.

DO: Shop for the holidays online or from catalogs. You will avoid mall madness.

DO: Attend religious services at the time when there will be the least number of children. Attend a service on a university campus, which is more adult focused.

DO: Volunteer at a nursing home or homeless shelter. It may help others having difficulty coping and in turn may help you.

DO: Plan for how you will answer uninvited questions about when you’re going to have children. Remember, you are not required to tell them your entire “story!”

DO: Meet and talk with others who are experiencing similar feelings. Finding that you are not alone helps.

DO: Communicate with your partner to let him/her know of your feelings. If you are single, call a friend with whom you feel safe sharing your feelings.

Peggy Orlin, MFT

The Trans fat, found in processed foods, may play a role in infertility. Implicated in prostate cancer, heart disease, and diabetes, and long thought to be a significant hindrance to good health, trans fat has been associated with ovulation disorders, according to a new publication¹.

Trans fats are created in food processing. To avoid rancidity in foods, manufacturers heat oils under pressure to convert natural unsaturated fat to partially saturated fat, adding hydrogen molecules to change the bonds between carbon atoms in the long fatty molecule. Saturated and partially saturated fats are sometimes called partially hydrogenated fats. Saturated fats melt at a higher temperature, and are more stable on the grocer’s shelf. Partially saturated fat is resistant to oxidation and damage, melts at a higher temperature, and does not take on rancid odors and taste. Crisco, partially saturated cottonseed oil, was the first commercial product to be produced with the technique in the early 1900s.

Foods prepared with partially saturated fats can contain up to 45% trans fats. French fries, cheeseburgers, fried chicken, cookies, and chips are common offenders. An order of large French fries can contain 15g of trans fat. Oreo cookies contained trans fat until a lawsuit in 2003 induced Kraft Foods to alter its recipe.

Ideal for a manufacturer interested in long-term storage, saturated fats are not so well tolerated by the human body. Raising levels of LDL and lowering levels of HDL cholesterol, saturated fats have been implicated as a prime cause of the rising risk of coronary heart disease through the 20th century. According to the Nurses’ Health Study², each 2% increase in trans fat calories doubles the risk of coronary artery disease. Since trans fats carry no health benefits and are potentially risky, experts have recommended reducing trans fats to trace amounts in the diet.

Infertility has been associated with trans fat intake. A study published in the January issue of American Journal of Clinical Nutrition from a group of researchers at Harvard University found that women with ovulation-related fertility problems tended to eat more trans fats than fertile women. Obtaining just 2 percent of total calories from trans fats was associated with a doubled risk for this type of infertility. The study showed that each 2% increase in dietary trans fat calories was associated with a 73% increased risk of ovulatory infertility³.

It has been difficult to separate out the effects of total fat and trans fat, since a diet high in trans fat diet is often high in total fats. In contrast to trans, higher total fat is known to decrease the risk of ovulation problems, improving ovulation, whereas women with a diet high in trans fat have an increased risk of ovulation disorders.

Dietary fats have been linked to markers of inflammation, a possible mechanism of trans fat effects⁴. In a randomized crossover study, 50 men consumed diets for five weeks that varied in trans fat content. Inflammatory protein markers were higher in men after the trans fat diet, showing that dietary fatty acids can modulate markers of inflammation.

The data is preliminary, but concerning. Since trans fats have no benefit and carry potential risks, they are best limited in the diet. Labeling requirements now include listing of trans fat content for foods. Lawmakers in several major US locales have passed regulations banning trans fats. Tiburon, California, on a voluntary basis was the first city to have trans fat free restaurants. Restaurants in New York City and Philadelphia are barred from using trans fat containing frying oils and spreads. The ban will be expanded to all restaurant foods next year. California is considering a statewide ban on trans fats.

Reducing processed foods and avoiding trans fats in your diet is an excellent goal for all, but patients with infertility may have special concerns. While more research is required regarding infertility and diet, there is no question a healthy diet is important. A diet of diverse and balanced carbohydrates, proteins, and fats, including omega-3 fats, will provide personal and possibly reproductive benefits for years to come.

Philip Chenette, MD

References:

1. Chavarro JE et al., May 2007, A prospective study of dairy foods intake and anovulatory infertility, Human Reproduction, 22 (5): 1340-1347.

2. Hu, FB et al. 1997 “Dietary fat intake and the risk of coronary heart disease in women”. New England Journal of Medicine, 337 (21): 1491-1499.

3. Chavarro JE et al., January 2007, Dietary fatty acid intakes and the risk of ovulatory infertility. American Journal of Clinical Nutrition, 85 (1), 231-237.

4. Baer DJ et al., June 2004, Dietary fatty acids affect plasma markers of inflammation in healthy men fed controlled diets: a randomized crossover study. American Journal of Clinical Nutrition, Vol. 79, No. 6, 969-973.

The American Society for Reproductive Medicine (ASRM) is the largest organization in the United States for medical professionals in the field of Reproductive Endocrinology and Infertility. In 2002, ASRM published medical and psychological guidelines for ovum donation. The psychological recommendations for donors are general guidelines for addressing moral, ethical and psychosocial issues that may confront ovum donors. Included are standards for what should be included in a psychosocial screening of donors and reasons to exclude donors. A few of the objective reasons for donor exclusion include known substance abuse, positive family history of heritable psychiatric disorders such as schizophrenia or bipolar disorder, or instability in donors’ lives. To determine “inclusion” I take a psychosocial history and administer a psychological test that informs me about the donor’s personality profile, including just how much they are trying to impress me – the “fake good” factor. I am also assessing motivation to donate and the donor’s “need” versus “desire for” the compensation. Stability, stress levels, and reproductive history are also part of an ASRM assessment of donors.

Although I would like to base my entire decision on objective information, much of my decision on donor acceptance must, in fact, be based on intuition. Throughout my 25 years as a therapist, I have found that my intuition is quite accurate, but it is not fool proof.

There is one major controversy in the field that may hinder a psychotherapist’s ability to screen donors. That is the hotly debated topic on compensation of donors. In August 2000, the Ethics Committee of The American Society for Reproductive Medicine concluded that there is no consensus on the precise payment that oocyte donors should receive. It was suggested, “sums of $5,000 or more require justification and sums above $10,000 go beyond what is appropriate.” Due to costs of living and the scarcity of available donors, there are significant regional variations that affect these rates.

The Society for Assisted Reproductive Technology (SART) has attempted to assist clinics and patients by creating a list of Egg Donor Agencies that have signed an agreement stating that they will abide by the Ethics Committee Guidelines governing the compensation of egg donors.

The debate centers on the fact that donors could feel undue inducement and exploitation in the process if the fee is so high as to be coercive. Part of the job of the mental health professional is to provide donors with informed consent. Might donors conceal pertinent medical information that could be important for themselves or offspring if the monetary incentive is so high? Will donors discount risks to themselves? How can the donor actually give informed consent about the medical procedure and pay attention to the risks if $$ signs are floating before their eyes?

Ethicists and some in the field of women’s health advocacy express concern “that lucrative payments are enticing young women with credit-card debt and steep tuition bills to sell eggs without seriously evaluating the risks.” Can the payment cloud someone’s judgment and can we assess that? How much is too much? Where is that line?

When I began working with PFC in 1998, we were paying first time egg donors $2,500. Nine years later, the compensation is $6,500 for a first time donor and $7,000 for any subsequent donations. Even adjusted for inflation, the payment is rising at a phenomenal rate. Competition, supply and demand govern these rises.

As part of my objective/intuitive approach to interviewing donors, I discuss money with them. What would she use the compensation for? How does she support herself? What kind and how much debt does she have? While $25,000 in student loans points to a person’s drive toward positive goals, the same amount in credit card debt speaks to me of impulsive behavior. How much have they educated themselves on ovum donation? Whom have they talked with about their desires? Do they have their own children? Are they science majors who may be more likely to view gametes as DNA and not their own children? Are their answers well thought out?

My goal is to provide the recipients of donated eggs with intelligent, healthy, and thoughtful young women who understand the implications of ovum donation both for themselves and for the recipients. Donors who are motivated by the “need” for money are more likely to provide inaccurate information on their applications, or leave out information that could be pertinent to the recipients or their offspring. It is my job and the job of the Egg Donor Agency to determine motivation.

Although impossible to attain, we would all like donors to be motivated altruistically. We may diminish altruism by making the donation about eggs for money. However, I believe we can increase altruism by helping the donors to have a greater understanding of who the recipients are and what their struggles have been.

Peggy Orlin, MFT

Ms. Orlin served as 2006-7 chair of ASRM’s Executive Committee of the Mental Health Professional Group, is a member of Resolve’s National Mental Health Advisory Board. She co-teaches PFC’s Mind/Body workshops.

To register for the September 8th Mind/Body@PFC Workshop, please phone 415-834-3095.

As a patient undergoing fertility treatment, the many months of testing, uncertainty and waiting had begun to take its toll. Dividing my life into two week increments no longer had the same hope and anticipation that defined my first few months of trying to conceive. Seemingly harmless questions from friends and relatives, like “So…any good news to report?” had become annoying questions that received a snappy response.

Attending the Mind/Body workshop was a valuable experience on many levels. We began the day with a tasty breakfast and coffee while we introduced ourselves and spoke briefly about our own experiences trying to conceive. PFC instructors Peggy and Allison presented the research on the stress/infertility connection, and spoke about the isolating nature of infertility. Because the topic of infertility is not openly discussed in social situations, the person or couple going through treatment often lacks social support.

Next, we were introduced to relaxation techniques, which Allison and Peggy call “Minis” because they are short and easy to incorporate into daily life. We lay on yoga mats in a darkened room and slowly counted our breaths, letting go of the tension in our arms and legs. We were led through some basic tai chi moves, and then ended with a guided relaxation that put me immediately to sleep.

After a delicious lunch the discussion moved to the cognitive distortions that frequently emerge during stressful periods and cause people to magnify their problems. Peggy and Allison led us through some cognitive restructuring steps, which can help identify a true thought versus a magnified and distorted fear.

Questioning negative thought patterns is a difficult but extremely helpful way to take some of the blame off of myself and ease the level of stress I was feeling. Hearing that others had the exact same thought patterns as I did was also extremely reassuring and made me feel as though I was not alone in my challenging journey.

The next part of the day was my favorite. We learned a variety of yoga postures that can easily be done in a desk chair or in front of a computer. My co-workers may think I look funny, but I have been contorting myself at my desk ever since, and found that it truly does relieve the physical stress of staring at a computer all day, and provides me with a nice mental break before I start a new task.

After another guided relaxation session, which again left me in a deep sleep, we convened as a group to review the day. Peggy asked us to think about what brings us joy, and how we incorporate those things into our lives. As I looked around the room, most people were smiling as they wrote down the things that bring them joy – everything from pets, partners and family to bubble baths, traveling, and good food.

As we finished the day with questions, answers and good-byes I left feeling refreshed from my mini-naps and excited to have some tangible skills to utilize whenever I find myself too stressed to relax. From our very first discussions over breakfast to our final activity, I felt the isolation of my own stressed out perspective melting away. I’m grateful that I attended the Mind/Body workshop, both for the feeling of community and the concrete relaxation skills I came away with.

The Mind/Body Workshop was an invaluable experience. I came away feeling like I had:

• Gained tangible relaxation and yoga skills that I can use in my daily life.
• Decreased feelings of isolation and anxiety.
• Finished the day feeling calm, centered and ready for my journey to parenthood!

Erika Linden

Infertility can cause extreme feelings of stress and isolation. From diagnosis to treatment, the stress of infertility can affect every area of life including marriage, job, and family relationships. Pacific Fertility Center’s Mind/Body Workshop is designed to address the emotional and physical strain caused by infertility treatment and the far-reaching effects it has on one’s life. These workshops are run by Pacific Fertility Center’s Peggy Orlin, MFT and Allison Chamberlain, RN, who were both trained by Alice Domar, PhD, a Harvard Medical School expert and pioneer in the subject of the mind/body connection to fertility. The next Mind/Body Workshop will be held on September 8th. Please call 888-834-3095 for class information, fees and your registration form. This one-day workshop is a loving and supportive environment in which you can gain self-awareness and practice techniques that will give you strength as you travel on your journey.

- Allison Chamberlaine, Mind/Body Instructor and Clinical Coordinator The workshop provides people with a safe space to learn relaxation techniques and to connect with others that know how difficult the infertility experience can be.

- Peggy Orlin, Mind/Body Instructor and Marriage and Family Therapist

Many women are aware that very low body weight and low percentages of body fat can compromise ovulation and chances for successful conception. What many don’t realize is that excess body fat can also affect one’s chances.

A review of the literature shows that the majority of studies published report decreased chances of conceiving with in vitro fertilization (IVF) if a woman in significantly overweight. IVF data is useful to study this issue because all the women undergo similar treatments and because follow-up data on pregnancies is usually readily accessible to researchers. It may also be true that excess body weight is a negative factor in spontaneous conception and non-IVF treatment as well.

How much of a factor is weight in decreasing conception? One study from the Netherlands reported a higher cycle cancellation rate due to poor response to stimulation and lower fertilization rates¹ than normal weight women. Another study from Norway reported higher requirements for stimulation medications and a higher miscarriage rate in the first 6 weeks of pregnancy². One of the largest studies was from Cornell and reported on 960 women undergoing IVF. Although they did not find a statistically significant decrease in clinical pregnancy rates, rates of cycle cancellation were higher and gonadotropin dose requirements were greater in the obese patients³. Another large study from Iowa (1,293 patients) looked at outcomes in women who were obese and morbidly obese. Again, this study found that clinical pregnancy rates per egg retrieval were similar to normal-weight women but cancellation rates and gonadotropin dose requirements were much higher in the obese women. Furthermore, rates of pregnancy complications such as preeclampsia, gestational diabetes and cesarean section were higher in the obese women⁴.

How much weight is significant for this effect? Most studies calculate weight as Body Mass Index, or BMI. This calculation takes in weight vs. height. To calculate your BMI, many websites such as the one at the Centers for Disease Control ( www.cdc.gov/nccdphp/dnpa/bmi/index.htm) can provide a calculator. There is also a chart at the federal government’s website www.consumer.gov/weightloss/bmi.htm. You just need to know your height in feet and inches and weight in pounds. A normal BMI is between 18.5 and 24 and overweight is a BMI of 25 to 30. A BMI of 30 or more is considered obese and 40 or more is considered morbidly obese.

In general, it appears that excessive body weight can negatively impact a woman’s chances for conception and for a healthy, uncomplicated pregnancy and birth. It makes sense that being a normal body weight and in good shape is a good idea and should be a goal for aiding successful conception.

Carolyn Givens, MD

References

1. Gynecol Obstet Invest. 2005;59(4):220-4. Epub 2005 Mar 7. Obesity and Clomiphene Challenge Test as predictors of outcome of in vitro fertilization and intracytoplasmic sperm injection.van Swieten EC, van der Leeuw-Harmsen L, Badings EA, van der Linden PJ.

2. Hum Reprod. 2004 Nov;19(11):2523-8. Epub 2004 Aug 19. Impact of overweight and underweight on assisted reproduction treatment. Fedorcsak P, Dale PO, Storeng R, Ertzeid G, Bjercke S, Oldereid N, Omland AK, Abyholm T, Tanbo T.

3. J Reprod Med. 2004 Dec;49(12):973-7 Obesity and in vitro fertilization: negative influences on outcome. Spandorfer SD, Kump L, Goldschlag D, Brodkin T, Davis OK, Rosenwaks Z.

4. Obstet Gynecol. 2006 Jul;108(1):61-9. Obstetric outcomes after in vitro fertilization in obese and morbidly obese women. Dokras A, Baredziak L, Blaine J, Syrop C, VanVoorhis BJ, Sparks A.

Many couples, in the midst of their struggle with infertility and who may have undergone several cycles of fertility treatment, have a hard time visualizing success. They often have an even harder time believing they could conceive a multiple gestation. On the other hand, many fertility patients may see a twin gestation as a positive thing in that they can increase their family size all at once – a bargain!

In this country, we have seen an increase in the percentage of twin births that has become phenomenal and is mostly due to an increase in the use of fertility medications and assisted reproductive treatments. Of the 35,025 babies born from IVF in the year 2000, 44% were twins and 9% were triplets or more. Nationwide, the number of twins has increased by 65% since 1980 and by 38% since 1990. These numbers have not gone unnoticed by public health officials, insurance companies and increasingly, lawmakers.

Thankfully, although in the early 1990′s we saw astounding increases in the number of triplet and higher-order multiple gestations, the good news is that these numbers are falling. This change is felt to be due to increased awareness on the part of reproductive specialists and consequently better education of their patients about the desirability of avoiding triplet+ gestations.

Although most twin and even most triplet babies survive without serious problems, these pregnancies do involve significant increases in the risk for poor outcomes. This is because the gestational age at delivery (averaging 40 weeks for a singleton pregnancy) is decreased on average by 3 weeks for each additional fetus. Neonatal Intensive Care Unit admissions are significantly higher as a consequence. Only 9% of singletons end up in the NICU but 48% of twins and 78% of higher order multiples are admitted to the NICU. Intrauterine death (stillbirth) is increased 5-fold in twins. Neonatal death (death within the first month of life) is increased 7-fold for a twin as compared to a singleton. (See Table below.)

Treatment of prematurity has allowed even some of the lowest birth weight babies to survive. But survival may not mean disability-free living. Cerebral palsy is a devastating permanent brain injury that occurs either in the uterus or at the time of birth. For twins, the incidence is 4 times higher than singletons and the incidence is 17 times higher for triplets. Ultimately, the main worry is having a child with a severe handicap. This risk is 1.7 times higher for twins and 2.9 times higher for triplets. While the risks of twin gestation are definitely measurable, most high-risk pregnancy specialists do not advocate selective reduction of twin gestations. Most do advocate selective reduction of triplet+ gestations, however.

The maternal risks increase with multiple gestations and the risks rise with each additional fetus. These risks include high blood pressure, postpartum hemorrhage, excessive nausea, miscarriage, gestational diabetes, preterm labor, Cesarean section and even maternal death. Although obstetrics has come a long, long way in this country in the last 100 years, pregnancy and childbirth still pose medical risks to mothers and these risks are definitely affected by multiple gestation.

The purpose of this article is not to frighten patients considering fertility treatments. It is meant to educate our patients about these risks and to help our patients to understand why Pacific Fertility Center is doing its best to adhere to ASRM guidelines. However, we wish to retain the rights to individualize our treatments and adapt to the specific circumstances for each of our patients. We do not want to see the government interfere with medical decisions that should be made between physicians and their patients. This is why our motto is “Conception Solutions: One Healthy Baby at a Time.”

Carolyn Givens, MD

While many factors leading to female factor infertility are out of a patient’s control (genetics, for example), there are several measures patients can take that will help optimize their chances of conception.

At the forefront is receiving routine gynecological care. During the preconception phase, it is important that the patient have an up-to-date Pap smear and mammogram. Furthermore, the patient should undergo testing for infectious diseases (Hepatitis C, Hepatitis B, syphilis) and immunization status for varicella and rubella and hormones which can affect ovulation (prolactin and TSH). Any fibroids or polyps the patient has should be evaluated to make sure they wouldn’t adversely affect the chances of conception. Also, the patient should be taking essential prenatal vitamins as prescribed by her OB/GYN.

Certain behavioral factors should also be assessed and, in some instances, eliminated prior to trying to conceive. Smoking and drinking should be eliminated and exercise should be moderated. Incorporating a regular exercise program along with a balanced diet is recommended. The diet should include lean proteins, a colorful variety of fresh fruits and vegetables, combined with a limited intake of processed and fatty foods.

Women who are extremely thin or very heavy should seek the help of a nutritional counselor to attain a healthy weight without fad or crash diets. Embarking on a new, strenuous exercise regimen or crash diet just before attempting to become pregnant is not recommended. Medications being taken for preexisting medical conditions should also be evaluated to ensure they won’t compromise a pregnancy.

If the patient requires a fertility specialist, it is recommended the following tests be performed prior to seeing a specialist. This will streamline the diagnosis process and expedite them on their path to proper treatment. This includes testing of the ovarian hormones, follicle stimulating hormone (FSH), Estradiol; a semen analysis (for the male partner) and an HSG (dye study) to assess tubal patency. See more about fertility testing…

Age is a critical factor in the outcome of infertility treatment and it is important for patients to be more proactive the older the patient gets. At Pacific Fertility Center (PFC), our guideline for patients is to seek help from a fertility specialist after: 1 year of trying for women less than 35 years of age; 6 months of adequately timed intercourse or inseminations for women ages 35-39; 3-6 months of trying for women over 39. See more about age and fertility…

Again, time is of the essence when it comes to getting treatment from a reproductive expert, and, keeping that in mind, there are several tests that we do not encourage patients to take prior to seeing an infertility specialist based on their limited usefulness.

They include:

• Post coital test
• Sperm penetration assays
• Endometrial biopsy
• Serum antisperm antibodies
• Cervical cultures
• Laparoscopy
• Autoimmune factors

Ultimately, conceiving through assisted reproductive technology (ART) is a team effort involving the patient, OB/GYN, and fertility specialist, with the process beginning several months before the patient steps foot in an IVF clinic.

Click here for more information on pregnancy preparation.

– Eldon Schriock, MD