GIVF Fertility eNews
April 2008

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World-renowned for its pioneering work in infertility and genetics, GIVF developed or perfected many of the treatments and techniques used today in other centers around the world. 

Worldwide, GIVF is responsible for over 15,000 pregnancies.

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Secondary Infertility

Sunita Kulshrestha, MD, FACOG

Couple with Child 

Sometimes, men and women who conceived one or more children without medical assistance are surprised to find that they are having difficulty conceiving again. This kind of infertility is called secondary infertility, and is defined as the inability to achieve pregnancy after having had a previous pregnancy. The previous pregnancy(ies) may have ended in a miscarriage, abortion or a delivery.

A woman who is under the age of thirty-five, should consult a specialist if she fails to conceive within the first twelve months of trying to conceive. If she is over age thirty-five or if she needed fertility treatment for her first pregnancy, she should seek help if she has not conceived within the first 6 months, or earlier if she or her partner have a known fertility problem.

Secondary infertility is often unexplained. Sometimes, all of the historical factors and testing are normal and there is no identifiable cause of infertility. Although a previous pregnancy implies that at one point in time, egg quality, sperm quality, ovulation, timing of egg-sperm exposure, uterine factors and tubal status (with at least one open tube) were all normal, all of these factors can change. A new partner may have a fertility problem or the female may have previously had her tubes tied or the male may have had a vasectomy.

As a woman ages, the quality of her eggs declines. This decline accelerates after the age of thirty-five and becomes even more rapid after the age of forty. Older women also have eggs that are more likely to have chromosomal abnormalities. Both of these factors can decrease the chance of achieving pregnancy and increase the chance of early miscarriage.

Ovulatory patterns can change with time. Ovulation may be affected by extremes of stress, weight, diet and exercise. Other hormonal abnormalities may develop, including abnormalities of the thyroid gland, an overproduction of the hormone prolactin and exacerbation of polycystic ovary syndrome.

With time, some women develop fibroids (nodules of benign smooth muscle in the uterus) or their existing fibroids enlarge. Women can also have endometrial polyps. Fibroids or polyps may affect fertility if they involve the uterine cavity. If a woman has had any instrumentation or surgery involving the uterus (including a dilation and curettage for a miscarriage or an abortion), or a complicated delivery, she may develop intrauterine adhesions (scar tissue) inside the uterus. The chance of developing scarring in the uterus from any of these procedures, however, is quite low.

Fallopian tubes can become blocked if any inflammatory process involves the pelvis. This primarily occurs in the setting of a pelvic infection (most often chlamydia, gonorrhea or PID (pelvic inflammatory disease). Any surgical procedure in the abdomen or pelvis (including appendectomies, myomectomies (removal of fibroids), and tubal surgery can cause pelvic adhesions (scarring) and these adhesions can cause tubal obstruction. Some women have endometriosis, a progressive condition which can also be a cause of new adhesions in the pelvis.

At the same ages, the male does not have a comparable decline in sperm quality. However, some men as they age can develop varicoceles (dilated blood vessels on the scrotum). This may affect sperm quality. Additionally, sperm is far more sensitive than eggs are to environmental factors and these factors may have changed. Sperm can be affected negatively by certain medications, medical problems, fever, viral illnesses, excessive alcohol consumption and exposure to heat.

A woman who believes she has secondary infertility should consult a physician who is an expert in fertility. Based on the situation, the physician may order tests to include an assessment of ovarian reserve (egg quality), a semen analysis, a hormonal evaluation, and an evaluation of the anatomy (uterus and/or fallopian tubes).

The treatment is based on first identifying the cause and trying to correct it. Possible treatments may be as simple as lifestyle changes (appropriate weight loss, reducing excessive alcohol intake , smoking cessation and/or, stress management).

If testing reveals a hormonal problem, oral medications can be taken to help restore normal hormonal balance and to induce ovulation.

If a woman is of advanced reproductive age or has decreased ovarian reserve (problems with egg quality or response to medications), she may wish to be aggressive and consider IVF (if possible) or use a donor egg and have the embryos transferred into her own uterus. IVF with the use of donor eggs is a highly effective tool to bypass the issue of ovarian aging.

If a woman has tubal disease or has had a tubal ligation in the past, IVF will bypass the need for open tubes. The role of the tube is to collect the eggs and fertilize them. In IVF, the eggs are collected in a procedure called an egg retrieval and fertilization occurs in a dish in the lab. Surgical correction of tubal disease may also be an option in select cases. Fibroids, polyps and intrauterine adhesions can all be managed surgically.

For unexplained infertility, the goal is to improve the efficiency of the conception process. This can be accomplished by 1) Superovulation, a technique to enable the release of more than one egg; 2) Intrauterine insemination in which a higher concentration of sperm is delivered closer to the egg, and 3) In-vitro fertilization (IVF), in which normally fertilized eggs (embryos) are directly replaced into a receptive uterus. Of all these techniques, IVF offers the best success rates.

Conversely, if a problem with the sperm is identified, modalities used may include a urological evaluation and intrauterine inseminations (IUI) if it is a mild problem or in-vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) for moderate to severe problems. If the male has had a vasectomy then IVF/ICSI can be performed with an NSA (non-surgical testicular sperm aspiration). In IVF/ICSI, only one normal sperm is needed for each egg.

If you have any questions about this or other infertility topics, consult a board-certified reproductive endocrinologist.

What's New at GIVF

CYCLE IN THE SUMMER™ DISCOUNT IVF PROGRAM. Based on overwhelming patient response last year, GIVF is offering its Cycle in the Summer™ program again in 2008. If a patient has her first retrieval on or before the last day of Summer, (September 22, 2008), she may purchase two IVF cycles at the highly discounted rate of just $11,200. For additional information visit www.givf.comor call (888) 834-2229 for an appointment.
 
DONOR EGG IVF SUCCESS RATES. GIVF is proud to announce that our donor egg IVF success rate (per retrieval) for 2007 was 63.7% over the last six months and 55.3% overall for 2007. GIVF's donor egg IVF program continues to offer the largest selection of fully screened and available donors in the country (more than 170 donors). For additional information visit www.givf.com or call (888) 834-2229 for an appointment.
 
DR. KULSHRESTHA APPEARS ON NBC. Dr. Sunita Kulshrestha's expertise in donor egg IVF was highlighted in a recent story on Washington's WRC (Channel 4). Anchorwoman and health reporter Doreen Gentzler interviewed Dr. Kulshrestha about egg donors. According to Dr. Kulshrestha, "A good donor is a woman who is highly motivated, responsible, altruistic and from a medical standpoint is healthy and who can help achieve a healthy pregnancy." One of GIVF's egg donors was also interviewed. The donor said that when she was younger, she knew people who had difficulty conceiving and that her primary motivation for being a donor is to help others experience the  joys of having a family.
 
GIVF HOSTS RECEPTION FOR WASHINGTON AREA WOMEN'S FOUNDATION. On April 27 GIVF hosted a reception for Phyllis Caldwell, the incoming president of the Washington Area Women's Foundation (click here for photos). Ms Caldwell came to the Foundation from Bank of America where she had been President of Community Development Banking. Sunita Kulshrestha MD of GIVF, who is a member of the Washington Area Women's Foundation 100, made the introduction. Representatives of Doorways for Women and Families, a grantee partner of the Foundation, also made comments about their mission of providing financial counseling to abused women who are seeking to establish financial security and independence. GIVF will be hosting a noontime event on June 19 at its Fairfax Headquarters to feature volunteering opportunities with various Foundation grantee partners and programs. This event will be open to the public. Those interested can go to www.givf.com/event/ to sign up for a notification list about this event.
 
MICROSORT® PMA PROGRESS. The MicroSort® Division of GIVF has reached an important milestone in our effort to have MicroSort® approved by the FDA and made more widely available. The maximum number of MicroSort procedures that are allowed under the protocol has been reached, and we have requested that the FDA grant us permission to provide continued access to the MicroSort® technology. If permission to proceed is granted by the FDA, this step would not represent FDA approval, but would allow us to operate under the same rules as the clinical trial. We will provide more information as we receive feedback from the FDA with regards to our request for continued access. For additional information visit www.microsort.com.
 
GIVF BLOG. In order to provide a more frequent and informal discussion about infertility and reproductive issues, GIVF is now sponsoring a blog, "Infertility Bits." The blog does not necessarily represent the clinical or scientific views of GIVF, but rather is a vehicle for sharing ideas. For additional information visit the blog at  www.givf.com/blog.
 
 
Ask a Question
 
My husband had a vasectomy when he was in his early 20s. We thought about adoption but would like to have children that are genetically related to us. What are our options?

A vasectomy (vas = vas deferens; ectomy = to cut) is the surgical procedure that cuts or clamps the little tube that connects the testes (where sperm are produced) to the urethra (the part of the penis through which sperm passes during ejaculation). As a result the sperm cannot be ejaculated. Sperm production does continue after vasectomy, but at a greatly reduced rate. Vasectomies are reversible but surgery does not guarantee success. The length of time that has elapsed since the vasectomy was performed and the method used to perform the vasectomy are important factors. If the vasectomy reversal is successful, sperm production often can recover to pre-vasectomy levels. Sometimes scarring that develops after reversal blocks vas deferens.

Many couples achieve pregnancy after vasectomy reversal. If sperm production is very low, you may consider using an assisted reproductive technique such as IVF or ICSI (intracytoplasmic sperm injection, used in conjunction with IVF). If the vasectomy reversal is unsuccessful, or if you do not wish to attempt a reversal, sperm can be retrieved directly from the testes for use in an ICSI procedure.

Discuss your desire to have biological children with your gynecologist or infertility specialist. You also can do some research on vasectomy reversal and suggest that your husband discuss the procedure's pros and cons with his urologist. After you understand your options, you can make an informed decision about the course you want to pursue.

 
 
Two Women, Two Babies
 
By Aisha Shahid
 
Aisha Shahid is a GIVF donor egg coordinator. The following personal recollection talks about her work with a couple from 2005 up through the birth of twins in 2008. Aisha was invited by the parents and the gestational carrier to witness the delivery in Huntsville, Alabama. Aisha and GIVF were also featured in a Newsweek cover story. 

Aisha at Hospital

 
Mother Lisa Smith, Surrogate Jennifer Cantor, Father of the babies Kerry Smith, M.D., twins Ethan and Jonathan with Aisha Shahid GIVF Donor Egg Coordinator.
 
 
It was a moment that will be forever engrained in my memory. Lisa was crying softly at the foot of the bed. Kerry, Lisa's husband, was busy taking snapshots of each precious moment. Their twin boys, Ethan and Jonathan, were noisily announcing their arrival into the world. Jennifer, their surrogate, had tears in her eyes. There were tears in mine as well. How could such a beautiful, celebrated and, for this couple, long-awaited scene generate anything less than tears of happiness?
 
It's not often that we are able to experience the birth of the babies we help to bring into this world, but I had the good fortune to attend the birth of Jonathan and Ethan Smith on March 20, 2008. Their first day of life was documented by Newsweek, but their beginnings were right here at GIVF.
 
I first met Lisa and Kerry Smith in 2005. They had just met with their GIVF physician, Dr. Steve Lincoln, and were depending on me to provide the logistical support for the carrier whom they located in Alabama. This can be an incredibly stressful time for couples and, looking back, I remember seeing two people who felt very overwhelmed about all that needed to happen. Looking at the couple now, one would never guess all how much had to transpire to get where they are today-- a happy family at peace.
 
We inevitably become close to the patients whom we are blessed to assist. I am often told that the emotional support we provide is just as important as the medical care we offer. I personally don't doubt that for a second. This closeness allowed me to stay abreast of all the exciting things that took place after the Smiths's gestational carrier, Jennifer Cantor, became pregnant. I was the first to know that the pregnancy test was positive, the first to know they were expecting twins and even one of the first to know they were expecting boys. I was honored when the Smiths's asked me to be a part of their birth of their sons. By being part of that day, I was able to see a couple become a family.
 
Lisa and Kerry are like all of our patients. They come to us seeking hope, placing their dreams for a family carefully into our hands. And at the end of the journey, we are thrilled to see their dreams come true.

Copyright © 2008 Genetics & IVF Institute