ACRM

Family Building Options for Same-Sex Couples

By: Jim Toner, MD, PhD, ACRM

I bet you might wonder how to build your family if you’re in a same-sex relationship.  Well, the good news these days is that it can be done! 

The approach depends on your gender: female couples are missing only the sperm, so most times intrauterine insemination (IUI) of donor sperm will do the trick.  Beforehand, it makes sense to verify the eggs are healthy and the tubes are open, but that’s about it.  It may take a few cycles before pregnancy occurs, but it’s pretty straightforward.

Sometimes female couples want the eggs to come from one partner, and the resulting embryos to be carried by the other.  This too is feasible.  It’s essentially an in vitro (IVF) cycle, which has a higher pregnancy rate than an insemination cycle anyway, but is more involved and more costly.  Here the status of the tubes doesn’t matter very much, but the egg supply question is even more important.

For male couples it’s a bit more complicated, because in addition to 1. needing an egg donor to go through IVF to generate some eggs, 2. a different woman will need to carry the pregnancy, and 3. a lawyer will be needed to craft an agreement among all the parties, and also file a ‘pre-birth’ order with the court to establish intended parentage. 

But the good news is that having a family via assisted reproduction is possible no matter what kind of relationship you are in.

PCOS

By:  Sue Ellen Carpenter, MD, FACOG, ACRM

Polycystic Ovarian Syndrome (PCOS) is a medical condition, present in 4 to 12% of the female population.  PCOS is characterized by irregular menstrual cycles and elevated androgen (“male-type”) hormone levels.  Women with PCOS rarely ovulate on their own, which is the cause of their infrequent periods, and may also have acne and/or facial and body hair caused by the increased androgens.  Failure to ovulate regularly often leads to infertility in women with PCOS. 

The specific symptoms experienced by any individual woman are determined by her ethnic and genetic background as well as the severity of her hormonal abnormalities.  Thus, the presentation of polycystic ovarian syndrome can vary widely.   As a result, patients may seek medical advise to correct irregular menstruation, reduce excessive hair growth and acne or to achieve pregnancy.  Although 15% of women with PCOS are lean, many women with PCOS have difficulty with weight gain and benefit from nutritional guidance and increased exercise.  ACRM's nutritionist, Paige Espenship, is skilled in advising women with PCOS on approaches that are specific to their situation.

The diagnosis of PCOS is made on the basis of  the clinical history, androgen hormone levels (or  signs and symptoms of high androgen levels) and with pelvic ultrasound for polycystic ovarian morphology.  The ovarian follicle is the tiny “cyst” that forms around each egg.  Typically, women with PCOS will have an increase in the number of small follicles (more than 12  per ovary) as measured by vaginal ultrasound.  Often the follicles are arranged around the edges of the ovary like a “strand of pearls” around a central solid ovarian stroma.  AMH (anti-mullerian hormone) is a blood test that can be used to confirm the tendency toward PCOS.  The numerous tiny follicles present in PCOS are associated with higher than normal AMH levels.

The laboratory evaluation for PCOS is used to exclude other diagnoses that can cause irregular menses or hirsuitism: such as thyroid disorders, adrenal disorders and high prolactin levels.  Estradiol, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are evaluated to rule out other ovarian abnormalities.

There is an association between high insulin levels, adult onset diabetes and PCOS.  Woman with PCOS are screened for diabetes and high insulin levels by having a glucose tolerance test.  High cholesterol levels are associated with PCOS, so women should have an annual lipid panel.

Treatment for PCOS varies of the course of a woman's reproductive life.  Working to maintain ideal body weight is always important.  When pregnancy is not desired, oral contraceptive pills help to manage menses and control high androgen levels.  Anti-androgen medications (such as spironolactone) can be added to birth control pills to suppress androgenic symptoms such as excess hair growth and acne.

When women wish to conceive, ovulation induction is carried out using oral medications: clomid or letrozole.  Insulin-sensitizing medications such as metformin or glucophage are often added to improve the efficacy of the fertility medications.  Monitoring of ovulation with ultrasound, blood work, home ovulation predictor kits and progesterone levels, helps women to gain an understanding of how their ovaries are responding.

If oral medication is ineffective, the use of gonadotropin injections (injectable fertility medications FSH and LH with brand names such as bravelle, follistim and menopur) can be considered.  This is safest and most effective in the setting of  in vitro fertilization.  The use of injectable medication is associated with higher order multiple pregnancy (triplets or more) and ovarian over-stimulation.  These effects are mitigated in IVF where we can control the risk of multiples by limiting the number of embryos implanted in a single cycle. 

For some women, an outpatient surgical procedure called “ovarian drilling” may be used to improve the ovaries response to medication.  Your physician can help you assess when this option may be appropriate for you. 

In summary, polycystic ovarian syndrome is a complex disorder with varied clinical presentations. Even the experts sometimes disagree on criteria for diagnosis, but there are numerous treatment options available that can be tailored to meet your particular circumstances.  A specialized, complete evaluation will help you to understand your body and to choose effective treatment.

Reasons for using Donor Egg

By: Tamara Ard, RN, Third Party Coordinator, ACRM

For many couples, the use of donated eggs provides the only viable option for fulfilling their dream of parenthood. As Third Party Coordinator at ACRM, I see a wide variety of reasons why couples choose to use donor eggs. The most common reasons are; premature ovarian failure, diminished ovarian reserve, genetically transmitted diseases or a history of failed IVF cycles.

Ovarian follicles are the basic units of female fertility. The eggs or oocytes, develop inside the follicles. Premature ovarian failure results from either follicular depletion (low or few number of follicles) or follicular disruption (interference in follicular development). Causes of follicular depletion include genetic disorders such as Turners Syndrome and Fragile X Syndrome, or exposure to certain toxins like chemotherapy or radiation. Follicular disruption can be caused by an immune system response. In this case, your immune system produces antibodies against your own ovarian tissue causing harm to the eggs. In some cases follicular disruption is due to unknown factors.

Diminished ovarian response is defined as a large reduction in the ability of the ovary to produce good quality eggs. The most common reason for this is advanced maternal age. Women are born with a finite number of eggs, and this number declines with age.  There are hormone tests that help predict a woman’s ovarian reserve like FSH and AMH, but age is the ultimate measure.  If the couple finds that the woman, or both partners, are carriers of a genetically transmitted disease, such as cystic fibrosis or sickle cell, they may choose to use donor eggs to decrease the chance of passing this on to the child.

Finally, if a couple has failed IVF cycles using their own eggs in the past, the doctor may recommend using donor eggs, especially if they think egg quality may be an issue.

Sometimes sadness, disappointment and anger are common feelings experienced by women when they are told donor egg is the only option for them to conceive a child. Women often grieve the absence of their genetic influence, but it is important to seek counseling to work through these feelings.  Support groups are a good outlet for them to express their feelings with other women in the same situation.  The important thing to remember is that genetics are not what makes you a true parent. It’s the love and bond you will share with your child.

Top Questions to Ask your Insurance Company

By: Steven C. Gerson, CPA, MPAcc, Chief Financial Officer, ACRM

One of the best ways to be certain that there are no surprises with your infertility insurance coverage and payments is to be sure to ask a lot of questions to your insurance company, and to ask the right questions.  Here’s a guide for you in talking with your insurance company.

Do you know what type of fertility coverage your insurance company provides?

GENERAL:

What are my fertility benefits?

• Do I need a referral to obtain fertility treatments?
• Do I need a pre-certification to obtain fertility treatments?
• Do I have co-pay or deductible for fertility treatments?
• Do I have a lifetime maximum benefit for infertility?
• Maximum allowed attempts for IUI and/or IVF?

 

COVERED SERVICES:

Do you cover medication administration education (mixing medications and injections)?

What treatments or procedures related to treatments are covered?

• Ultrasound?
• Medical Fertility Therapy?
• IUI/artificial insemination?
• IVF?
• Intracytoplasmic Sperm Injection (ICSI)?
• Cryopreservation?
• Assisted Hatching?
• Preimplanation Genetic Diagnosis (PGD)?

Are there any requirements which must be met before my fertility benefits become effective?

• Certain number of IUIs before IVF can be attempted
• Documented medical history of infertility?

What diagnostic testing is covered?

• Diagnostic prenatal labs (Hep B, Hep C, HIV, etc)?
• Progesterone, Estrogen and AMH levels?
• FSH, LH, TSH and Prolactin levels?
• Semen analysis?
• Hysterosalpingogram (HSG), sonohysterogram (SHG), endometrial biopsy, ultrasound?

Are prenatal screening (infectious diseases) and genetic carrier screening tests covered?

Are lab services covered at the infertility clinic’s lab, or am I restricted to certain lab/facilities?

What treatments are excluded?

Are donor sperm and/or egg options covered?

Is cystic fibrosis carrier screening covered?

• CPT codes 83894, 83896, 83912, 83901
• ICD9 code V26.3

MEDICATIONS:

Which medications are covered?

• Clomiphene Citrate (Clomid)?
• Letrozole?
• Gonadotropin Injectibles (FSH or LH medications: Follistim, Gonal-F, Bravelle, Luveris,

                            Menopur, Repronex and others)?

• GnRH Agonists/Antagoinists (Lupron, Ganirelix, Cetrorelix and others)?
• Progesterone/Prometrium/Endometrin  (tablets, suppositories, injections and others)?
• Estrogen/Estrace (tablets or patches)?

 

(Note: These questions are meant as a guide only. You should be aware all expenses may not be covered.)

Treatment Options for Endometriosis

By: David L. Keenan, MD, ACRM

Endometriosis is usually diagnosed at the time of laparoscopy, which is an outpatient procedure to look inside the abdomen and pelvis with a lighted scope.  Endometriosis describes the condition where endometrial implants of tissue are found in the abdomen and pelvis, outside of their normal location inside of the uterine cavity.  Many patients have symptoms of endometriosis even though they have not undergone laparoscopy to make absolutely sure.  Symptoms include dysmenorrhea (painful cramps during menses), pelvic pain, dyspareunia (painful intercourse), and infertility. 

Treatment options include resection or removal or ablation of these tissue implants at the time of laparoscopy.  For treatment of endometriosis that cannot be removed surgically or for medical treatment without surgery, oral contraceptive pills and progestational medications have been used for suppression of symptoms.  GnRH analogues such as Lupron have also been used for medical treatment of endometriosis, but have a limited time period of treatment (usually around 6 months).  If the desire is to conceive after having the diagnosis of endometriosis, these aforementioned medications are precluded, and treatment is directed toward conception, while also hoping that symptoms of endometriosis are lessened after delivery.  For women with endometriosis trying to conceive, treatment options include superovulation (ovarian stimulation) with intrauterine insemination (IUI), in vitro fertilization (IVF), and laparoscopic surgical treatment. 

If you feel that you may be at risk for endometriosis or have experienced the symptoms mentioned above, especially if you are trying to become pregnant, should see a gynecologist or a reproductive endocrinologist for a definitive diagnosis, and treatment options.

Fertility Drugs: What they are, what they do, & when they are used

By: Sue Ellen Carpenter, MD, ACRM

Fertility medications are used to enhance ovulation; to stimulate the release of an egg from the ovary.  Women with very irregular menstrual cycles find that it is difficult to conceive because that are not ovulating regularly. First you will have testing to identify the cause of the anovulation. Some of these causes, such as thyroid, adrenal or pituitary abnormalities, may have specific treatments. 

Other patients will be advised to use oral medications such as clomid (clomiphene citrate) or femara (letrozole) to induce ovulation.  Both medications interact with the pituitary gland to increase in your body's own stimulation of the ovary.  They are  pills that are taken for 5 days early in the menstrual cycle.  Ultrasounds and bloodwork done a few days after treatment help your doctor gauge your response.  The goal is to produce 1 or 2 eggs in a timely manner, using the lowest effective dose of medication. 

Clomid and femara are also used in somewhat higher doses to augment ovulation in patients with unexplained infertility.  These patients may combine ovulation induction with intrauterine insemination (IUI) to enhance conception.

At times, ultrasound finds that a woman has eggs developing, but may have difficulty timing her ovulation.  An injection of HCG (there are several brand names: pregnyl, ovidrel, novarel and profasi) can be given to trigger ovulation.  In this case, HCG is used to mimic luteinizing hormone (LH).  LH naturally surges in the body just before ovulation.  The egg will be released 36 to 50 hours after an HCG injection so that the patient can time sexual intercourse or and IUI.

There are situations where patients do not respond to the interactive effects of clomid or femara.  In that case, injectable medications can be used to stimulate the ovary directly.  These medications are synthetic forms of the pituitary hormones follicle stimulating hormone (FSH) and LH.  There are a variety of brand names for these drugs such as follistim, bravelle, Gonal-F and menopur.  All are given by subcutaneous injection.  Patients learn to give the injections to themselves similar to the way a patient with diabetes learns to self-administer insulin. 

Because this category of fertility medications works to stimulate the ovary directly and is independent of the body's natural feedback mechanisms, treatment must be carefully monitored to avoid over-stimulation of the ovary.  During some parts of the cycle, this monitoring requires daily visits for ovarian ultrasounds and bloodwork.

For patients who do not have spontaneous cycles or respond to oral medications, gonadotropin stimulation (with FSH and LH) can be used with timed intercourse. A few patients with unexplained infertility will use this type of stimulation in conjunction with intrauterine insemination.  However, there is a significant risk of over-stimulation that can result in high order multiple pregnancies. 

Most often, patients who use gonadotropins for ovarian stimulations do so in the setting of in vitro fertilization (IVF).  In IVF, the development of 10-15 mature eggs is ideal.  The injectable medications allow this to occur so that optimal IVF success rates are achieved with minimal risk for multiple pregnancy.  The medication is used for 9 to 12 days.  Once the eggs have reached maturity the patient is given an injection of HCG and eggs can be retrieved from the ovary 35 hours later. Mature eggs are inseminated; embryos develop in the laboratory and can be transferred to the uterine cavity 1 to 3 embryos per cycle.  

We are fortunate to have a variety of fertility medications available for individual use.  Your physician can help explain the best option for you.

Intrauterine Insemination (IUI)

By: Robin Fogle, MD, ACRM

In order for a woman to conceive, the egg and the sperm must meet at just the right time, in just the right place.  When couples have sex, millions of sperm are deposited into the vagina and cervical mucous.  The cervical mucous serves to transport the sperm into the uterine cavity and also to filter out some of the less desirable sperm.  The process is not very efficient, and only thousands of sperm actually make it into the uterine cavity.  Those sperm then have to swim out to the fallopian tube where the egg is waiting.  More sperm are lost in this phase, such that only hundreds of sperm ever get close to the egg.  

Some men have low numbers of sperm in their ejaculate.  If they start out with only a few million sperm, compared to the normal 20-40 million, then you can imagine that the number of sperm that actually make it close to the egg will be drastically reduced.  For that reason, infertility specialists use a technique called intrauterine insemination (IUI), to get more sperm in close proximity to the egg or eggs.  An IUI is performed on the day a woman is thought to be ovulating.  That morning, her partner provides a semen sample which is then processed by the laboratory for over one hour.  The processing helps separate out the “best of the best” sperm from those that are not so good.  Then, a speculum is placed in the female's vagina, allowing visualization of the cervix.  A tiny, flexible catheter (about the diameter of a coffee stirrer) is gently introduced through the cervix and into the uterine cavity.  At that time, the sperm are released into the uterine cavity.  This allows for millions of sperm to swim into the uterus and thousands to swim out to the tube and egg. 

An IUI is also used when helping single women or lesbian women conceive.  In those situations, donor sperm is introduced into the uterus via the IUI technique when the woman is ovulating. 

An IUI can be used to treat couples with unexplained infertility.  In those situations, there is still a significant improvement in pregnancy rates by combining an IUI with the administration of oral fertility medications.

Other scenarios where an IUI might be used are:  1) When the female has an infectious disease (HIV, Hepatitis B) that could be transmitted to her partner if they were to have unprotected intercourse; 2) In couples where the male partner has erectile dysfunction; and 3) In couples where the woman has too much pain with regular intercourse.

An IUI does not hurt and takes only a few minutes to complete.  Women are encouraged to resume their normal exercise and physical activities the same day as an IUI.

Recurrent Pregnancy Loss

By: André L. Denis, MD, MPH, ACRM

Recurrent Pregnancy Loss (RPL) has classically been diagnosed when a couple has suffered 3 unexplained clinical (as opposed to biochemical) miscarriages. Most investigators today agree that it is prudent to initiate an evaluation after 2 unexplained clinical losses. RPL is one of the most frustrating diagnoses we see. It is obviously heartbreaking to lose a pregnancy but many couples find it even more emotionally difficult to deal with the repeated loss of pregnancies when compared to outright infertility. It is frustrating to them to be able to conceive, often without any difficulty, only to go on to lose the pregnancy. 

Another problem which adds to the sense of frustration is that a diagnosis for the cause of the recurrent losses can be elusive. An explanation for the losses cannot be identified in somewhere between one third and one half of cases. Another unusual aspect of this diagnosis is that despite multiple losses, couples can still have a surprising good chance of success in their next conception even when no specific cause has been identified. This combination of factors coupled with an unclear diagnosis, and possible success without treatment, lead many to believe that unproven treatments can be helpful. This belief may lead to the use of potentially harmful and ineffective treatments. It is critical that we only use treatments that have some scientific basis under the care and supervision of a medical professional.

Despite the social and emotional difficulties mentioned, the workup for recurrent pregnancy loss is medically straightforward. There are many known reasons why a couple will miscarry repetitively. Abnormalities of the uterus proper can lead to RPL. These can be both congenital as well as acquired causes. Examples of this are uterine anomalies such as a uterine septum or acquired causes such as fibroids within the uterine cavity. Genetic causes can also cause RPL. Individuals can carry what is called a balanced translocation in which one chromosome may be physically attached to another. When that individual is making sperm or eggs, there will be an unbalanced amount of chromosomal material in the resulting egg or sperm. This unbalanced state will lead to a genetically abnormal embryo which will go on to miscarry. Couples can also suffer from RPL due to abnormalities of blood clotting. There are a variety of causes for this sort of tendency toward excessive blood clotting. Of course there can be individuals who have abnormal eggs or sperm. The most common cause of this is aging. If the eggs or sperm are abnormal, the embryo will also be abnormal consequently, and the pregnancy will fail. In some cases other hormonal disease or exposures to chemicals, radiation or even poor lifestyle choices can cause RPL. The good news is that the testing is simple, generally consisting of a number of blood tests, X-rays, and tests of the sperm. An entire work up can be carried out in less than a menstrual cycle and an appropriate treatment course can then be delineated once test results are available.

Although RPL can be a very emotionally difficult problem, the story generally has a happy ending. We are able to find a treatable cause for this problem in the majority of cases via simple tests and interventions.

TTC, When should we get help?

by Mirrin Reagan, RN, CNS, WHNP, MSN

"Is it crazy to see a specialist when we've only been trying for 8 months?"

"I have no idea when I ovulate - my periods are so unpredictable since I stopped the pill.  Should we see a specialist just to help with timing???"

"We haven't even started trying yet, but I'm turning 40 next month and I'm worried about our chances."

Nearly all subfertile couples will worry about these issues when deciding when to seek help from an infertility specialist.  Believe it or not – there are some simple answers. If you are under 35 years old and have been trying for one year or more, you should seek help. If you are over 35 and have been trying for 6 months or more, you should seek help. There are some situations when you should see a specialist even sooner.

• If either partner has ever been through cancer treatment.

• If either partner has had a vasectomy or had her “tubes tied.”

• If the female partner has infrequent or no spontaneous periods.

• If the male partner is taking testosterone or a medicine for high blood pressure called a “Calcium Channel Blocker” - both of these medications can drastically lower sperm count.

• If your gynecologist has ever told you that you may have difficulty getting pregnant.

• If you are getting pregnant but having recurrent miscarriages.

 “We aren't ready to do IVF even though we've been trying to get pregnant for two years. Should we even bother seeing a specialist?”

 One big misconception is that if you decide to see a fertility specialist you will probably have to do In Vitro Fertilization (IVF). Actually, approximately 75% of all patients seeking treatment with a Reproductive Endocrinologist will begin with simple treatments like Intrauterine Insemination (IUI). At ACRM, approximately 25-30% of our patients become pregnant with less invasive treatments including IUI.

If you're wondering if you should be seeing an infertility specialist now, go ahead and schedule a consultation with a Reproductive Endocrinologist to find out what you may could do own your own to increase your chances of pregnancy or what the specialist would recommend next on your journey to growing your family.  

 Mirrin Reagan, Director of Clinical Services, joined ACRM in 2003.  She received her undergraduate degree in nursing at Emory University and completed her graduate training at Georgia State University where she received her Master of Science in Nursing (MSN) in a dual degree program as a Clinical Nurse Specialist (CNS) in Perinatology and a Nurse Practitioner (WHNP) in Women's Health.  She is a board certified Nurse Practitioner and licensed in the State of Georgia. 

Mirrin is a member of the RESOLVE National Nurses Advisory Board and the American Society for Reproductive Medicine Nurses Professional Group.  She is also adjunct faculty and a clinical preceptor in the graduate program at Emory University's School of Nursing.

Recipient-Donor Matching Process

By: Tamara Ard, RN, Third Party Coordinator, ACRM

Matching recipient patients to egg donors is an important part of my job here at ACRM. I like to meet with all of my recipients face to face to get a feel for what is important to them in finding a donor match. It’s sometimes hard for patients to communicate these things over the phone and often times they don’t really know what to say or questions to ask. I assure them that all of the donors are healthy, and screened prior to the matching process. The first piece of criteria, to narrow the pool, for most couples is ethnicity. Once this is discussed, we move to blood type match. If the recipient couple does not want to disclose that an egg donor was used, the donor must be a blood type match to the couple as well. Then it’s a matter of finding a donor candidate that has similar physical features. Lastly, we try to satisfy any personality traits or level of education the couple feel is important to them.

Here at ACRM, we realize that if given a choice, patients would want to use their own eggs to achieve their family and that this is not always an easy process. By carefully matching recipients individually with donors on a one to one basis, we feel we are giving the patients the next best thing.