On The Cutting Edge

One of the biggest advances in our field has been the ability to preserve female fertility by freezing unfertilized eggs. While egg freezing has been around for a long time, original data showed low egg survival and pregnancy rates.  By 2003, new freezing technology, called vitrification, substantially improved outcomes such that egg survival rates increased to over 85% and pregnancy rates began to compare with those seen in fresh (non-frozen) eggs. 

Sadly, although this technology has rapidly advanced, few women are aware that they can and should take advantage of the opportunity to freeze their eggs while they are still of good quality.  If you think about it, as women have increasingly joined the workforce, they have delayed their childbearing for 5-10 years. The average age of women pursuing fertility treatment in my San Francisco-based practice is almost 39 years old. Many of them still report that they were unaware of their reproductive clocks and the aging of their eggs. Few women come to freeze their eggs and those that do are typically over the age of 35 (the age under which the best outcomes are demonstrated).

In our next issue of Lane Fertility Magazine, we will review the indications for freezing your eggs. Who should consider it? Where do you go to have this procedure done?  How much does it cost? 

We can’t wait to share this cutting edge technology with you!

– Danielle Lane, MD

Aaron & Grace

By: Aaron Kayce

There are things you dream about but know will never happen, winning the lottery, being famous, maybe owning a private jet, and when you never experience those things you’re fine with it, you knew life wasn’t going to be like that anyway.  Then there are things you work for but eventually realize you might never attain, for some it might be the corner office, a vacation home, perhaps even the respect and understanding of a relative, and when those don’t pan out you deal with it.  There’s frustration but life continues; you’re okay.  But when something so basic and fundamental to your world view that you assume it, something you never even questioned, never even really thought about – like the ability to have a child and a family – when that doesn’t happen, life doesn’t go on.  It stops.  It’s not okay.  When you’re unable to conceive a child and that’s the only thing in the world you and your partner want, nothing else matters.  Nothing can fill that void.  Nothing. 

My family’s story begins like I assume most do, by attempting to conceive a child naturally and never thinking this might be a problem.  After about one year of what at the time we considered “trying” (this word would soon take on a whole new meaning) with no results my wife and I scheduled an appointment to speak with a doctor.  This would be the first of many doctors we’d visit and the first of many tests my wife would have to endure.  

After a battery of exams we were told that as far as anyone could tell there appeared to be nothing physically wrong (at least nothing they could determine) and we should continue “trying,” but perhaps a bit more aggressively.  Having researched the topic extensively online we sort of knew what to expect: monitoring my wife’s basal body temperature to determine her ovulation cycle, Clomid (infertility/ovarian stimulation drug) and then intrauterine insemination (IUI) if need be. There were other measures for sure, but we wouldn’t need that. My wife was in her twenties when we started this process and my sperm was fine. We’d be pregnant in no time!

Wrong again.

The years went by slowly, held back by fears and sadness.  Doctors, drugs, specialists, tests, acupuncture, massage, diet restrictions, scheduled intercourse, several IUIs, we did it all (mostly my amazing bride) and it took a toll on both my wife and I.  The anger.  The shame.  The guilt.  Constantly asking “Why us?”  The way my wife would look at me, desperate to bring a child into our home.  It became hard to be around children or pregnant people; we even began to resent friends and loved ones for the news that “yet another person is pregnant.” 

It’s very difficult to describe the death of hope and what that can mean.  Each and every month hope inevitably rises, “This could be the one!  This will be the one!”  Everybody stresses the mental aspect, how powerful our brains are; we have to stay positive!  That’s a great theory and likely very true, but it’s loaded with problems.  By saying that the couple, specifically the woman, has to keep a positive, relaxed, but also strong mental outlook, you are saying that in some way maybe this is her fault.  That if she could just relax and stop worrying about getting pregnant, and if she could just somehow “let go” it would all work out.  Every month is a reminder that it’s not working out.  Every period represents the death of hope. 

After years of being told “no” by doctors and pregnancy tests my wife and I were considering adoption.  Maybe having a child just wasn’t what God intended for us.  There was a fair amount of guilt associated with not simply being okay with adopting.  And it’s not that my wife and I are against it, in fact I think there’s a strong chance we may adopt in the future, but the internal drive (something Mother Nature has hard coded into our DNA) to have our own biological child was overwhelming and we were not ready to give that up just yet.  We knew there were other options, but they became far more aggressive at this point.

And this is where our story takes a dramatic turn.  It began with a referral to a fertility specialist. After so much disappointment “hope” might be too strong of a word here, but it was clear very early on that we had found an amazing doctor and there was immense comfort in feeling that if nothing else, we were at least now working with the best of the best.  My wife and I learned more about our options and our real statistical chances of conceiving a child in a couple of appointments with a fertility specialist than we did in years of bouncing around other offices.

In the end our road led to in vitro fertilization (IVF).  And though our fertility physician seemed to know that’s where we were headed (should we so desire), she also highly encouraged less invasive measures first.  And when it came time to make the very big, and extremely expensive, decision of whether or not to do IVF, we were gently led through all of the details and allowed to come to our own decision in whatever manner we wanted.

The IVF process is long, stressful, emotional and often complicated (this coming from the man’s perspective!), but our doctor and her team were incredible in every sense of the word.  Not only did they constantly put us at ease with their obvious expertise, our doctor also made herself available any time day or night, quite literally walking my wife and I through a set of at home injections on more than one occasion. 

There were times, like after the first round of IVF not working, that my wife and I were extremely low. Without even really trying (or at least not letting on) our doctor always managed to lift our spirits. By explaining every aspect of our situation and supporting the conversation with success rates, personal experience and extensive medical research and managing to translate it to layman’s terms, our doctor made it so that we never felt lost or alone and in the case of my wife and I, with knowledge really did come power and we were able to carry one another when we most needed it.

Today I glow with excitement and smile as I watch my wife’s belly grow with each passing day. 

Finding Your Qi

By Susan Fox

Paige was 37 and had been trying to conceive for over 6 months. She had tried timed intercourse, ovulation predictor kits, and basal body temperature. She had been to see a fertility specialist, but was leery of jumping into treatment.  Her lab tests were all normal and her uterine lining looked ready for implantation. Unsure of what to do next, Paige decided to try a friend’s recommendation and meet with an acupuncturist. But what are the benefits of acupuncture she wondered?

Here is what fertility acupuncture specialist Susan Fox, ABORM has to say about this ancient component of Traditional Chinese Medicine.

Over 3,000 years old, acupuncture views a woman’s menstrual cycle as following natural rhythms of Yin, Yang and Qi.  Yin represent the more cooling, fluid aspects of our being; Yang are the more warming, drying aspects of our being; and Qi are the aspects that address movement.

In recent years, acupuncture has re-surfaced as a beneficial treatment to improve fertility.  Western medical journals such as Fertility & Sterility have published multiple studies describing the method by which acupuncture improves fertility outcomes.  First, acupuncture is thought to stimulate the release of hormones that influence menstrual cycles, ovulation and fertility. Acupuncture also stimulates blood flow to the uterus. Certain acupuncture techniques are thought to inhibit the stress response. Finally, acupuncture can augment in vitro fertilization by making the treatment cycle dynamics more fertile.

In the first part of a woman’s natural menstrual cycle (the follicular phase), Yin is involved with the ovaries’ response to the follicle stimulating hormone (FSH).  Acupuncture treatments are directed toward increasing blood flow to the uterine and ovarian arteries to nourish the growing follicles and support growth of the uterine lining.  This often includes stimulating points on the sacrum. There are also foods that complement this phase of the menstrual cycle because of their tonic quality. An example is royal jelly, the part of a honeycomb that is sequestered for the Queen bee.  Rich in essential amino acids, vitamins and antioxidants, royal jelly is produced by nursing bees in the hive to enable the Queen bee to lay more eggs and keep the population increasing. Fatty fish is also thought to be beneficial but because of concerns about methyl-mercury contamination, patients may  elect to take triple-washed fish oil.

According to Chinese Medicine, successful ovulation (release of the mature egg) requires heat and movement to encourage the egg to “burst” from its follicle. At this point the warming properties of Yang and the moving properties of Qi are necessary to support circulation to the region of the ovaries and uterus. Acupuncture treatments may incorporate moxibustion. Moxibustion is a heating therapy using the herb artemesia (commonly known as mugwort) that warms the deeper tissues of the body before the skin becomes too warm.  This is the time to add foods that are more warming in quality such as meats (preferably organic and pasture-fed), walnuts, and warm-sweet spices including cinnamon, fennel and curry.

The luteal phase refers to the part of the menstrual cycle after ovulation.  During this time, the ovary provides the hormone progesterone which is critical support for the implanting embryo.  From five days after ovulation through the first day of a new menstrual cycle, the focus of acupuncture is to “Raise Qi”.  This is done to encourage the upward movement of energies and support an implanting embryo with gentle microcirculation to the uterus.  Herbs used during this phase are intended to strengthen the immune and vascular systems. In Chinese Medicine this is known as the spleen system. Foods recommended during this phase include fibrous root vegetables, meats, nuts and seeds. 

The days leading up to a new menstrual cycle (days 21-28), are termed the premenstrual phase.  During this time, a woman’s body is filled with hormones that must be broken down. Supporting a healthy premenstrual phase is achieved by encouraging the movement of Qi throughout the entire body. This improves symptoms such as breast tenderness, abdominal bloating, and mood swings.  However, since this is potentially a time of early pregnancy, acupuncture points must be considered carefully. 

In addition to the menstrual cycle specific benefits, women often report that acupuncture allows them to relax during an otherwise stressful time in their lives. Symptoms associated with stress, such as anxiety, depression, insomnia, digestive complaints and immune deficiencies may be ameliorated with acupuncture.  Many women and couples have found acupuncture and Chinese Medicine to be very beneficial to their quality of life during their fertile years.

Should I be concerned?

By: Danielle Lane, MD

The most significant predictor of a woman’s ability to conceive is her age. While societal trends continue to demonstrate delayed child-bearing, reproductive biology has not changed.  Peak fertility in women occurs around age 22, and by age 32 studies have shown a gradual but significant decline in fertility. A more rapid decline occurs after the age of 37.  The result:  an increased number of women and couples who experience age-related fertility challenges and miscarriage. So when should you be concerned about your fertility? Below are some guidelines to help with your thinking.

In general, if you are ready to try and conceive, it is a good idea to let nature take its course initially. Studies have shown that 85% of couples where the woman is under the age of 35 and having regular unprotected intercourse will conceive without assistance. Therefore, if you are less than 35, the American Society for Reproductive Medicine (ASRM) suggests formal evaluation for fertility challenges if you have been trying for more than one year.  But, earlier evaluation should be considered if you: are older than 35, have irregular or no menstrual cycles, have a known problem with your uterus or fallopian tubes, are diagnosed with endometriosis, or if your male partner is known to have a fertility challenge.  In women from 35 years of age up to 40 years of age, formal evaluation is recommended if you have not conceived within the first 6 months. If you are over the age of 40, immediate evaluation is prudent when you are ready to get pregnant.

Fertility evaluation of the male usually parallels the evaluation of their female partner.  Approximately 20% of fertility challenges are solely due to problems with the male partner, and in another 30-40%, the male’s fertility plays a contributory role.  In general, evaluation is recommended when no pregnancy has occurred after one year of regular, unprotected intercourse.  Again, if your partner has a known fertility issue, earlier evaluation is appropriate.

What if you are not ready to have a baby yet?  For couples and women who think that they will not be ready to conceive until their mid- to late-30’s or beyond, a fertility consultation should be considered.  If the woman is single, new techniques for egg freezing (vitrification) should be considered to preserve fertility.  With the current technique of vitrification, studies show that 80% of frozen eggs survive the freeze-thaw cycle and that a pregnancy is obtained for approximately every seven eggs frozen.

For couples, a woman’s eggs can be fertilized with her partner’s sperm and embryos can be frozen. Using vitrification, 80% of high-quality embryos will survive the freeze-thaw cycle, and a pregnancy is typically obtained for every four embryos frozen.  Single men are fortunate since they typically do not demonstrate a reduction in their sperm quality or quantity until much later (mid-fifties). So while a baseline semen analysis will not hurt, it probably isn’t necessary until closer to this age.

It is important to have a realistic outlook on family planning to ensure that you have enough time to achieve the number of pregnancies that you wish.  If it takes you a year to conceive your first child, by the time you attempt to conceive your second child, it will likely take even longer and by then, time will not be on your side.  If your goal is to have three or four children to complete your family, then it is even more important to consider getting started sooner.

The goal of your fertility specialist is to try and determine whether you can expect to conceive on your own without assistance, whether you can conceive using your own eggs or sperm with assistance or whether donor eggs or sperm should be considered. Making this determination is based on an assessment of your eggs, your partner’s sperm, your uterus, and your fallopian tubes.  An initial consultations typically lasts sixty to ninety minutes and includes an extensive history of you (and your partner, if relevant), a transvaginal ultrasound to evaluate your uterus and ovaries, and blood work for both you and your partner.

Armed with this information, you and your fertility specialist can develop a treatment plan that works for your current lifestyle and your family planning.

ABOUT THE AUTHOR

DanielleDanielle E Lane, MD, Reproductive Endorcinology and Infertility Specialist. Dr. Lane attended McGill University before completing her medical training at the University of Pittsburgh School of Medicine, her residency at Yale-New Haven Hospital and her fellowship at the University of California, San Francisco. She opened the Center for Reproductive Health at Kaiser Permanente in Napa-Sola-no in 2005. In 2009 she founded Lane Fertility Institute. The Institute has grown to a three physician practice with a state of the art embryology laboratory. She is committed to providing education for women about preservation of their fertility and developing lower cost models to improve access to care.

Rustic Breakfast Frittata

By: Jabir Ponce

1 Tbls Olive Oil

1 Small Zucchini

4 Eggs

½ Small Onion

¼ C Soy Milk

1 Carrot

2 Tbls chopped fresh Basil

Pinch of Salt

4 Slices of Turkey

Pinch of Pepper

1 Small Tomato

Turn oven on to 500 degrees.

1.         In the large bowl, grate the Zucchini,

            Carrot and Onion.

2.         Dice the Tomato and the Turkey and add them to the bowl.

3.         In a smaller bowl whip together Basil, Soy Milk and Eggs, then add mixture to larger bowl and stir together.

4.         Add Salt and Pepper, mix again.

5.         Add olive oil to pan and place pan on stove top and turn flame to high.

6.         Work oil around pan buy tilting, so that oil coats the entire interior of pan.

7.         Pour the mixture into pan.

8.         Cook for 1 minute.

9.         Place in oven for about 15 minutes.

10.       Turn oven to broil for about 5 minutes or until the center of Frittata is firm to touch.

11.       Remove from oven, cut and serve.