ACRM

Can sexually transmitted diseases affect fertility?

By: Robin H. Fogle, MD, ACRM

As part of an infertility evaluation, physicians inquire about a couples' past exposure to sexually transmitted diseases (STDs).  Often times, a patient will reply, “Oh I had chlamydia once, but it was a  long time ago when I was a teenager”.  What happened “a long time ago” in a patient's mind, might be the red flag we are looking for to explain why pregnancy isn't happening now.

Chlamydia, and to a lesser degree Gonorrhea, is one of the biggest causes of tubal damage in women. Unfortunately, many cases of chlamydia are silent, so tubal damage may have occurred without a patient knowing.

Chlamydia is contracted through sexual intercourse.   It starts by infecting the cervix, causing cervicitis.  The bacteria can then travel into the uterus, causing “endometritis”, and fallopian tubes, causing “salpingitis”.  The inside of the fallopian tubes are lined by delicate cilia, or hairs, that are extremely important in moving eggs, sperm, and embryos into the right locations.  When a chlamydia infection occurs in the fallopian tubes,  the cilia and inside of the tube may be damaged.  

If the chlamydia infection goes untreated, PID (pelvic inflammatory infection) may occur.  This results in scar formation in the pelvis which can block the openings of the tubes or pull them into unnatural positions.  If a hydrosalpinx forms, where the tube is blocked and fills up with fluid,  the fluid can drip into the uterine cavity and prevent embryos from implanting, or wash away embryos that are already there. 

Tubal damage can result in failure to conceive because the tube is unable to pick up an egg from the ovary.  It can also result in ectopic, or tubal pregnancies, because the dysfunctional tube is unable to adequately move the embryo into the uterus.  The presence of a hydrosalpinx can decrease the success of an IVF (in vitro fertilization) cycle or increase the risk of miscarriage and must be removed surgically if present.

Tubal damage from a prior sexually transmitted infection is frequently detected by HSG (hysterosalpingogram) during an infertility evaluation.  The HSG x-ray can show if a tube is blocked.  It is very good at revealing a hydrosalpinx.  However, even when tubes appear to be open on the HSG film, that does not guarantee that the tubes function normally.

Past infections of chlamydia can be detected with blood work.  When chlamydia antibodies are present, the likelihood of a tubal problem increases.

Men's fertility is less clearly impacted by STDs than women's.  Severe infections may result in scarring in the male reproductive tract blocking the pathway of sperm to come out during ejaculation.  More often, though, asymptomatic infections are diagnosed at the time of the semen analysis.  White blood cells may be seen in the sample, suggesting an infection is present.  These white blood cells may result in excess reactive oxygen species in the semen which may impact sperm function.  Antibiotics are usually given to the male partner in these situations.

Other bacteria, like Ureaplasma urealyticum and Mycoplasma hominis have not been clearly linked with infertility.

Sexually transmitted diseases are unfortunately a well-known cause of tubal factor infertility.  Sadly, these diseases frequently occur in patients without them ever knowing.  A standard infertility evaluation  will always take into consideration the possibility of a prior exposure to an STD.  A thorough history taken by your physician, along with gonorrhea and chlamydia  cultures, chlamydia antibody titers, and an HSG will help determine if a patient's infertility is related to a prior STD exposure.

Robin H. Fogle, MD, fertility specialist in Atlanta, GA, joined the Atlanta Center for Reproductive Medicine in the Fall of 2007 after completing her fellowship training in Reproductive Endocrinology and Infertility at the University of Southern California Keck School of Medicine, Los Angeles, California.  As a Georgia reproductive specialist, Dr. Fogle's clinical interests include in vitro fertilization, polycystic ovarian syndrome, premature ovarian failure, and reproductive surgery. Her research interests center around uterine receptivity and embryo implantation, especially in donor IVF and gestational carriers. Dr. Fogle is Board Certified in Obstetrics and Gynecology and Board Certified in Reproductive Endocrinology.

For more information, or to schedule an appointment with Dr. Fogle please call 678.3841.1089.

The Big Freeze: Vitrification of Eggs and Embryos

By:  Steven Voelkel, PhD, HCLD, ACRM

I find that one of the most common questions asked by Egg Donors, Fertility Preservation and IVF patients is “How do you freeze/ store the eggs?”  The short answer is; through the process of vitrification.  Vitrification is a method of freezing cells in which the temperature is lowered so quickly that water does not have time to crystallize into ice.  This is important because ice crystals can damage critical elements of the cell’s architecture.  The use of vitrification techniques for cryopreservation of oocytes (eggs) and embryos is a fairly new technology, but it has gained popularity in Assisted Reproductive Technology (ART).  The potential for using vitrification for cell preservation in mammals was first recognized in the 1930's, it was not until the mid 1980's when the first reports of successful vitrification of embryos from a mammal were published.

Vitrification and traditional freezing methods differ in their approach to cryopreservation.  Traditional methods of embryo freezing involve first exposing embryos to a solution containing approximately 10% cryoprotectant such as glycerol.  The embryos are then slow cooled to around -31^o F at which point they are placed directly into liquid nitrogen (-320^o F) for storage.  Vitrification involves initial exposure of eggs or embryos to much higher concentrations of cryoprotectant compounds and then plunging them directly into liquid nitrogen for storage without the slow cooling step.  Though the objective of both traditional cell freezing and vitrification is to remove enough water from the cells to prevent formation of damaging ice crystals within the cells, vitrification has shown less instances of ice crystal formation in cells when they are finally placed into liquid nitrogen for storage.

When cells are successfully vitrified, the liquid inside and outside of the cells forms a solid “glass” rather than ice crystals.  Embryologists (like myself) will use the terms “vitrify” and “warm” to describe the vitrification process rather than “freeze” and “thaw”, since the latter terms connote formation of ice crystals.

Vitrification is much more effective than slow cooling for cryopreservation of eggs.  This has created the option for IVF patients to store their unfertilized eggs rather than their developing embryos, and has permitted ART laboratories to create banks of stored donor eggs for use by their patients.  Vitrification has also given women more options in regards to fertility preservation.  Women wishing to “vitrify” their eggs for future use, or prior to undergoing treatment for major illness (i.e. cancer), that may render them infertile, now have that option available to them.

Low Sperm Count

By: André L. Denis, MD, MPH, ACRM

Male factor infertility is an extremely common reason why a couple may not be able to conceive. The good news is that, generally speaking, treatments for male factor infertility are highly successful. Male factor infertility is usually identified by means of a semen analysis. Most lay people tend to focus on the concentration of sperm in the analysis. Keep in mind that what really matters is not the concentration of sperm by itself but rather the total number of living and moving sperm that are available to find and fertilize the egg. A high concentration may not mean very much if the percentage of sperm which are actually moving is low. Similarly, if the volume of ejaculate is high, the total number of sperm available may be fine even if the concentration is low. For these reasons we tend to pay more attention to the Total Motile Count (TMC).

A typical ejaculate of a normally fertile male will usually have a TMC greater than 50 million. It has been shown that if a male has a TMC of at least 20 million, pregnancy by means of intercourse is still possible. Pregnancy becomes increasingly unlikely if the TMC is below that number. During intercourse only a small percentage of the ejaculated sperm actually make it into the uterine cavity. Typically only 5-10% of the viable sperm within the vaginal environment will end up in the uterine cavity. It has been shown that if 5 million or more sperm reach the uterine cavity the likelihood of conception remains good. Given this fact, one can see that if a man has a TMC of fewer than 20 million but at least 5 million, he should be able to establish pregnancy if those available sperm are placed directly into the uterine cavity. This is the rationale behind Intrauterine Inseminations (IUI). A male who has a low number of viable sperm, can be “normalized” if the same number of sperm, which would typically reach the uterus from the vaginal environment, can be placed directly into the uterine cavity. This would be the case even though, on his own, he wouldn't have enough to establish pregnancy by intercourse.

There are many cases where the man has a TMC of even fewer than 5 million. In those cases, even IUI is not likely to allow him to establish a pregnancy. Previously, these men would probably never have established pregnancy. Today this is no longer an absolute barrier to conception. We have reached the point in Reproductive Medicine where we really only need one sperm. During In Vitro Fertilization (IVF), we can inject a single sperm into each egg using the technology called Intracytoplasmic Sperm Injection (ICSI). Therefore, if we retrieve 10 viable eggs from a woman, for example, we really only need 10 sperm. This technology has allowed men with extraordinarily low counts to establish pregnancy.

Male factor infertility is very common, but it is also one of the rewarding ones to treat. Technological advances have allowed men with low counts, who likely would never have established pregnancy naturally, to do so today.

Being Still

By: Mark A. Lewinter, L.Ac., ACRM

The beauty of acupuncture is that it can help one achieve balance by providing a state of deep relaxation and open perspective, as well as slowing the mind down.  This can all immediately happen with the placement of just a single needle.  When this state occurs, we feel more freedom around all issues in our lives, including the fertility process.

Some of the most common words after a patient’s first acupuncture treatment are, “Wow! that was very relaxing.”  It can be shocking to realize how tense one has become.  After that first treatment, many patients feel a return to the “true” part of themselves and restored in subtle but meaningful ways.

Unfortunately, all too often, it is only when we reach a point of being overwhelmed that we will take a positive action to restore the body and mind. But it doesn’t have to be that way.  Creating moments of renewal during the fertility journey is paramount.  We all know it takes effort to create opportunities for stillness, but the gift in return is peace and confidence.  The more effort placed on achieving states of deep stillness while trying to conceive, the better.

As we enter into any journey, it is so important to maintain our resources in the process.  When a significant amount of resources go in to a hyper identification with all of the aspects of our mind, our thoughts, feelings, and emotions, we have wasted energy that could have been put to better use.  Acupuncture is an energetic medicine, so in every treatment the acupuncturist is focused on helping the patient’s mind and body use its resources in the most wholesome way.

There is so much that patients can’t control in the fertility process; however, I am pointing to something that can be managed, the practice of stillness.  Simply put, when our resources are managed in the best possible way, it is always a step in the right direction.

Fertility-Enhancing Foods

By: Tracey Singh, RD, LD, CDE, MPH, ACRM

  Most people are aware that being in a healthy weight range can enhance fertility, but did you know certain foods boost fertility as well?  Below is a list of certain food groups that can help enhance fertility:

1)      Low Glycemic Foods - Low glycemic foods like whole wheat bread, brown rice, whole wheat pasta, and oatmeal can actually help boost fertility.  These foods are slowly digested and do not cause a rapid spike in blood sugar like other refined carbohydrates (chips, white bread, sweets).  Keeping your blood sugar stable can help enhance fertility.  Plus, these foods make you feel full in your meals which can help keep your weight in check.  Another added bonus! 

2)      Plant Proteins - Increasing plant proteins like kidney beans, black beans, garbanzo beans, lima beans, and lentils can help boost fertility.  Beans are high in fiber and iron – another fertility booster!

3)      Monounsaturated Fats - Consume more monounsaturated fats like olive oil, nuts, and avocado and less saturated and trans fat.  Did you know the recommendations for both men and women are 0 g of trans fats per day?  Trans fats are found in a lot of commercially baked goods and products.  So always read the food label and make sure the product you are buying has 0 g of trans fat.

4)      Fruits and Vegetables - Fruits and vegetables are high in antioxidants and vitamins which help promote fertility.  Fruits and vegetables are also a great way to increase fiber in your diet.  Make it a habit to add a serving of vegetables to every lunch and dinner meal.

If you would like to learn more about nutrition and its impact on fertility please call 678-841-1089 or e-mail info@acrm.com.  ACRM also offers FREE nutrition seminars! Sign up today! Space is limited.

Nutrition Seminars offered exclusively at ACRM!

Weight in both women and men can have a significant impact on reproductive health, infertility treatment success and pregnancy risk.  Pregnancy rates with fertility treatment can be 35% lower when BMI exceeds the optimal range.  Being overweight also causes ovulation problems in many women.  Women with polycystic ovaries (PCO) often have this issue.  It is good to know that even small losses of weight often restores more regular ovulation patterns.  Being underweight can also affect cycle regularity and ovulation.

ACRM is pleased to offer FREE group Nutrition Seminars to support men and women in their journey to parenthood as well as for those who are trying to manage Polycystic Ovarian Syndrome (PCOS).

Led by ACRM's Registered Dietitian, Tracey Singh, RD, LD, CDE, MPH, the nutrition seminars are available to both the patient and their spouse/partner as well as non-patients of ACRM.  Group size is limited to 8 people. For the nutrition seminars, participants will need to bring their own lunch as this will be a part of the program.


The Details:

All Nutrition Seminars will be held in ACRM's conference room at our centrally located perimeter office at:
5909 Peachtree Dunwoody Road, Suite 720, Atlanta, GA 30328. 

Nutrition Seminars currently offered at ACRM include:

• Healthy Eating in the New Year
• Fertile Foods
• Weight Loss: Strategies that work
• Smart Shopping at the Supermarket
• Healthy Eating at Restaurants
• Overcoming Emotional Eating

Space is limited to 8 people.  Prior registration is required.

The Thyroid Gland and Reproduction

By: Kathryn C. Calhoun, MD, ACRM

Background

The thyroid gland is located in the base of the neck and plays a key role in metabolism, development and reproduction.

The thyroid gland is under the control of the pituitary gland, which secretes Thyroid Stimulating Hormone (TSH) in response to feedback from circulating levels of thyroid hormone and Thyroid Releasing Hormone (TRH) from the hypothalamus.

Dietary iodine is transported in the blood as iodide, which is taken up by the thyroid gland in response to TSH. Iodide is then combined with tyrosine to form thyroxine (T4) and triiodothyronine (T3) which are the thyroid hormones. T4 and T3 are stored as part of the thyroglobulin molecule within the thyroid until their release is stimulated by TSH.

T3 is more biologically active than T4. In fact, T4 is primarily a prohormone for T3, meaning that the body converts T4 to T3, according to its needs. T4 is more tightly bound to transport proteins in the blood to leave T3 free to effect biologic activity.

That’s great … but why do we care?

Both hypothyroidism (low thyroid function) and hyperthyroidism (high thyroid function) can have significant effects on health and fertility.

HYPOTHYROIDISM: low thyroid function/low thyroid hormones

This may be primary (due to thyroid gland dysfunction) in which case the TSH will be high and the thyroid hormone will be low – in other words, the brain is working overtime to get the thyroid gland to do its job. It may also be secondary (due to central hypothalamic/pituitary dysfunction) in which case both the TSH and thyroid hormone will be low – i.e. thyroid hormone is low and the brain cannot respond to compensate.

Often, the reason for hypothyroidism cannot be determined and does not impact treatment. Sometimes it is due to an auto-immune attack on the thyroid (Hashimoto’s thyroiditis) where the body attacks its own gland with antibodies. Hypothyroidism becomes more common as we age; women should be screened every 5 years starting at age 35 and every 2 years starting at age 60. Of course, if a woman is symptomatic, she should be screened immediately.

Symptoms of hypothyroidism:

• Mental slowness (memory, speech, attention)
• Decreased energy
• Cold intolerance or low body temperature
• Constipation
• Low-pitched voice
• Edema or water retention
• Menstrual irregularities
• Delayed reflexes
• Slow heart rate

Screening for hypothyroidism:

Unless there is suspicion for secondary hypothyroidism or evidence of other pituitary/hormonal abnormalities, your doctor will usually start with a TSH level. If this is high, a Free T4 level is checked to see if thyroid hormone production is adequate.

Subclinical hypothyroidism is when the TSH is high but the thyroid hormone level is still normal – this could reflect an acute/limited or a chronic/ongoing need for increased pituitary stimulation of the thyroid gland to produce adequate thyroid hormone. There is an increased risk of miscarriage for women with both clinical and subclinical hypothyroidism, so thyroid hormone replacement is indicated for women with subclinical hypothyroidisms who are trying to conceive.

Thyroid hormone replacement is best accomplished with synthetic T4 (thyroxine). Formulas that contain both T4 and T3 provide more T3 than the body needs; it is better to replace the T4 and allow the body to convert what it needs to T3. Once on replacement, adequacy of dosing should be check by monitoring TSH levels after 8 weeks (it takes the pituitary many weeks to reflect to changes in blood thyroxine levels.) In women of reproductive age, we often aim for a TSH level ? 2.50 uU/ml, as this level has been suggested to optimize reproductive outcomes. Medication requirements increase in pregnancy and frequent monitoring to assure the optimum TSH range is essential.

Thyroxine is not helpful in women with normal thyroid function and too much thyroxine can lead to osteoporosis (it increases bone re-absorption.)

HYPERTHYROIDISM: high thyroid function/high thyroid hormones; “thyrotoxicosis”

Common causes for an overactive thyroid include Graves disease (autoimmune attack) or Plummer’s disease (postmenopausal women with a history of a goiter), but can also include thyroid cancer. In hyperthyroidism, the TSH will be low and the Free T4 and/or T3 will be high.

Symptoms of hyperthyroidism:

• Nervousness, emotional instability
• Insomnia
• Heat intolerance
• Weight loss
• Fast heart beat, skipped heart beat
  (“palpitations”)
• Menstrual irregularities
• Sweating
• Diarrhea
• Tremor
• Goiter (enlargement of the neck over the thyroid
  gland)

Screening for hyperthyroidism:

Your doctor will usually start with a TSH level. If this is low, a T4 or T3 level is checked to see if thyroid hormone production is high. Your doctor may also check for antibodies and/or recommend a thyroid scan. A neck/thyroid exam will check for nodules, which may need to be aspirated or biopsied to rule out thyroid cancer, which is more common in women than men.

Subclinical hyperthyroidism is when the TSH is low but the thyroid hormone level is still normal – this is more common in women and African Americans. Progression to full hyperthyroidism occurs more frequently with lower TSH levels. Often, subclinical hyperthyroidism warrants evaluation but not necessarily treatment.

Treatment of hyperthyroidism:

Anti-thyroid medications decrease T4/T3 production. Beta-blockers may be necessary for patients with irregular heartbeats. Some patients may need radioactive iodine exposure, ablation or surgical treatments.

Bottom line …

The thyroid gland is important to our overall health, particularly reproduction. Thyroid problems are more common in women, and they increase with age.

Women should begin thyroid screening at age 35. Earlier screening is appropriate for women who experience any of the above symptoms, especially women with irregular periods or a history of miscarriage. 

Insurance Coverage and Infertility Care

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

Dealing with insurance while seeking infertility care can be quite the challenge.  Insurance coverage in this area of medicine is not as straightforward as in most other areas, and truly won't be exactly like the insurance interactions you may be used to when seeing your primary care provider.

We see all different variations of the kinds of coverage that our patients have, and it's really important for you to know exactly what your policy covers and doesn't cover.  That way you won't have any surpririses.

• Some plans have coverage for testing to determine why you are infertile, but no coverage for its treatment.
• Many times payment depends on why the service was performed. For instance, if we do an ultrasound of your ovaries to ensure that an ovarian cyst is shrinking, it will be paid, but if we do the ultrasound to track your response to fertility medications, it may not be paid.

It can be really confusing, and what can be so confusing for folks is that, for example, the same blood test may be covered one day, because it was done for diagnostic reasons, and it won't be covered the very next day, because it was done then for treatment (to achieve a pregnancy) reasons.  In the first example, because it was covered you might just have a co-pay to pay, whereas in the second example you would have the full cost to pay.

What a challenge this can be! 

So . . .here's my suggestion.  Read carefully the plan description you received when you signed up for your insurance.  If you don't have a plan description, get with your H.R. department to get a plan description.  Go to the section on infertility coverage (or infertility exclusions) and read it in detail.  If you don't understand it, or it is confusing, do one or more of the following.

• Call your insurance company for explanation
• Ask your H.R. department for explanation (if your comfortable disclosing that you're seeking infertility care).
• Call us.  We're glad to help you navigate through your plan and help you figure what it covers and what it doesn't. 

Ask Your Insurance Company

By:  Irene Laschuk, Manager, Patient Financial Services, ACRM

My name is Irene Laschuk.  As manager of Patient Financial Services, I work closely with insurance companies and know how important it is to have a full understanding of the specifics of your policy as they relate to your infertility coverage.  This is why we've scripted a list of questions to ask your insurance company in order to help you fully understand the extent of your coverage.

1. Who is the network that administers the plan?  Are my physicians in network?  If not, are there out-of-network benefits?
2. What type of plan is it (PPO, POS, HMO, Indemnity)?  Am I required to notify you that I am seeking infertility treatments?  If so, how?
3. When will coverage become effective?
4. Who is covered on the policy? 
5. What is the copay for a visit to a specialist?     
6. Are phone consults covered?  If so, does the copay apply? 
7. Are radiology and laboratory services performed in the doctor's office covered?  Are they subject to my deductible?  Does a copay or coinsurance apply? 
8. Are there well-care benefits?  Are labs to screen for infectious diseases covered if I present with no symptoms?
9. Does the policy carry infertility benefits?  Does the benefit level change for these services? 
10. Does the policy cover the diagnostic testing to determine the cause of infertility (diagnosis     codes – V26.21, 628.8, 628.9)?
11. Once given a diagnosis of infertility, are there benefits?
12. Does the plan include coverage for semen analysis or other infertility testing?
13. Is karyotyping or other genetic testing covered? (CPT codes for karyotyping 88230, 88262, 88291).
14. Is screening for “carrier status” of genetic conditions covered? 
15. Does the policy cover the treatment of infertility, or any services related in assisting in the     attempt to gain a pregnancy; example:  intrauterine insemination and in vitro fertilization (diagnosis codes – V26.1, V26.8)?
16. Are any services excluded from the plan?
17. Are pregnancy tests covered?    
18. Does the plan include maternity benefits at a specialist's office?
19. Are infertility medications covered?  Must they be purchased through a specialty pharmacy?
20. Are there any limits to the number of attempts, annual or lifetime?
21. Is authorization required?  On what procedures?
22. What are the deductibles and maximums?  Are the maximums annual or lifetime?
23. What is the name of the associate at the insurance company with whom you spoke?  Ask for a call reference number (if available).

 

Am I Covered Too?

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

So often we see patients who think “My friend has ‘XYZ’ insurance; I have insurance with the same insurance company.  My friend told me she has coverage for infertility care.  Since I have insurance with the same insurance company, that means I must also have coverage.” 

Be really cautious with this line of thinking.  What a particular insurance plan covers and does not cover is totally driven by what the person’s employer decided to have included.  This is especially true with infertility care.  Infertility coverage often is a separate rider that can be added to a policy by the employer.  Thus, when comparing two policies side-by-side, everything might be identical, except that one may have infertility coverage and one may not.

Even if infertility coverage is provided for in an insurance plan, read it really carefully to determine what it covers.  Is it only covering the diagnostic phase of care?  In other words is it covering only the care rendered to determine why the infertility exists?  OR – does it cover care given after the cause is determined to actually help the patient try and achieve a pregnancy, through say IUI or IVF?

So . . .the big take-away here is study your plan.  Know what it does and does not cover, and be certain you understand any restrictions or exclusions.  This will help take the “surprise” factor out of your infertility journey in terms of insurance.