Sweet’s Rules: Four simple rules I use each day to guide me as I diagnose and treat my infertile patients

During National Infertility Awareness Week, I’d like to share my four patient care rules. I made them up rather spontaneously nearly 22 years ago and I still use them each and every day when I am uncertain of what to tell a patient or how we should proceed.

Before the rules are invoked, it is most important to first understand what brings patients to my clinic. By understanding the causes of their infertility, I will better be able to tailor a treatment plan specific to their needs. Some patients feel this is a waste of time and want to proceed immediately to treatment, but I strongly recommend understanding the issues first before proceeding forward.

So, once the evaluation is complete, my Sweet’s Rules are used to guide us forward-

1. Get my patients pregnant as fast as I can

Time can be an enemy and patients are not necessarily patient. We need to complete the evaluation quickly and move forward as most of my patients wanted to be pregnant many yesterdays ago. Some will call this a “duh!” rule, but it is still a good one to keep me moving forward as the patient desires.

2. Achieve success in the most cost-effective manner possible

We always want to choose the least costly conception method. This might even mean sending the patients on a date to try natural means for a tad bit longer. Hopefully, the successful patient potentially saves a bundle by my guiding them away from costly alternatives. Sometimes, adoption is also the best option and I’ll send them down this new road, if it is needed, even if the practice loses a patient. My cardinal rule is to treat the patients like family and tell them what I would tell someone close to me, regardless of the gain or loss to the practice. Practicing this way has always served may patients well.

3. Minimize complications (i.e., no litters)

I took an oath to do no harm and I take that oath very, very seriously. A multiple pregnancy can be a million dollar pregnancy with complications too long to list here. Always pull back, no matter how much pressure from the patient, if I fear a complication is likely.

4. Minimize the use of procedures with minimal chances of success

This may be the most important rule. I do not like being a “Gynechiatrist” (borrowed from the movie “Knocked Up”) by performing procedures that are unlikely to work. While some patients need to try a procedure destined for probable failure, to have closure and the inner knowledge that they gave it a shot, I prefer to move quickly through these treatments and get the patient to understand what will truly bring them to their goal.

I tell patients these rules when I am trying to guide them through their treatment plan. I believe it helps them to understand why I am telling them something, especially when they don’t necessarily want to hear it. Understanding my motivations, I believe, helps them to appreciate that I truly have their best interests at heart. By following these simple four rules, I will always keep my patients’ needs first and foremost.

While I may not be successful with all my patients, I will always try my best, give them the best information I can and provide options that simply make sense. Interestingly, these rules help me keep on the path, as much as they simultaneously guide my patients, as we make decisions and travel the infertility to fertility journey together.

By: Dr. Craig R. Sweet

Medical Director & Founder

What to Say & What Not to Say to the Infertile Patient

By: Dr. Craig R. Sweet, Medical Director & Founder

(Reprinted from Florida Parenting News, February, 1994, revised September, 1999 and again April, 2011.)


Introduction:

Infertility affects nearly one in six couples. Approximately 40% of the time, the problem is related to the female partner, another 40% is related to male difficulties and 20% of the time both partners will have medical problems. Most of the time, infertility is a symptom of an underlying disease process, a disease process that the infertile patient has no control over. To these patients, infertility can be a crisis of the deepest kind. Every menstrual cycle represents a failure and is a time of grief for the potential child that never came to be.

The infertile patient or couple will often express their feelings through anger, frustration, feelings of inadequacy, depression and guilt. Relationships with family members who have children can suffer, marriages and relationships are strained and well-meaning friends and family can overload the patient with advice and pressure. Family and social gatherings become a reminder of infertility. Baby showers can be a traumatic experience. Mother's and Father's Day are often very, very difficult.

We want to offer some tips that provide support to patients who have not yet had the blessing of a beautiful child to love. With your assistance, most patients going though the process of trying to conceive can maintain a positive attitude.


What Not To Say…

Don't ask a childless person when they are going to have a child. They may be going through the process of trying to conceive, but have not yet achieved success. Asking them only reminds them of their problem and they need no extra reminders.

Don't relate stories of your fertility to them. Hearing “my husband just has to look at me and I get pregnant” is very annoying. While well meaning, the statement is insensitive and unhelpful.

Don't give advice such as “just relax,” “you are trying too hard” or “take a vacation.” All of these very common comments imply that patient has control of their fertility. Most of the time, these patients have absolutely no control over their fertility. Implying control leads to feelings of failure and guilt when this advice doesn't work. It simply is not their fault and they are doubtfully doing anything wrong in what they have done thus far.

Don't offer advice such as sexual timing, position, herbal medications or other totally unproven therapies. There are literally hundreds of old wives’ tales that, when followed, can drive an infertile patient nearly crazy. Their physician will have covered those natural aspects of their care that may maximize their chances for conception. Once again, please to not imply that they have a sense of control as they lost it long ago.

Don't express your derogatory personal opinions regarding insemination procedures, test-tube babies or adoption. Sometimes, these are their only hope for having a child. These are your opinions and uninvited advice is rarely neither desired nor constructive. You are absolutely entitled to your opinion; simply keep it your own. If they ask for your advice, then feel free to state your opinions, but do so in a kind and considerate manner.  Please, do not be judgmental.

Don't place blame by accusing the couple of exercising too much, eating the wrong foods or drinking alcohol. These patients may already be blaming themselves. Their physician will have already covered the medical and reproductive consequences of obesity, smoking, alcohol and recreation drugs. Support them in the cessation of these activities and minimize the guilt associated with their consumption. The guilt rarely leads to cessation but often moves the individual to increased consumption.

What You Can Say and Do…

Do provide couples with plenty of emotional support by saying “It must be difficult to go through this” and “I'm here to listen if you need to talk.”

Do remember that men can be just as emotional about the problem, sometimes even more so. They may feel their masculinity is at risk. Be sensitive to their egos and personality traits.

Do understand the couple's need for privacy.

Do try to understand that if they are your employees, frequent doctor's appointments may be necessary during business hours. Please try to accommodate them as much as possible. Not doing so may also be construed as a form of discrimination and place you at legal risk.

Do understand why they may not make it to a baby shower or a holiday event. These frequent events can become overwhelming for an infertile patient.

Do tell the infertile couple that there is hope.

Conclusions:
Please remember that the vast majority of infertile patients have minimal control of the diseases that causes their infertility. Giving them emotional support during this trying time is a wonderful way to assist them. Giving them subtle hints that they have control plants the seeds of personal failure in the minds of the infertile patient.

Please be kind, be thoughtful and always be supportive.

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Do The Risks Of Ovarian And Borderline Ovarian Cancer Increase With IVF Treatment?

Does infertility treatment cause ovarian cancer?

We are commonly asked if IVF increases the risk of ovarian cancer. Studies conducted over the past 20 years have tried to answer this question. A recent publication by van Leeuwen, et al., examined this issue carefully and produced some very interesting results.

What were the study basics?

The study published recently in Human Reproduction involved a very large retrospective analysis (data collected from the past) in the Netherlands of 25,152 infertile women (19,146 IVF and 6,006 non-IVF infertility patients) who received their infertility treatment between 1983 through 1995. The extensive follow-up period, which averaged about 15 years, made this study unique amongst others.

Why might infertility treatment result in ovarian cancer?

It has been theorized that the risk for ovarian cancer, which is estimated to be a 1/72-lifetime risk in the US, would increase because of ovarian stimulation and/or multiple ovulation sites forming across the surface of the ovary. Partially dispelling these concerns, this study did not show any increased risks for ovarian cancer for non-IVF infertile patients treated with either oral or injectable fertility medications. Also, further debunking the theory was the fact that the risk for ovarian cancer did not increase as the number of IVF cycles increased.

Is there something special about the IVF patient that increases her risk for ovarian cancer?

We also have wondered if the IVF patient simply has something wrong with her ovaries that predispose her to infertility, IVF treatments as well as ovarian/borderline ovarian cancer. The fact that there was a much larger percentage of “unexplained infertility” patients in the IVF-treated group suggests the IVF and non-IVF patient groups were indeed very different from each other.

Also understanding that borderline ovarian cancers normally make up only 20% of all ovarian cancers and are not anywhere as lethal as the more common ovarian cancers, it was somewhat unexpected to find that 46% of all ovarian cancers identified in the infertility patients in this study were borderline cancers. This high percentage of borderline lesions also suggests that something was unusual about the IVF-treated patient population.

What were some of the important findings in the study?

In reading this paper carefully, I was able to identify the following important points, some of which were not emphasized in the study:

  • Tubal infertility IVF patients (i.e., past and/or chronic pelvic infections) were twice as likely to have invasive or borderline ovarian cancers.
  • Those IVF patients who never conceived were twice as likely to have any ovarian cancers and three times more likely to have borderline ovarian cancers.
  • In the study, the actual risk for any ovarian cancer by age 55 was estimated 1/141 (0.71%) in the IVF group compared to 1/222 (0.45%) for the normal population, an overall increased risk of 1/3rd but still a very rare event.
  • Also in the study, the actual risk for borderline ovarian cancer by age 55 was approximately 1/600 for the IVF patients compared to 1/1,200 for the general population, essentially doubling the risk. Still the actual incidence was still very, very rare.

What did we really learn from the study?

While I feel the authors did an amazing job collecting and analyzing the data, I felt the discussion section missed a few very important points:

  • Those that underwent IVF, especially unexplained infertility patients, may still differ in some way which may increase their risk for both prolonged infertility and ovarian/borderline ovarian cancers.
    • In other words, it may not be the IVF procedure itself as much as the underlying characteristics of the IVF patients, which predispose them to ovarian cancer risks.
  • Acute or chronic pelvic infections may very well increase the risk of borderline ovarian cancer.
    • The fact that IVF-treated patients were far more likely to have past pelvic infections may have been responsible for many of the findings described in this study. To the best of my knowledge, this has not been described before. Interestingly, chronic inflammation in other areas of the body also predisposes to some forms of cancer. Perhaps the pelvis is the same.
  • If one conceives through IVF, the risks for ovarian and borderline ovarian cancers drop to normal levels.
    • Either the pregnancy helps reduce the ovarian cancer risks or those who conceive are inherently at a reduced risk for ovarian cancer compared to those who never conceive.
    • This point has been found to be true with past studies that showed an increased risk of borderline ovarian cancers with the use of oral clomiphene citrate when used for more than 12 cycles without an eventual pregnancy. Once pregnancy occurred, even resulting in a miscarriage, the borderline ovarian cancer risks normalized (Rossing MA, et al. 1994).
  • Current regimens used to stimulate the ovaries are very different from those used prior to 1995.
    • The current risk factors could be better, worse or the same as those described in the study because IVF protocols have significantly changed since 1995.

In summary:

The risks for ovarian and borderline ovarian cancer for infertility patients undergoing IVF may be incrementally increased compared to the non-IVF population. Interestingly, far less lethal borderline ovarian cancers are found in a greater percentage in this very special patient population. Confounding factors, such as tubal factor infertility with acute/chronic infections, may increase the risk for ovarian malignancy in this patient population.

No matter how statistically significant the findings are, one still must note that the actual risks described in this study for women age 55 are still extraordinarily rare: 1/141 for any ovarian cancer and 1/600 for borderline ovarian cancers. These risks also are unlikely to deter a highly motivated infertility patient. Keep in mind that the average risk for a genetically abnormal child in IVF-treated patients is probably closer to 1/100, which is far higher than any of the risks for cancer listed in the current study. Let us all keep our perspective.

Still, we need to collect further data as many of the women in the study were only in their middle 50’s and the risks for ovarian cancer generally increase with age.

Above all, an IVF conception may very well reduce the ovarian cancer risks significantly. If conception never occurs, this may signal physicians to monitor the unsuccessful patients more carefully for future potential ovarian malignancies, although the actual incidence of the disease may still be quite rare.

Congratulations to the researchers who put an amazing amount of work into this study and we thank them for their dedication to infertile patients and to those of us who care so much for them.

Craig R. Sweet, M.D.
Reproductive Endocrinologist
Specialists in Reproductive Medicine & Surgery, P.A.
Fertility@DreamABaby.com

References:

van Leeuwen FE, Klip H, Mooij TM, van de Swaluw AM, Lambalk CB, Kortman M, Laven JS, Jansen CA, Helmerhorst FM, Cohlen BJ, Willemsen WN, Smeenk JM, Simons AH, van der Veen F, Evers JL, van Dop PA, Macklon NS, Burger CW. Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort. Hum Reprod. 2011 Dec;26(12):3456-65.

Rossing MA, Daling JR,Weiss NS, Moore DE, Self SG. Ovarian tumors in a cohort of infertile women. N Engl J Med 1994;331:771–776.

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In Memory of the Perfect Imperfect Pregnancies

Pregnancy Loss Remembrance Day – October 15, 2012

Craig R. Sweet, M.D.
Reproductive Endocrinologist
Medical and Practice Director
Specialists in Reproductive Medicine & Surgery, P.A.

Over the Past 27 Years:

Starting my OB/GYN residency in 1985 with completing my fellowship in reproductive endocrinology, infertility & genetics in 1991, I can recall hundreds of pregnancy losses over the past 26 years. There were so many tears, emergency D&Cs, and especially, so many unanswered questions in the tear-filled eyes of my patients.

Nearly all of the women seemed to blame themselves. They felt it was something they did wrong. Perhaps it was the sex they had with their partners. Did they cause the loss by not resting enough? Did they worry the pregnancy into destruction? Was it punishment for a prior pregnancy termination? Was there really a vengeful God? Whose fault was it? What did they do wrong? The questions went on and on. I wanted to find some answers.

The Beginning of my Research:

In 1988-9, the last two years of my OB/GYN residency, I began one of my first real research studies into the causes of pregnancy loss. At that time, we thought that about one-half of all pregnancy losses were genetically abnormal. The method used to provide this estimate was flawed requiring the laboratory to grow miscarriage cells. When the pregnancy didn’t grow well inside a perfect womb, the chances for growth in the laboratory were severely hampered. Not only did the cells frequently fail to grow with no answers provided, the most common reported result was 46,XX (normal female). The 46XX result was was reported twice as often as the 46,XY result (normal male). Understanding that there aren’t twice as many girls born as boys, we suspected that the healthier maternal cells, which are always mixed in with the miscarriage cells, overgrew the poorly growing baby’s cells in culture. Since the two different cell lines didn’t come “color coded,” there was no easy way for the laboratory to tell if the results reflected the mother’s cells (often) or the baby’s true chromosome makeup, termed karyotype. Overall, we found the karyotype truly reliable in only 30%+ of the spontaneous loss cases.

My research goal was to examine recurrent miscarriage tissue directly without growing the cells using a device called a flow cytometer. This research took many months to complete but we learned two extraordinary things:

  1. Direct analysis worked well and we were able to identify pregnancies with missing or extra chromosomes using the flow cytometer.
  2. Many of the reported “normal” 46,XX results were actually the mother’s chromosome makeup with the pregnancies themselves found to be severely genetically abnormal.

In reality, we discovered a new method to evaluate miscarriages finding answers where few had previously existed.

Quite unexpectedly, I received an award for the research in my residency and was asked to present my data at the American Fertility Society meeting (now the American Society for Reproductive Medicine) in San Francisco, in 1989, during the first year in my sub-specialty fellowship. It was this research and work performed by many others which helped us to finally understand that 70%+ of all first trimester spontaneous losses were genetically abnormal. Later, during my fellowship, I also complemented my previous work becoming co-author on research examining autoimmune pregnancy loss wherein acquired antibodies attacked the pregnancy resulting in a miscarriage. I was still seeking answers for my patients understanding that we had a very long way to go.

My Motivation: The Parents of the Perfect Imperfect Child

No matter how imperfect the pregnancy was found to be in the laboratory, these were perfect children to the hopeful parents. These innocent and extraordinarily young lives never kept a parent up all night, vomited on their favorite dress or screamed until any sane adult would cry uncle. These pregnancies and children were flawless. They were always beautiful, always bright and always wonderful. These pregnancy losses were perfect beings in the eyes of the parents as they contained every hope and dream they held for their future children. They were potential NFL football players, fishing buddies, best friends and even future Presidents of the United States. They were everything the parents ever dreamed their children might become. It makes perfect sense that they were and, even to this day, often called angels. It was so hard form my patients to loose such a perfect being.

These pregnancy losses were perfect beings in the eyes of the parents as they contained every hope and dream they held for their future children.

In Memory of my Patients and Their Perfect Imperfect Child

We still lose about 25% of all of our pregnancies and it is heartbreaking. While we certainly try their pain, no words seem to do justice for a parent experiencing such grief. For over two decades, though, my practice has been making charitable donations in memory of their pregnancy loss. It was our little way of having something good coming out of such a sorrowful event. While I doubt it made a tremendous difference in the hearts and minds of my patients, I think it gave them some level of comfort. On this 2012 Pregnancy Loss Remembrance Day, I would like to offer a gentle challenge to all of my peers to consider paying it forward by making a similar charitable donation, or performing some other act of kindness, in memory of all of our patient’s pregnancy losses. I believe it would be appreciated by our grieving patients, good for our own souls and would serve the public in a productive and kind manner.

In the Present:

Fast-forward to last year in 2011 where I was involved in a study, now 22 years later following my first flow cytometer study, using newer technology to once again examine the pregnancy tissue directly. This newer technology was called microarray analysis. Using the microarray analysis, we now obtain reliable results 80-90% of the time again providing answers where only guesses existed in the past. I now use the less expensive, rapid and extraordinarily reliable technique on nearly all of our pregnancy losses in the practice. Showing the patients that it wasn’t the food they ate, the swim they took or the short walk they had which caused the miscarriage, but rather, a terrible but uncontrollable flaw in early development of the embryo and fetus, their perfect imperfect child is extraordinarily valuable and does provide some solace.

Sill, We have Only Just Started:

I know we have much more work to do to not only understand why pregnancies are lost but what we can do to change their destiny. Will we someday be able to treat eggs, sperm and early embryos thereby healing the genetic problems before the pregnancy advances to a point of no return? We can only hope for future intervention.

I am fully aware that answering the question of why these perfect imperfect children were lost doesn’t answer all the questions or fully diminish the self-blame that is so commonly felt, but it is a good place to start.

To the memory of all of those we lost and may they keep those of us in the field of reproductive medicine humble and motivated driving us to answer the questions our patients ask of us regarding why they lost their perfect imperfect pregnancies.

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Embryo Donation – Option for Infertile Couples & Waiting Lives

I recently had the opportunity to be on Theresa Erickson's Internet radio show, Voice America. Known as the Surrogacy Lawyer, Theresa is renowned for her work on behalf of many patients faced with infertility looking for third party options. During my interview, we discussed the option of embryo donation  from the physician, recipient and donor perspectives.

One of our donors, Tori, discussed her infertility experience as well as her and her husband's  decision to donate their remaining embryos following a  successful IVF procedure culminating in the delivery of her twins. You can see a picture of her twins and information regarding her amazing embryos by visiting our website.

Tori's Twins!

Tori and her husband decided that they wanted to “pay it forward” to other infertile couples. Here is a combination of her own words during the interview and some other comments she told me separately:

“Donating the embryos brought on a wide range of emotions; some expected such as the happiness to help another infertile couple, peace in setting the embryos ‘free’ by finally making a decision on their fate and others were a bit of a surprise  such as a brief feeling of sheer panic that I ‘forgot’ something after leaving the clinic. The donation experience to me is like paying it forward to other infertile couples. I did not see any reason to leave the embryos suspended in time, did not want to see them destroyed and there was no reason to donate them to stem cell research when there are so many infertile couples in the world going through the same anguish I went through.

That feeling of anguish kept coming back, that longing and yearning for something that was so easy for others to have, yet so very difficult for me to obtain. I wanted to help someone relieve that awful feeling and by donating my embryos, I had a very good chance of doing just that.”

To listen to the show, please visit our Audio Gallery and click the play button to the right.

I am so thankful for people like Tori and other donors who consider giving their frozen embryos life while helping other people building their families at the same time. If you'd like more information on the process, please visit our embryo donation page on our Website, contact us at (239) 275-8118 or e-mail us at Fertility@DreamABaby.com.

Also, for additional details on surrogacy or fertility via third party assistance, I encourage you to read Theresa's book: Surrogacy and Embryo, Sperm and Egg Donation: What were you thinking?

Please stay tuned for the launching of our expanded embryo donation program called Embryo Donation International! I hope that many couples will consider to “pay it forward” just as Tori and her husband did.

Your thoughts and comments are always welcome.

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Thoughts on "The Switch"?

Did you see the new Jennifer Anniston movie, “The Switch” this weekend? What did you think about how it portrays the subject of infertility? Did you appreciate its humor or just find it way off base? If you didn’t see it, do you plan to? Share your thoughts!

Talk: Male Infertility

Infertility is often believed to be a woman's problem. However, studies indicate that 30 percent of infertility is related to male factor problems such as structural abnormalities, sperm production disorders, ejaculatory disturbances and immunologic disorders. Infertility is a couples' problem and one that must be faced as a team.

Discovering the source of infertility often isn’t the “Aha!” experience a couple may hope it to be. While patients may be relieved to know what the barriers to pregnancy are and how to address them, there is often a challenging emotional reaction for both men and women. Men can feel particularly “alone” in their journey, and it may prove difficult for them to discuss their feelings with their partners, family and friends. Fortunately, there are many support groups available for men, and for couples, struggling with infertility. Many are moderated by trained social workers and infertility specialists, while others are organized by people who have themselves been diagnosed with infertility. Speak to your health care practitioner about support groups in your area, contact a national fertility organization for listings or explore online groups and message boards such as those at ivillage.com, babycenter.com and webmd.com.

Share your comments below. For more information on infertility, visit http://www.dreamababy.com/ or call 239-275-8118.

Looking for Emotional Support?

We understand that our patients may have some difficulty dealing with the emotional stress of infertility and other medical conditions. If you feel you would benefit from psychological counseling, please mention this to us and we will make an appropriate referral to a professional experienced in the specific areas of concern. We recognize the importance of caring for the whole patient and that brief psychological counseling may be an important aspect of treatment. If you are looking for support, please call 239-275-8118 and our staff will help you find the resources you need.  In addition, RESOLVE, The National Infertility Association, has a list of resources that may be of help to you.

The Fertility Chase, Episode 4, WE TV, 5/22/2010

I was in a meeting starting Friday night, all day Saturday and then went to yet another one on Saturday evening, so I was a bit delayed on my post regarding the 4th episode of The Fertility Chase (TFC). I hope you will find that it was worth the wait.

A Woman’s Reproductive Age:
Maria Bustillo, Kimberly Thompson and Juergen Eisermann were the Reproductive Endocrinologists from the South Florida Institute of Reproductive Medicine in the first segment. I know all of these physicians and they do a very good job.

Angelique was the infertility patient. She went through six intra-uterine inseminations (IUI’s). I couldn’t tell if oral or injectable medications were used. Laparoscopy was the next step wherein “unexpected” problems were discovered. In vitro fertilization (IVF) was used next and she conceived and delivered her son, a “mini-me” of her husband. Really, the likeness was quite striking.

The theme was the influence of a women’s age in their quest for parenthood, a topic that has resounded through nearly all the episodes of TFC. It is the single most difficult issue for us to deal with as we cannot make ovaries younger or increase the production of healthy eggs when few exist.

Angelique did highlight a couple of interesting points. All of us have been caught by doing IUI procedures followed by a laparoscopy (out-patient belly button surgery) only to discover that the IUI procedures were unlikely to work because of problems found at the time of surgery. My feeling is that if surgery is to be contemplated, that one not perform too many IUI procedures before doing it. Understand, however, that laparoscopies do not always significantly improve the natural pregnancy rates, it is a “catch-22”. Even so, laparoscopies do often give us a diagnosis and provide us with enough information and confidence to continue the IUI’s procedures or to quickly move to other alternatives. As they say, hindsight is “20/20”, and it is always easier to look back and think of treatments that we would have modified and a bit tougher to do it from the get go.

My last comment has to do with fact that Angelique had infertility insurance coverage. I have seen numerous cases where the treatment plan was different compared to someone without coverage. For example, where a non-covered patient may only try 3-4 IUI procedures, a covered patient may try 6. While not a tremendous difference, each failed month takes it toll on the patients and it so easy to let the insurance coverage influence the treatment plan. I call this the “insurance trap”.

Polycystic Ovarian Syndrome (PCOS):
Edward J. Ramirez, M.D., from The Fertility and Gynecology Center, Monerey Bay IVF, was the Reproductive Endocrinologist in the second segment. Brandi and Monique were the patients featured.

For the readers, the diagnosis of Polycystic Ovarian Syndrome (PCOS) requires that at least two out of three of the following are true:

  1. The woman doesn’t release her eggs on a regular basis.
  2. Male hormone levels are increased in the blood or there is an excess of facial or body hair in such locations as the chin, neck, back, abdomen and chest. Acne can sometimes also present.
  3. That each of the ovaries have more than 12 small cystic structures, which we call antral follicles.

PCOS is the most common endocrine disease in reproductive age women affecting about 6% of the population. It is a very common cause of infertility.

Dr. Ramirez stated that 80% of the patients didn’t ovulate (release their eggs) on either clomiphene citrate (Clomid) or letrazole (Femara). I believe that number is a bit high. In fact, there is ample evidence that it is more likely that 80% will ovulate on the medications, although not all of these will conceive. Nevertheless, these oral medications are a good starting point in addition to treating the other issues that are commonly present including pre-diabetes and even diabetes itself. Problems with weight are also found in about 80% of the PCOS patients so diet and exercise are an essential, although difficult, component of the treatment plan.

I was struck by the words and phrases these young women used to describe their diagnosis of PCOS and infertility including “alone”, “not female”, “jealousy”, “shame” and “depression”. I was very concerned about Monique’s comment that she didn’t have “the will to live”. This level of depression must be treated seriously and be carefully followed by the clinician. Fortunately, Monique conceived and delivered. I hope Brandi soon does the same. Perhaps TFC can follow up on Brandi in the near future.

Male Factor Infertility, Spinal Cord Injuries:
Dr. Randall B. Beacham from the University of Colorado School of Medicine was in the next segment discussing spinal cord injuries inmen. Jasmin was the injured male patient who apparently was unable to ejaculate naturally. Dr. Beacham is well respected and well published.

This couple told a story of being seen by four doctors being told different things before finding Dr. Beacham. Male factor infertility really requires the assistance of a highly trained Reproductive Endocrinologist who also sees male patients and/or a Urologic Infertility Specialist such as Dr. Beacham. Both of these types of physicians are a bit rare so infertility patients have to seek them out.

Jasmin entered an experimental study where clomiphene citrate (Clomid), a medication usually reserved for women, was given to him in the hope of stimulating sperm production. This medication has been studied in the past and was not shown to be useful in the vast majority of men suffering from male factor infertility. I had to laugh when Jasmin said he bought six pairs of shoes and had an urge to shop while on the medication. In reality, Clomid hopefully increases the male hormone in men and the female hormone minimally, if at all. I think he just wanted an excuse to go out shopping.

It appeared that Dr. Beacham was able to stimulate ejaculation through a technique called “electro-ejaculation” wherein a probe is placed into the rectum and electrical current is released resulting in a type of spasm that produces an ejaculate. His wife underwent hormone stimulation of her ovaries to increase the number of targets for the limited quality and quantity of sperm. Presumably, she had an IUI procedure and conceived a little girl. The macho Jasmin clearly wanted a boy but I’m sure he will treat his little girl as a princess.

My only concern in this piece was that it needed to be emphasized that Clomid has not been found to be useful in the previous randomized and controlled studies and had fallen out of favor. I did a search to see if there were any prospective studies published on the subject over the past 10 years and found none. Dr. Beacham made it quite clear that there were no magic medications for male infertility but he apparently feels that this medication may be of some use in this particular kind of patient. If it is to be used, I urge that it be done in a study setting, as it was with Dr. Beacham, so as to not give false hope, waste time or result in unrealistic expectations.

Re-cap:
The last segment was a collection of past segments, including ours from last week about embryo donation. The show ended with the comments that infertility patients were misinformed, misled, suffered in silence and felt powerless. Clearly, TFC is trying to change that and more power to them. I’ll certainly support their effort.

As always, if you agree to disagree with whatever I write, please do not be shy and leave a comment or two. Questions will also be answered when possible. Until then, go forth and try to multiply.

Don't forget to tune in to The Fertility Chase this weekend!

Don’t forget – “The Fertility Chase” airs on this Saturday at 8:30 a.m. on WEtv. A story appeared this week in the Naples Daily News featuring a Naples couple’s journey through infertility: http://bit.ly/aG8fnk