SCIENCE PULSE    Fibroids and Pregnancy

Will my fibroids prevent me from getting pregnant?
A recent PFC study can help answer that question.

Every complete infertility evaluation includes a thorough evaluation of the uterus, where embryo implantation is expected to occur. At Pacific Fertility Center we typically start with a vaginal ultrasound to evaluate for the presence of fibroids (benign growths of the muscle layer), polyps (benign growths of the lining of the uterus), measure the lining thickness of the uterus and observe the uterine lining pattern. If uterine abnormalities are noted, a saline hysterogram (saline ultrasound) or hysteroscopy (visualizing the uterine cavity with a thin telescope) may be recommended.

Fibroids (uterine leiomyomas) are present in 20-40% of reproductive age women. The location of the fibroid(s), relative to the lining of the uterus, is important in determining if it will impact chances of pregnancy. Fibroids which distort the uterine lining and cavity are known to decrease pregnancy rates for patients undergoing fertility treatment. Only about 5% of fibroids directly distort the uterine cavity. The influence of fibroids which do not distort the uterine cavity has remained controversial.

To best determine if non-distorting fibroids also may have an impact on fertility treatment, requires the analysis of a large number of fertility cycles following patients who have non-distorting fibroids, and patients who have no fibroids. Most studies have small numbers of observed cycles, making statistical analysis difficult. One strategy for circumventing this problem, and gathering enough treatment cycles to draw meaningful statistics, is to have large IVF centers collaborate and “pool” data. This type of study is called a multi-center study.

Pacific Fertility Center (PFC) and the University of California San Francisco (UCSF) IVF centers collaborated in just such a study; gathering data on past treatment cycles of egg donor recipients with non-cavity distorting fibroids and without fibroids. Analysis of pregnancy (PR) and implantation (IR) rates were assessed. A total of 369 cycles were analyzed, of which 94 were for patients with fibroids. All recipients underwent their first oocyte donor cycle, and a fresh embryo transfer. Any uterine abnormalities other than non-distorting fibroids were excluded from the study analysis. The primary outcome measure was a clinical pregnancy. Implantation rate was a secondary outcome of the study. We also analyzed to see if the fibroid location: subserosal (growing towards the outside of the uterus) versus intramural (confined to the muscle layer) or if the fibroid diameter impacts PR and IR, as well as miscarriage and ectopic rates.

The following results were revealed.

The clinical pregnancy rate (PR) was not different between the two groups (no fibroids vs fibroids) (54% vs 47%). The implantation rate (IR) was also similar between the groups (38% vs 36%). Miscarriage rates were similar (9% vs 15%). Ectopic pregnancy (which is typically a rare outcome) showed results of 1% vs 4%, which also was not statistically significant. Location and diameter of fibroids did not show a significant impact on PR.

When screening ultrasounds identify fibroids, “treatment” of these lesions is tempting to both providers and patients, especially in cases of unexplained infertility. Our data suggest that there is inadequate evidence to conclude that fibroids which do not distort the uterine cavity have a significant effect on clinical pregnancy rates (PR) in patients undergoing IVF. Thus, there is inadequate evidence to support myomectomy for patients with non-distorting fibroids. Myomectomy may unnecessarily place the patient at risk of delayed treatment, as well as possible surgical morbidity. It is also unknown whether surgery itself may have a negative impact on pregnancy outcome- though our data did not show a lower PR in patients who had past myomectomies.

Future collaborative studies will investigate whether the distance of the closest fibroid to the uterine lining may impact PR and IR. Fibroid volume will also be investigated. These studies are currently in the design phase.

 Isabelle Ryan, MD

“The effects of fibroids without cavity involvement on ART outcomes independent of ovarian age”, PC Klasky, DE Lane, IP Ryan, VY Fujimoto, Hum Reprod Advance Access, published September 22, 2006.

Isabelle Ryan, MD is recognized by prestigious medical associations for her pioneering research leading to new insight into the important clinical problem of endometriosis related infertility. She offers patients a combination of clinical expertise and warm personal care. Dr. Ryan is Director of Pacific Fertility Center’s Third Party Parenting Program which includes our in-house egg donor agency. She has been singled out as a “Best Doctor” in national surveys of her peers (See www.BestDoctors.com).

PFC SPOTLIGHT    My Journey to PFC

My Name is Rosemarie S. Tagle. I am the billing manager at Pacific Fertility Center. I was born in the Philippines, the youngest child in a family of six children--three boys and three girls. Our parents brought us to America to seek a better life and for better opportunities. We immigrated to the U.S. when I was only three years old. We were fortunate that our father served in the United States Armed Forces during World War II because this gave him preferential treatment; we were classified as non-quota immigrants and were able to come to the U.S. without any problems; others weren't as lucky.

In 1967, my family sailed to the United States on the USS Cleveland Cruise Ship. At the time, with six children in tow, it was the most economical way to travel. The journey took us nineteen days. We disembarked at Pier 37 in San Francisco. Waiting for us was our father who arrived a year earlier to get settled and prepare for our arrival. We have remained in San Francisco ever since.

I chose a secure career in the health care field and obtained my Medical Assistant certificate at Bryman College in San Francisco. My first job was working in an Ophthalmology practice. It was a one-physician office with a receptionist, the doctor and me. I enjoyed being a Medical Assistant; however, when a position for Office Manager became available in the Ophthalmology practice, I was ready for more challenging work. I applied for and was offered the job and stayed with that practice for the next fifteen (15) years.

The practice grew during those years from just two to a total of nine employees under my management as well as an addition of an Optometrist and an Optician. Eventually, the office expanded to include the first Optical boutique in San Francisco. Sadly, I left the practice in 2000 after Dr. Leon B. Metz, Jr., the physician for whom I worked, developed cancer and passed away. I was devastated. Dr. Metz, along with his wife and children, became my close friends over the years. I credit Dr. Metz for teaching me the ropes of running a practice well and helping me grow. Though I had the opportunity to continue to work at the office, I decided that it was time to move on.

Shortly after my decision to leave, I heard of a job opportunity at Pacific Fertility Center. At the time, I knew little about IVF or other fertility treatments, but it sounded like an interesting place to work. In 2001 I joined the PFC team. Although I knew it would be an adjustment moving from a small office to a larger one, it did not take long for me to realize that I was going to enjoy working at PFC.

On a personal note, I am the mother of two children; my daughter is 23 years old, and my son is 20 years old. My daughter is a nursing student at San Francisco City College. My son is in the process of obtaining his Barber license and is hoping to open his own shop. I also have a five-year old granddaughter who is in kindergarten and is my pride and joy. During my free time, I take ballroom and Salsa classes, and occasionally have the opportunity to perform.

I also enjoy taking classes at San Francisco City College where I recently obtained an A.S. degree in Administration of Justice/Criminology and a certificate in Forensic Science. I came to this new degree in the process of trying to help a relative who was in trouble with the law. My family and relatives were struggling to understand what was happening, so I became the family's resource for "information interpretation" and stepped in where I could to help during the justice process.

I have learned so much since I started at PFC six years ago. Working here has been a very rewarding and challenging experience. Being the financial manager allows me to see first hand the financial sacrifices that couples and/or individuals make on their journey to becoming parents. I am proud to be a part of a team that can help fulfill that dream. I admire and respect each of the physicians, as well as the rest of the PFC team for their total commitment and dedication to providing the best possible care to patients without reservation. I feel very fortunate to be a part of this team and to be working towards the same goal. Being a manager in any medical practice is always a good way to help people, but this practice is special. We are in the business of giving the gift of life.

 Rosemarie S. Tagle

FROM US TO YOU    Acupuncturist Visits PFC

From time to time, PFC has visitors to the Center wishing to learn more about the field of infertility. We have had medical students from UCSF, visiting reproductive endocrinologists from Europe, and most recently, an acupuncturist studying for her doctorate in Traditional Chinese Medicine (TCM).

Heidi Kao is a licensed acupuncturist and herbalist in San Francisco and a student at the American College of Traditional Chinese Medicine, one of only 8 colleges accredited to award a doctoral degree in the U.S. She is also involved in teaching other TCM students at the college.

Her private practice is specialized in women’s health and chronic pain management, as well as an entire range of ailments. She is now interested in learning more about the Western medical approaches to infertility to better serve her infertility patients. Heidi is spending a minimum of 12 hours per month at PFC, working primarily with Dr. Givens. She is observing everything from initial consultations to ultrasound monitoring and inseminations as well as all the in vitro fertilization procedures performed at the Center. She is also spending time in the IVF laboratory, familiarizing herself with the behind-the-scenes activity of the lab.

We are also learning from Heidi. She is providing literature on the practices of TCM with regards to improving fertility. She has developed a survey for the Center in order that we might know more about how many of our patients are using complementary TCM in conjunction with their fertility treatments here. She is also involved in demonstrating her practices to the staff at the Center.

Please welcome Heidi if you see her around the office during the next few months.

 Carolyn Givens, MD

ASK THE EXPERTS    Will abortions affect my fertility?

  Pacific Fertility Center Team
Left to Right: Front: Philip Chenette, MD, Isabelle Ryan, MD, Carolyn Givens, MD
Back: Joe Conaghan, PhD, Carl Herbert, MD, Eldon Schriock, MD

Question:

I had two elective abortions more than 10 years ago and I am worried that somehow that has something to do with the infertility I am now experiencing. Could the abortions be the reason I am now having trouble conceiving?

Answer:

Most elective pregnancy terminations are done in the middle of the first trimester and are relatively simple, uncomplicated procedures. There is no reason to automatically assume that abortions have anything to do with subsequent infertility. Unless there is an infection, excessive bleeding requiring a second procedure or some other complication, the uterus and fallopian tubes should not suffer any long-term damage. On the other hand, any uterine procedures associated with prolonged bleeding or infection can lead to minor or major scarring of the uterine cavity or the fallopian tubes.

A mid-cycle ultrasound, just before ovulation, should be able to verify that your uterine lining is adequately thick and free of scar tissue. Also, a hysterosalpingogram (HSG) can detect uterine scarring or any obstruction of the fallopian tubes. Even if there is any scarring, which is unlikely, a simple procedure called operative hysteroscopy can often remove the scar tissue effectively. Only the most severe cases would require the use of a gestational carrier (surrogate).

Many, many women have had prior elective abortions and go on to have uncomplicated pregnancies. Women suffering from infertility often also suffer feelings of guilt about prior terminations. Some even think they are being punished for having elected to terminate a pregnancy. This thinking is irrational and is best replaced with positive thinking and a healthy attitude towards the future. This allows them to be active partners in the process of overcoming infertility.

 Carolyn Givens, MD

PFC EGG DONORS    Exceptional Young Women

DonateYourEggs.com

Pacific Fertility Center provides an in–house egg donor agency as a convenient way for our patients to find carefully screened egg donors. Our Egg Donation Agency is always looking for new egg donors to add to our registry. Do you know a college graduate, a student, a young professional or an exceptional woman who might be willing to make a life-altering difference? She could be a young woman who has chosen to delay childbearing or has decided to be childless and wants to help others become parents, or she could be a mother who wants to share the joy of parenthood through the gift of egg donation.

Please send them to our agency’s Egg Donor website www.DonateYourEggs.com. The website has more information about becoming an egg donation and also has an online application.

Please note: Because age is a critical factor in the success of IVF with egg donation, egg donors must be healthy and between the ages of 21 and 29.

Click here: PFC Egg Donor Agency for information about the services we provide egg donor recipients.

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