A note from Dr. Keller

Dear Patients,

As I look for the silver lining in this pandemic, it has to be that my adult children have come home once again.  We have not all lived together for over seven years.  Although, the disappointments of life interrupted are hard, ie cancellation of college graduation, leaving the city and friends that have become a new home, this time together is allowing us to build memories that we would not otherwise have had.  Our house seems somewhat smaller, but it helps to remind me of what is truly important.

Despite the joy of having them near, however, I feel a sense of loss as well.  I feel a loss of purpose, as my role as a physician is a big part of who I am.  I love taking care of and getting to know my patients.  I love the rhythm of our office and the amazing people who are a part of the team.  This week has been especially hard as our group has had to furlough many of the talented and loving individuals who help us do what we do.  Although, they will be back “as soon as possible”, the not knowing “when” makes the loss harder to bear.

Mostly, I worry about my patients.  I know that struggling with infertility is hard enough, but to add the isolation and loneliness of self-distancing, only adds to the pain.  Also, the disappointment of life interrupted and not knowing when help will be available again, can only compound the frustration. “When” we are able to resume our journey together, please know that we will do whatever we can to help.  In the meantime, be kind to yourself.  Eat, sleep, exercise…do what you need to do to survive the process.  We are here for you now and always.  Stay Safe!

Dr. Sarah Keller

Zika Virus UPDATE: 9 things you need to know when planning a pregnancy 

  1. How is it spread? The Zika virus is spread by the Aedes Aegypti and Aedes Albopticusmosquitos, which also carry Yellow fever and the Chikungunya virus.
  2. Why the big fuss? It is usually not harmful in healthy adults but there is a suspected link with microcephaly in unborn children
  3. What are the consequences of Zika in a fetus? The CDC has reported that of the 1,450 infants born in the U.S. territories after confirmed or possible Zika virus infection during pregnancy, 1 in 7 had neurologic sequelae possibly related to Zika infection.
  4. What are the chances of having a child affected by Zika? Per CDC preliminary data: Zika virus-associated birth defects have been found in10% of pregnancies of pregnancies with laboratory-confirmed Zika virus infection and in 15% of those where infection occurred during the first trimester.
  5. What is the good news? As of February 2019, there has been no local risk of transmission of Zika virus in the continental U.S., even in Florida or Texas (which last reported transmission during 2016-2017).
  6. What are the symptoms of Zika infection? Symptoms are flu-like and nonspecific (and they can include red eyes, headache, fever, rash, muscle and joint pain).
  7. I am trying to conceive. Can I travel to the Caribbean, Mexico or what? You should talk to your doctor and take precautions if you must go. Currently there are no places that have “CURRENT outbreaks,” but this is subject to change at any moment. Travel to places that have “CURRENT #ZIKA outbreaks” should be avoided.
  8. What about m
    y partner? 
    If travel to a “No current outbreak” area cannot be avoided, prevent mosquito bites during and after travel and take note of the following if you are #ttc Men w/partner #ttc: Use condoms or abstain from intercourse for at least 3 months upon return before resuming #ttc For women #ttc: note the above if traveling with partner, but if traveling alone, then wait at least 8 weeks before resuming #ttc
  9. What if I don’t want to wait and want to proceed with fertility treatment? TALK TO YOUR DOCTOR. Zika testing as noted above is not perfect and there may be risks of Zika even if testing is negative (Zika may live longer in semen). Talk to your doctor before making decisions about travel plans AND #fertility treatment timing. Each situation is unique.

Want the most updated information on Zika? Visithe CDC website: https://www.cdc.gov/zika/index.html

By: Vinita Alexander, REI Fellow

I just miscarried. What now?

By: Dr. Kenan Omurtag

As we reach the end of October, wanted to leave people with information about what happens next (both short term and long term) after one is confronted with the fact that they no longer have a viable pregnancy. Below are 4 macro steps 

Step 1. Grieve – Don’t be afraid to cry. We welcome it. You should feel like you are in a safe space to release your emotions. Partners, you too. Don’t forget to grieve. Its hard, but you are equally invested in this goal. Partners used to feel like they wanted to fix things, now, they are very good at simply being present and being a shoulder to lean on when needed. But they too need a shoulder…Lean on your support system, and do not be afraid to ask for professional counseling as well. #ivfdoctors and #obgyns can direct you to such services. There is no right or wrong way to grieve. Remember that whether this is your first miscarriage or your 10th, (yes, we‘ve seen it) you can be successful. Let’s repeat that: Its hard and often times unbelievable, but you can have a live birth!   

Step 2. Managing the Resolution of the current pregnancy –  there are three options: wait and let nature take its course, active management w/cytotec that causes the uterus to contract and expels the products of conception, or active management with a D & C. Each has pros and cons that will resonate with people on an individual basis. Talk to your doctor about which approach is right for you. You don’t need to decide immediately as oftentimes the news of a miscarriage can be so disorienting. Take a day or two to process if applicable. 

Step 3. Looking Ahead (while grieving) – Our patients have shared with us that looking ahead assists with the grieving process. In response, we lay out a timeline including necessary action items before they are able to “try again.” Once the pregnancy has been resolved, we wait for the next period which, for example, could be 4-6 weeks after the identification and active management of a pregnancy loss. In many cases, with that subsequent period, we do a cavity evaluation with a sonohysterography and then with the subsequent period, if ready physically and mentally, allow return to #ttc 

Step 4. Making adjustments and #TTC – sometimes we make adjustments to a treatment plan, sometimes we do not. Talk to your doctor about what’s right for you.  

Remember you are #notbroken. This process will work for and we will be there to support you along your journey.

Kenan Omurtag, MD (he/him)
Associate Professor, REI
Associate REI Fellowship Program Director
@drkenanomurtagmd (IG) 

 

What to look for in a fertility clinic

Finding a trusted fertility specialist can be intimidating in the era of mass information and online social networks. Your OBGYN might present a list of specialists and tell you to pick one or they might recommend one themselves. Eitherway, just like any service, patients typically investigate through friends and online reviews (much like we do with any purchase of goods or services these days) to try and optimize “fit.” The relationship between patient and fertility physician AND his/her practice is critical.

That being said, look for the following when selecting a Fertility Practice, particularly in the United States:

  • Are the physicians board certified in reproductive endocrinology and infertility by the American Board of OBGYN (ABOG) – this designation means that the physicians took 3 additional years of training specifically focused on fertility treatment and practice
  • Does the clinic report to the Society of Assistant Reproductive Technologies (SART). By law, ALL fertility clinics in the US have to report success rates to the government (CDC), but SART member clinics are a group of clinics that subscribe to the highest standard of care. Approximately 90% of US fertility practices are SART members.
  • Be careful interpreting success rates when comparing clinics. Steps have been made in recent years by SART to minimize gaming but clinics will advertise the highest success rates on their website that may only apply to certain patients. Make sure the success rates that the clinic quotes you are reflective of your test results, age and medical history.

When it comes time to see your fertility specialist, make sure any fertility testing results are readily available as this will help the provider triage any further testing and prescribe treatment. The visit usually takes 30-60 minutes. If your partner is available he/she should attend, but is not required. In the visit the provider should lay out a short term and long term plan that consists of any diagnostic testing that remains to be completed and then a 3-4 month treatment plan depending on the results of testing. The provider should set expectations about what to expect with interacting with his/her office as well as introduce you (not necessarily in person, though) to the members of his/her team that will be assisting in your care.

Fertility treatments typically go for 3-4 months before a follow up visit is scheduled. If there are any concerns the patient should feel comfortable calling the office at any time to have those questions addressed. Most physicians have a nurse coordinator and an assistant, both of whom the patients get to know very well through regular communication. Our patients have electronic access to a portal system which allows regular, secure electronic communication with the office.

As mentioned above the fertility clinic visit can be intimidating. Using your online resources and asking your OBGYN are the most common resources that people utilize when selecting a clinic. Your friends and family want to be helpful, and often are, but sometimes sharing your infertility story with them can leave one frustrated so its normal to be hesitant. Ultimately, you will make the right choice. Do not be afraid to leave a clinic and seek out a change of scenery if your experience is not what you think it should be.

Progesterone and IVF: So why do I need this?

Progesterone helps support implantation and the IVF process blunts your body’s natural ability to make progesterone. When one undergoes a fresh IVF cycle for example, all of those follicles that are aspirated at the time of egg retrieval makde progesterone but the hormone signals from the brain that KEEP those follicles making progesterone is blunted by the IVF medications that are responsible for prevented ovulation. As a result, progesterone supplementation is required in IVF.

Which route and for how long, though, have been questions studied for some time and practice patterns vary by clinic so talk to your MD about what is right for you.

Studies have shown that progesterone injections are equivalent to vaginal progesterone suppositories in FRESH IVF cycles as it relates to livebirth rates. Interestingly, some patients prefer injections over vaginal suppositories. Eitherway, if you are not tolerating injections, talk to your doctor about whether vaginal progesterone is right for you.

Progesterone and FET: Differences
Unlike in a fresh IVF cycle where your body makes some progesterone, in *most* frozen embryo transfer (FET) cycles, your body does not make any progesterone. As a result, FET cycles are completely reliant on progesterone as a REPLACEMENT.* There are fewer studies and less agreement about the equivalence of progesterone injections and progesterone vaginal suppositories in FET cycles. So. More clinics might prefer progesterone injections in FET cycles.

*SIDENOTE: some clinics have moved to modified natural cycle FET preps in which the luteal phase is supported by the body’s own progesterone AND supplemented with exogenous progesterone as well.

How long do I need to take this?
Progesterone production is the domain of the ovary until the placenta takes over progesterone production at around 8-10 weeks gestational age. Because of the estimated timing and the desire to be conservative, most IVF clinics in the US recommend progesterone supplementation for 8-10 weeks after egg retrieval/FET. Again talk to your MD if you have questions about your specific situation.

Do I need to check progesterone levels while on progesterone?
There is a lot of variation on this among clinics. Some do it, some don’t. Clinics that check it might adjust progesterone doses based on the level.

How it works and what you need to prepare to freeze your eggs 

SCHEDULE APPT: make sure you see a board certified reproductive endocrinologist/fertility clinic that
has experience freezing eggs. The consultation will be 30-60 minutes. Come prepared to answer questions about your reproductive goals. Bring along a member of your support system 🙂

GET TESTING: Our physicians will check markers of ovarian reserve, specifically an AMH and ultrasound antral follicle count to help set expectations and qualify how many eggs you might get with one cycle of egg freezing (more on that below). AMH is a blood test usually done that day and the US may be done that day or later depening on where you are in your menstrual cycle.

GET COUNSELING: Our physicians will review pros/cons of the egg freezing process and utilize the above test results to help you understand how many eggs are necessary to achieve 40-70% livebirth. This information will help you determine whether you might need to be prepared for more than one egg freeze cycle.

DECIDE: The decision to freeze eggs is highly personal. On one hand it will help extend one’s future fertility, but on the other, its not a guarantee for future livebirth and may incur significant cost. Some have used referred to a, so called “sweet spot” to freeze eggs, which is thought to be age 33-37.

MAKE PAYMENT: Egg freezing costs $5-10,000 per cycle. Very few employers provide coverage for this.

TWO WEEKS: A cycle of egg freezing requires about 2 weeks of time during which you are giving yourself 1-2 separate “bee sting” like injections daily for about 10 days. During those 10 days of daily injection, you will visit the fertility clinic 3-5 times for estrogen blood levels and vaginal ultrasounds to measure your response. After about 10 days, then you are triggered with a third injection (in the hip) and then 36 hours later – you undergo an egg retrieval, which is an outpatient surgical procedure.

FREEZE EGGS: Eggs are stored temporarily onsite and then moved to a long term storage facility. Annual fees for storage are about $300-400.

REPEAT MAYBE: some patients will elect to cycle again to retrieve more eggs. Steps 5-7 are then repeated and a month later more eggs are frozen.

Make an appointment

To schedule an appointment with a Washington University fertility specialist, please call our office or request an appointment online.
314-286-2400

5 ways to improve your reproductive health & reflections from the 30th annual meeting of the New England Fertility Society (NEFS):

Dr. Jungheim at Mount Washington Resort in Breton Woods, New Hampshire where the conference was held. It was built in 1902, and back in the day it was a place where families went for the summer to retreat from the hustle and bustle of Boston – very cool piece of history!

I was invited to participate at the NEFS annual meeting this year by my friend and one of our former trainees, Kerri Luzzo, MD.  Kerri practices reproductive medicine in New England with Boston IVF.  It was great to see her and to catch up, and to exchange ideas about improving care for all of our patients.

While at the conference I gave two presentations—both focused on modifiable lifestyle factors that may impact health in young, reproductive-age women and men.  My talks were toward the end of the day, and the talks that preceded were largely focused on genetic applications in IVF. The genetic talks were fantastic—thought provoking, and forward thinking.  They reminded me how important it is for today’s reproductive medicine specialists to be on top of the latest tools and techniques used for genetic screening and testing, and also how important it is that we provide our patients with top notch genetic counseling so that patients can make informed, empowered reproductive choices.

When the time came for me to give my last talk of the day, I opened by letting the audience know I was going back to basics.  We had spent the bulk of the day talking about genetic tools to improve embryo screening in IVF, and talking about the future of IVF, but we hadn’t spent much time discussing patients and how to help them improve their reproductive health and outcomes.

Most reproductive age women are extremely healthy.  But, there is a lot of great data that lifestyle factors like nutrition and diet, exercise and sleep can be optimized to help improve reproductive function and outcome.  What are some things that I’d recommend?

  1. Start taking folic acid: 800 mcg comes in most over-the-counter prenatal vitamins and not only helps reduce the risk of having a child with a neural tube defect, but there is data that it may help with ovulation. So, I recommend all of my patients who aren’t already taking a prenatal vitamin start to take one.
  2. Pay attention to glycemic index: Glycemic index is a mark of how much a carbohydrate makes your blood glucose spike. You can evaluate your favorite carbs by doing a Google image search for “glycemic index”.  You’ll see multiple examples of charts that rate foods by glycemic index.  You should avoid foods that have a high glycemic index and replace them with ones that have a lower glycemic index.  If you note there are foods in your pantry on the high glycemic list, stop stocking your pantry with them and pick up more of the foods with the lower glycemic index.  This is especially important for women with conditions like polycystic ovary syndrome who may have insulin resistance.  Insulin is the hormone we use to metabolize glucose.  Blood glucose levels spike when we eat foods with a high glycemic index. If we are insulin resistant, that glucose sticks around and can negatively impact the ability of our body’s cellular metabolism.
    • Examples of what to eat? Whole grains like quinoa, farro, brown rice, steel cut oats.  Also, if you enjoy sandwiches, replace your bread with lower calorie bread—breads in the 30-60 calorie range per slice are often higher in whole grains than some of the others.
  3. Revise your meat intake. If you are a meat eater, try to cut down on beef, chicken, pork and turkey, and replace some of your intake with fish high in omega-3 fatty acids and vegetable proteins. Omega-3 fatty acids decrease inflammation.  Also, in work investigating proteins intake and ovulation, it seems women who get more protein from vegetable sources may ovulate better than women who get their proteins from meat.
    • Examples of what to eat? Salmon! Canned tuna.  Many women worry there is too much mercury in these. You’re okay!  Eat up!  2-3 times per week if you like it.  What else? Vegetable proteins:  soy/tofu, peas, beans (chickpeas, kidney beans, northern beans, etc.).  Beans are great to cook up on the weekend into a stew or dish with brown rice. Split your dish up into storage containers to take on the go for lunch during the week.
  4. Sleep regularly. What does this mean?  We often worry we aren’t getting enough sleep, and many of you aren’t.  We make up for lost time when we can, but we don’t often think about getting regular  See if you can try to keep on a schedule—keep a bedtime.  We’re working to look at how regular sleep impacts fertility at Wash U, and we’re finding some really interesting things.  Stay tuned for the data!
  5. Morning hike! Just a reminder that exercise doesn’t have to be painful. It can be a simple, peaceful walk.

    Exercise, but not too much. Exercise is great.  It can alleviate stress, and it keeps us strong.  It can also keep our metabolism in check as we get older.  The older I get the more I appreciate the exercise I got when I was younger, and I wish I had more time for exercise now.  If you are concerned you exercise too much (you know who you are) check with your physician and ask.

 

 

Have questions or want to make an appointment?

We see patients from all over the country. To schedule an appointment with a board certified Washington University Fertility Specialist, please call our office at 314-286-2497.

How Genetic Counseling Can Make a Positive Difference for You

Hello!  I am happy to be able to introduce myself: my name is Marisa Andrews, and I am a certified genetic counselor. I recently joined the Fertility & Reproductive Medicine Center, and I am so pleased to be a part of this incredible team.

All of us, patients and healthcare providers alike, are excited by the rapid progress in the field of medical genetics.  Genetic information has enormous potential to improve our health outcomes, including within the world of reproductive medicine.  Yet as genetic testing becomes a more common part of healthcare and the complexity of testing increases, we face an important challenge.  How do we ensure patients and providers understand their genetic testing options and the results they may uncover?

This is where a certified genetic counselor can be helpful. As the National Society of Genetic Counselors explains, “genetic counselors have advanced training in medical genetics and counseling to guide and support patients seeking more information about how inherited diseases and conditions might affect them or their families, and to interpret test results.” The goal of genetic counseling is to provide accurate and up-to-date information and to support your decision-making process so you can make the choices that are best for you and your family.

In the Fertility & Reproductive Medicine Center, I see patient for many different reasons.  Before I talk about genetic testing related to fertility and pregnancy, however, it is very important to say most babies are healthy!  Most genetic conditions are rare.  Yet for those whose lives are touched by a genetic condition in themselves or a family member, understanding and adapting to the diagnosis can be challenging and emotional.  Genetic counselors can help guide patients through that process.

You may already be aware of some types of genetic testing offered to patients who are planning a pregnancy such as genetic carrier screening.  Genetic carrier screening can help identify patients who are at increased risk to have a child with a genetic condition, such as cystic fibrosis, due to a variant in one of their genes.  Carriers are typically healthy and do not have any symptoms of the condition themselves.  In most cases, they also have no family history of that condition.  This is one example of why genetic counseling is beneficial for all patients planning a pregnancy, not just those with a family history of a genetic condition.

Patients may also be referred to discuss whether or not genetic testing could help explain why a health issue has occurred in themselves or their family members.  Common examples include a history of two or more miscarriages, intellectual disability, or deafness.  If genetic testing does identify a cause, the results may provide important information for the affected individual’s medical care such as prognosis or treatment options.  Additionally, the results may help you understand how likely it is your own children could have the same condition. 

Patients who know they have an increased chance to have a child with a genetic condition often see me to discuss their options to prevent the condition from being passed on.  One exciting option is preimplantation genetic testing, which is used to identify genetic abnormalities in embryos created with in vitro fertilization (IVF).  This test gives patients the opportunity to greatly reduce the risk of a genetic condition in their child prior to pregnancy.

As much as I believe in the power of genetic testing to improve lives, it is equally important to recognize not every patient wants this type of information.  For some patients, genetic testing and the information it provides might cause anxiety they would rather avoid.  Other patients know the results would not change their family-building plans.  For instance, they would not choose to test their embryos or a pregnancy even if they knew their child was at risk for a genetic condition.  It is essential we respect a patient’s “right not to know” genetic information about themselves.

There are more options for genetic testing now than ever before.  While all genetic tests have potential benefits, it is just as important to understand their limitations.  By discussing your options with a genetic counselor, you will learn whether a genetic test can really provide the answers you want.  With genetic counseling, you can be assured you have the knowledge and support you need to make genetic testing work for you.

Do you have questions about your family history?  Are you wondering whether a genetic test is right for you?  Would you like to discuss your genetic test results to better understand their meaning?  If so, I would be happy to meet with you.  To request an appointment, please contact our office at (314) 286-2400.

Family get-togethers: How to manage in an uncomfortable situation

November 28, 2018

Hi! Dr. Jungheim here! The holidays are coming up.  So much fun, but also a painful reminder for some of us that another year has gone by and we’re still trying.  I watched a movie on Netflix the other day called Private Life and it reminded me of some of the dynamics that go on when we’re struggling to have a child.  The movie follows a couple who has been trying to have a child for a number of years.  They are in their forties and they’ve decided to move on to using donor oocytes.  They’ve asked a younger relative if she would consider being an oocyte donor.  She is excited to help them.  What an amazing thing in my book, but at Thanksgiving dinner when she announces to the family she is doing this (after a few glasses of wine), her mother pulls her aside and is upset.  The daughter counters that if a family member needed a kidney, her mother would volunteer to be a donor.  The mother counters back and refers to the woman struggling with infertility by saying, “it’s not like she’s dying”.  The daughter yells back, “HOW DO YOU KNOW”!?!

WOW!  The movie hit the feeling spot on… sometimes it can feel like you are dying…

Sorry to get so serious, but seriously, recognize your family loves you.  The don’t want to be insensitive.  They may just not understand.

How do we navigate these situations and stay strong?  Cocktails?

Maybe one or two, BUT, advice from some of you who’ve found things that work would be wonderful!

My advice?  Stay close to your partner during the holiday celebrations…whether its physically standing/sitting near them, or having a pep talk before entering one, or regrouping afterwards.

Looking forward to what others have found helpful…
Please share your advice in the comments of this post on our facebook page!

Pregnancy and Infant Loss Awareness Month

October 23, 2018
This is pregnancy and infant loss awareness month…so glad this issue is getting attention.  While I regularly work with individuals and couples who are struggling with pregnancy loss or who have lost children, it is difficult to talk about.  It is difficult to write about.  I think, and I think most who have gone through it will agree, it is one of the most difficult things we can endure.  Why?  Because having a child is love.  Being a parent is love.  The emotions we experience in these relationships are at the core of what it means to be human.  So, despite the fact that it is difficult to talk about pregnancy and infant loss, I love my job, and I am grateful to have the opportunity to work with individuals and couples through their grief as they continue to build and raise their families.  These are the families that make up the communities we live in and enrich our lives.

I am also grateful to have the opportunity to work with the March of Dimes (MOD) Prematurity Research Center at Washington University.   The MOD has a long history of supporting families with premature babies, but they are branching out.  More recently, the March of Dimes has broadened their attention to supporting healthy mothers and healthy communities.  They recognize that these elements are essential to having and raising healthy children. The work I’ve been doing with the MOD focuses on things that we can modify prior to pregnancy to lead to reduced risks of miscarriage and improved chances of a healthy baby.  Our most recent findings from this work were presented at this year’s annual meeting of the American Society for Reproductive Medicine in Denver, Colorado.  Here’s a summary from one reporter about our findings:

I’ve learned a lot working with the MOD, and I’m proud to be a part of it.  In addition to supporting the Prematurity Research Center at Washington University, the MOD also supports research centers at 4 other centers in the U.S. including the Ohio CollaborativeUniversity of Pennsylvania, Stanford University, University of Chicago-Northwestern-Duke along with one international center at London Imperial College.  We work cooperatively with these centers to learn more about the causes of adverse pregnancy outcomes and to understand how we can improve pregnancy outcomes in the future.

Kelle Moley, MD recently joined the MOD as their Chief Scientific Officer.  Kelle was part of our team at Wash U for years, and she was my fellowship director when I came to Wash U in 2005.  I trained in her lab during my fellowship and that’s where my interest in preconception modifiable risk factors was sparked.  As a fellow in Kelle’s lab I studied the impact of obesity and diet/nutrition on pregnancy outcomes.  I’ve learned a lot from Kelle.  She is an incredible scientist and physician (she’s a member of the National Academy of Sciences), and it will be exciting to see how she impacts the MOD and their research mission in the future as we strive for improved maternal-child health here and across the globe.

Post by: Emily Jungheim, MD, MSCI