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

Yoga + Fertility

The diagnosis of infertility and the decision to pursue treatment can present significant emotional, financial and physical challenges for individuals and couples that ultimately contribute to increased anxiety and depression.  Behavioral interventions such as meditation and yoga, that focus on increasing mindfulness and self-compassion, have been successfully implemented in couples undergoing fertility treatment and have been shown to improve psychological distress and coping strategies.1,2

The success of assisted reproductive technology therapy relies on numerous factors that are outside the control of any one individual.  Developing a mindfulness practice that facilitates finding peace within the chaos, periods of waiting and unknown is critical to maintaining overall quality of life throughout the process.

As September is National Yoga Awareness month, we want to give a nod to the practice of yoga, as it has been shown to be an incredibly effective tool when implemented prior to and throughout initiating fertility treatment. In addition to the physical benefits such as increased strength and flexibility, the mental benefits from an increasing inner calm, stress reduction and overall relaxation can positively impact many areas of life.3The additional beauty of yoga is that it can be done in the comfort of your own home without any equipment (you don’t even need a mat!) and you can practice anytime you want. So what’s stopping you?

What kind of yoga should I do?
Much of the research that has focused on yoga as an intervention in individuals undergoing fertility treatment has used hatha yoga, which is a type of yoga that combines movement with breath, but you can choose whatever practice suits you best. Other common styles include vinyasa, deep stretch and power yoga. Regardless of the style of your practice. the focus should be on the breath, because that’s where the yoga truly is. Once you learn to breathe and center yourself effectively within the movement, you can translate that practice into everyday life… when you’re stressed about a deadline… while stuck in traffic driving to work or driving to your next appointment… when you find all the ultrasound appointments and injections overwhelming… while waiting in the waiting room… you can find a sense of calm and centeredness within the chaos and keep breathing.

What evidence is there for yoga with fertility treatment?
One study of women undergoing IVF treatment demonstrated that as little as one 55-minute yoga practice once a week for six weeks leading up to IVF treatment resulted in significantly improved overall quality of life, emotional and mind-body scores in addition to a significant reduction in mean anxiety and depression scores.4Another study used a combined approach emphasizing mindfulness of thoughts and feelings through breath, guided body scans and hatha yoga which resulted in improved self-compassion, coping strategies and improved scores in all domains of a quality of life assessment.2

How do I get started?
Make a commitment to dedicate one hour a week to yourself to get started, and see what happens. You could do three 20 minute sessions, two 30 minute sessions, or one hour straight through. Whatever suits your schedule and mind best. Choose a positive mantra to begin your practice with and when you notice your mind wandering, repeat it throughout your practice:
“I am strong… I am capable… I am beautiful… I am resilient… I am a survivor… I am grateful…” Choose a mantra that speaks to you.

There are numerous free yoga videos on YouTube to get you started. Check out our Yoga quick links to view some of our favorites! Once you have the basics down you can simply turn on your favorite music, set a timer for 20 minutes to an hour, go with the flow and breathe. If you prefer a group exercise setting, multiple studios offer very reasonable walk-in rates for anywhere from $5-$10 class.

Commit to taking care of yourself, one breath at a time.

If you have any questions, give us a call! We’re happy to chat!

Namaste,
Ashley Eskew, MD
Wash U Fertility Team

  1. Galhardo A, Cunha M, Pinto-Gouveia J. Mindfulness-Based Program for Infertility: efficacy study. Fertil Steril2013;100:1059-67.
  2. Li J, Long L, Liu Y, He W, Li M. Effects of a mindfulness-based intervention on fertility quality of life and pregnancy rates among women subjected to first in vitro fertilization treatment. Behav Res Ther2016;77:96-104.
  3. Valoriani V, Lotti F, Vanni C, Noci MC, Fontanarosa N, Ferrari G, et al. Hatha-yoga as a psychological adjuvant for women undergoing IVF: a pilot study. Eur J Obstet Gynecol Reprod Biol2014;176:158-62.
  4. Oron G, Allnutt E, Lackman T, Sokal-Arnon T, Holzer H, Takefman J. A prospective study using Hatha Yoga for stress reduction among women waiting for IVF treatment. Reprod Biomed Online2015;30:542-8.

 

Thoughts on PCOS

September 21, 2018

In honor of PCOS awareness month, let’s open up a conversation…

Polycystic ovary syndrome? What is it? 
The first people to describe PCOS were Stein and Leventhal.  They described it in 1935 in an article published in the American Journal of Obstetrics and Gynecology.  They described a handful of women with irregular menstrual cycles, a sign of irregular and unpredictable ovulation, and excess hair growth.  Ultrasound wasn’t available at the time, but Stein and Leventhal took these women to the operating room, and they did laparotomies (abdominal incisions) and took a look at these women’s ovaries.  They found them to be “polycystic” in appearance. Stein and Leventhal took wedges out of these women’s ovaries and post-operatively most of the women started to ovulate regularly and got pregnant.

The story of Stein and Leventhal’s success in helping these women conceive is terrific.  Especially given the fact that there was so little we could do in 1935 to treat infertility.  BUT, our understanding of this condition has changed dramatically over the years, and our options for treating PCOS medically has also improved.

So, here we are over 80 years later…
How do we diagnose PCOS today?  Well, there are a number of different expert opinions on this.  For this I like to turn to the American College of Obstetricians and Gynecologists.  They just published a new Practice Bulletin for OB-Gyns to look to for guidance in helping patients.  To summarize their advice, here goes:

  • PCOS is characterized by hyperandrogenism (high androgens measured by blood test like testosterone, excess hair growth, and/or acne), irregular menstrual cycles (<8 per year or >35 days between menstrual cycles), and/or polycystic appearing ovaries on ultrasound.
  • PCOS can only be diagnosed once other causes of these symptoms have been excluded. These potential causes include thyroid disease, pituitary adenoma, testosterone secreting tumors, and non-classic congenital adrenal hyperplasia.

Overall, how we diagnose PCOS is a lot more nuanced than it used to be, and how we treat it should really be based on what a woman’s symptoms are and what her treatment goals are.

We have a PCOS clinic at Wash U where we work with women to address their goals.

For women who may want to get pregnant in the future, I recommend checking an antimüllerian hormone (AMH) level.  AMH is made by follicles in the ovary—follicles contain eggs and AMH tells us how many eggs are sitting, resting in the ovaries that could potentially be recruited if someone were to undergo fertility treatments.  Easy, repeatable tests to measure AMH only became clinically available recently.   How we counsel women on improving fertility today is largely based on what their AMH value is.  So we may counsel someone with a low AMH value differently than how we might counsel a woman with a high AMH despite the fact that both women might technically meet diagnostic criteria for PCOS.

PCOS & Insulin Resistance
For women with PCOS who are insulin resistant, we may add medications or counsel on specific dietary plans that may help improve insulin sensitivity.  Insulin is the hormone we make that helps us metabolize carbs.  If we have insulin resistance, our ability to metabolize carbs (or glucose/sugar) is impaired.  Sometimes a low-carb diet may be helpful.  This doesn’t necessarily mean NO-carb…NO-carb can be difficult to sustain (oh, how I love pasta, bread, and ice cream).  It means eating good carbs, and being sensible.  We can eat ice cream once in a while, but if we have insulin resistance we should limit it and keep it in check being aware of all of the other carbs we are eating.

So how do we know if we have insulin resistance?  There are lots of way to screen for it, but the easiest way is probably to measure a hemoglobin A1c.  If your level is 5.7 or higher you may be insulin-resistant.  You may also be pre-disposed to developing diabetes down the road. The good news about this though is if you know you are insulin resistant, you can do something about it! You can modify your lifestyle (diet—food choices, exercise habits, sleep habits), consider medications, and improve your long-term health outcomes.  You can do it!

In regards to pregnancy, the main reason PCOS can impede our chances of conception is that it is associated with infrequent ovulation.  So we can’t predict when we are going to ovulate making it difficult to time intercourse.  There are a number of simple oral medications we can use to help improve ovulation. Letrozole is a common one to start with. Clomid used to be our first choice, but a study published in the New England Journal of Medicine in 2014 showed that letrozole may lead to pregnancy faster.  The side effect profile of letrozole is a lot better than Clomid too. So letrozole is often where we start.

Aside from ovulation, there are other things that can impact our chance of pregnancy including our partner’s sperm counts and the uterus and fallopian tubes.  I often discuss this with my patients.  I ask my patients to consider having imaging of their uterine cavity and fallopian tubes with some non-invasive imaging and that their partners to consider having a semen analysis performed.

Overall if ovulation is the only issue we are dealing with pregnancy comes quickly and somewhat simply with the right treatments!

Education is key in managing PCOS.  There is a lot of good information out there, and we have a lot of experience in helping our patients achieve their goals.  If you have questions we can help you!  Give us a call and let us know! 314-286-2400


Post by: Emily Jungheim, MD, MSCI