CRM Fertility Journey Description IVF Tue, 27 August 2019 00:00:00 Tue, 27 August 2019 00:00:00 The Facts About Exercise and Fertility CRM Orlando Is there a link between exercise and fertility? Does engagnig in regular, rigorous exercise impact your ability to conceive? In their latest infographic, the fertility experts of CRM Orlando's fertility clinic in the greater Orlando area go over everything you need to know about exercise when you're trying to conceive.  If you and your partner have been trying to conceive without success, it may be time to seek help. Contact us today at 407-740-0909 to schedule an appointment with one of our fertility experts and start on your path to parenthood. Tue, 27 August 2019 00:00:00 What about Male Partners? CRM Orlando A recently published multicenter study of the association between total testosterone (TT) levels, semen analyses, and live birth rates in men with unexplained infertility, found that low  TT (<264 ng/dl) in the male partner was associated with low sperm morphology (normal forms) and a lower live birth rate. The design of the investigation was a secondary analysis of the prospective, randomized clinical trial “Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation” (AMIGOS). Seven hundred eighty-one men with a median TT of 411 (318-520) ng/dl were included.  There was no association between low TT and low semen volume (<1.5 ml), sperm concentration (< 15 million/ml), or motility (<40% moving) and among couples in which the male partner had low TT, 21 (18.8%) had a live birth, compared with 184 (27.5%) live births in couples where the male partner had TT>264 ng/dl. Perhaps the larger question to be answered from this study is whether all men undergoing infertility investigations should have baseline endocrine testing. And is total testosterone sufficient? Should men be checked for other, perhaps more subtle endocrine disturbances such as thyroid disease, prolactin disorders, vitamin D insufficiency, estrogen excess and perhaps others? What if abnormalities are found? Shouldn’t men have a follow up consultation with the appropriate physician, e.g., reproductive endocrinologist, reproductive urologist, or medical endocrinologist? Isn’t time that men, like their partners, have more thorough reproductive evaluation than a simple semen analysis?  Moreover, is a single semen analysis, ever enough? This study certainly suggests a role for baseline blood screening of male partners as part of the initial fertility evaluation. Identified hormonal abnormalities may be then treated and may enable more couples to conceive naturally or to experience increased success with fertility treatments [intrauterine insemination (IUI) or in vitro fertilization (IVF)]. Such more in depth evaluations of the male may prove highly cost effective; however, more studies are needed to answer this and a number of the related questions above.   Reference: Trussell JC, Coward R, Santoro N, Stetter C, et al: Association between testosterone, semen parameters, and live birth in men with unexplained infertility in an intrauterine population. FertilSteril 111:6, Jun 2019 Thu, 18 July 2019 00:00:00 Association of IVF with Childhood Cancer in the United States CRM Orlando A recent study published in the Journal of the American Medical Association Pediatrics considered the incidence of childhood cancers among children conceived in IVF relative to children conceived naturally. Dr. Logan Spector of the Division of Epidemiology/Clinical Research, Department of Pediatrics, University of Minnesota, was the lead author of the multicenter investigation.   The analysis was a retrospective, population-based cohort study linking cycles reported to the Society for Assisted Reproductive Technology (SART) Clinical Outcomes Reporting System from January 1, 2004, to December 31, 2012, that resulted in live births from September 1, 2004, to December 31, 2013, to the birth and cancer registries of 14 states, comprising 66% of United States births and 75% of IVF-conceived births, with follow-up from September 1, 2004, to December 31, 2014. The study included 275,686 children conceived via IVF and a cohort of 2,266,847 children, in which 10 births were randomly selected for each IVF birth. A total of 321 cancers were detected among the children conceived via IVF (49.1% girls and 50.9% boys; mean age, 4.6 years for singleton births and 5.9 years for multiple births), and a total of 2042 cancers were detected among the children not conceived via IVF (49.2% girls and 50.8% boys; mean age, 6.1 years for singleton births and 4.7 years for multiple births). The overall cancer rate per 1,000,000 person-years was 251.9 for the IVF group and 192.7 for the non-IVF group. The rate of hepatic tumors was higher among the IVF group than the non-IVF group (hepatic tumor rate: 18.1 vs 5.7); the rates of other cancers did not differ between the 2 groups. There were no associations with specific IVF treatment modalities or indication for IVF. This study found the rate of hepatic tumors was significantly higher among children conceived via IVF than among children conceived naturally (hepatic tumor rate, 18.1 vs 5.7); the rates of other cancers did not differ between the two groups. The study suggests an association between IVF and childhood cancer and does not determine whether the increased risk of liver tumors was due to IVF-related procedures or to the infertility population who underwent IVF to conceive.  Although the association of conception by IVF with childhood cancer is small and limited to rare tumors, further surveillance of cancer occurrence among children conceived via IVF is certainly warranted.   Reference:  JAMA Pediatr. 2019;173(6):e190392. doi:10.1001/jamapediatrics.2019.0392 Thu, 11 July 2019 00:00:00 An Antibiotic May Treat Endometriosis CRM Orlando Investigators at Washington University School of Medicine in St. Louis have found that treatment with the antibiotic, Metronidazole, reduces the size of endometriotic lesions. The mechanism is thought to involve reduction of the gut microbes that may be causative of the disease. Although this study was performed in mice, the researchers are planning a large, multicenter clinical trial to test the drug metronidazole in women. Endometriosis is a chronic inflammatory condition that affects up to 10 percent of reproductive age women and up to 45% of patients who frequent an infertility clinic.  More than 175 million women worldwide are thought to be affected. The condition results from uterine lining (endometrial) cells refluxing into the pelvic-abdominal cavity. These estrogen-dependent lesions tend to be self-propagating and defiant of the immune system.  Current treatments are both medical (hormone therapy) and surgical; however, both approaches involve potential side effects, risks, and disease recurrence. The St. Louis group found that treating mice with metronidazole reduced the size of endometriosis-related lesions, whether treatment was started before the lesions began or after endometriosis was already well-formed. The findings also suggest that bacteria in the gut (microbiome) play a role in the progression of the disease. An additional finding off the study was that some of the gut bacteria associated with bowel problems are also associated with endometriosis. When mice were treated with the broad-spectrum antibiotic metronidazole, not only were the endometriosis lesions reduced in size but bowel inflammation also was reduced. (It is well-known that reproductive-aged women with inflammatory bowel disease are more likely to develop endometriosis.) Other antibiotics were also tested; however, ampicillin, neomycin and vancomycin did not diminish endometriotic lesions or bowel inflammation. Furthermore, the research team found that levels of a protective type of gut bacteria were very low in the mice with endometriosis, so that following antibiotics, it may be possible to employ probiotics to boost levels of the protective bacteria. This work opens the door to identifying gut bacteria that can promote or prevent endometriosis and may become a path to simpler methods for diagnosing endometriosis. Although human studies have not yet been performed, there is a huge and growing body of  human studies to suggest that a healthy gut with diverse bacterial species affects general health, susceptibility to disease and the burden of disease.  A diet rich in probiotics may have a protective effect upon endometriosis.  Reference: Sangappa B Chadchan, Meng Cheng, Lindsay A Parnell, Yin Yin, Andrew Schriefer, Indira U Mysorekar, Ramakrishna Kommagani. Antibiotic therapy with metronidazole reduces endometriosis disease progression in mice: a potential role for gut microbiota. Human Reproduction, 2019; DOI: 10.1093/humrep/dez041 Tue, 02 July 2019 00:00:00 Follow-up Data of Children Born after Preimplantation Genetic Diagnosis Reassuring CRM Orlando Preimplantation Genetic Diagnosis (PGD), an IVF-related technique used to select genetically competent embryos, has been much debated with respect to the health of the resulting children. A chief concern has been the safety of the embryo biopsy. When performed on the day 3 embryo (8 cells) just one cell is removed for PGD and when performed on the day 5 or 6 embryo (blastocyst, 130-150 cells), a few cells are removed. PGD in the case of the blastocysts requires cryopreservation with transfer of genetically unaffected embryo(s) in a subsequent cycle. An analysis of 88,010 live births after PGD or IVF/Intracytoplasmic sperm injection (ICSI) reported no increased risk of preterm birth or low birth rate when PGD is performed, even after adjustment for confounding factors (female age, infertility diagnosis, number of previous IVF attempts, number of eggs retrieved, insemination type, day of embryo transfer), demonstrating safety of the embryo biopsy itself.[1] In the very recently published issue of Fertility and Sterility, Dr. Malou Heijligers and colleagues of Maastricht University Medical Center (Utrecht, The Netherlands) compared the growth, health, and motor development of 5 year-old children born after PGD to similar aged children born after IVF/ICSI and to children from families with a genetic disorder born after natural conception (NC).[2] The mean height, weight, and body mass index were comparable in all groups. A major congenital abnormality was noted in 5.8% (6/103) of PGD, 4.4% (4/90) of IVF/ICSI and 8.6% (5/58) NC children. In short, children born after PGD show normal health, growth and development relative to IVF/ICSI and NC children born to families with genetic disorders. [1] Sunkara SK, Antonisami B, Selliah HY, Kamath MS. Pre-term and low birth weight following preimplantation genetic diagnosis: analysis of 88,010 singleton live births following PGD and IVF cycles. Hum Reprod 2017, 32:432-8. [2] Heijligers M, Peeters A, van Montfoort A, Nijsten J, Janssen E, et al. Growth, health, and motor development of 5-year-old children born after preimplantation genetic diagnosis. Fertil Steril 2019; 111:1151-8. Tue, 25 June 2019 00:00:00 Deter Alzheimer's: Brush and Floss! CRM Orlando For the past twenty years various epidemiologic studies have shown that a potential link exists between periodontal disease (poor oral hygiene) and cardiovascular disease. Both processes, decades in the making, are associated with chronic inflammation. But good dental hygiene not only prevents tooth decay, gum disease, and perhaps atherosclerosis, recently investigators at the University of Bergen, Norway have uncovered a connection between gum disease (gingivitis) and Alzheimer’s disease. Bacteria causing gingivitis (Porphyromonas gingivalis) can move from the mouth to the brain and the bacteria produce a protein that destroys nerve cells in the brain, which in turn leads to progressive memory loss and eventually, Alzheimer´s. Researcher and spokesperson Piotr Mydel at Broegelmanns Research Laboratory, Department of Clinical Science, University of Bergen notes that the bacteria are not causing Alzheimer´s alone, but the presence of these bacteria raises the risk for developing the disease substantially and is also implicated in a more rapid progression of the disease. There is good news. This study suggests that there are some things one can do to deter or postpone Alzheimer´s: frequent brushing of the teeth, daily flossing, regular dental checks and professional cleaning. In short, excellent oral hygiene may retard this common form of dementia. The gingivitis-causing bacteria can move from the mouth to the brain where the harmful enzymes they excrete can destroy the nerve cells. Now, for the first time, the Bergen research team has DNA-evidence for this process from human brains. The team examined 53 persons with Alzheimer´s and discovered the enzyme in 96 per cent of the cases. Based upon this discovery, the Norwegian investigators have developed a drug that blocks the harmful enzymes from the bacteria, postponing the development of Alzheimer´s and initial testing of the new agent are slated for later this year.   Journal Reference: Stephen S. Dominy, Casey Lynch, Florian Ermini, Malgorzata Benedyk, Agata Marczyk, Andrei Konradi, Mai Nguyen, Ursula Haditsch, Debasish Raha, Christina Griffin, Leslie J. Holsinger, Shirin Arastu-Kapur, Samer Kaba, Alexander Lee, Mark I. Ryder, Barbara Potempa, Piotr Mydel, Annelie Hellvard, Karina Adamowicz, Hatice Hasturk, Glenn D. Walker, Eric C. Reynolds, Richard L. M. Faull, Maurice A. Curtis, Mike Dragunow, Jan Potempa. Porphyromonas gingivalis in Alzheimer’s disease brains: Evidence for disease causation and treatment with small-molecule inhibitors. Science Advances, 2019; 5 (1): eaau3333 DOI: 10.1126/sciadv.aau3333 Thu, 20 June 2019 00:00:00 Older Fathers May Affect the Health of their Partners and Children CRM Orlando Women have “biological clocks.” Men have “biological clocks.” A recent study from Rutgers University, published in the journal Maturitas, reviewed 40 years of research on the effect of the father’s age on fertility, pregnancy, and the health of resulting children. While it is generally well known and accepted that reproductive changes occur in women in the mid-thirties, most do not know of the physiological changes happening in men of the same age. In fact, there is no clearly accepted definition of “advanced paternal age.” In the medical literature, it ranges from 35 to 45 years with a doubling of the genetically abnormal sperm every eight years after the age of 20. In large part due to IVF, the number of infants born to fathers over 45 has risen 10 percent in the United States during the past 40 years. Importantly, the Rutgers study found that men 45 years of age and older  experience decreased fertility and that advanced paternal age places their partners at risk for increased pregnancy complications such as gestational diabetes, preeclampsia, and preterm birth. Babies born to older fathers were found to be at higher risk of premature birth, late still birth, low Apgar scores, low birth weight, higher incidence of newborn seizures, and birth defects (e.g., congenital heart disease and cleft palate). In addition, these children were found to have an increased likelihood of childhood cancers, psychiatric conditions, cognitive disorders, and autism. There is a natural decline in testosterone with aging, as well as an increase in poorer semen quality. With aging sperm tend to be less “fit,” and damage to sperm from the various stresses of aging can lead to changes in the genetics incorporated into the DNA of cells in the bodies of children conceived. Such germline mutations also may contribute to the association of older fathers and children with autism and schizophrenia. The “biological clocks” of men should be discussed by physicians as well as by the lay media. Men who delay fatherhood should consult their doctor and consider banking sperm before age 35 to lessen the increased risks to the health of the mother and child.   Reference: N. Phillips, L. Taylor, G. Bachmann: Maternal, infant and childhood risks associated with advanced paternal age: The need for comprehensive counseling for men. Maturitas, 2019; 125: 81 DOI: 10.1016/j.maturitas.2019.03.020 Thu, 06 June 2019 00:00:00 IVF: Choosing the Most Intelligent Embryo CRM Orlando Within the next 10 years couples undergoing IVF treatment could be given the chance to pick the “smartest” embryo, according to Dr. Stephen Hsu, senior vice president for research at Michigan State University. Genetic screening advances mean that it may soon be feasible to reliably rank embryos according to potential IQ. Of course, the first and most logical question is an ethical one: “Just because we can do something, should we?”  In addition to moral concerns, the prospect of highly genetically- selected babies inevitably leads to questions about possible unintended medical consequences and the potential for worsening existing social inequalities. Genomic Prediction, Hsu’s New Jersey-based company (, already offers testing for screening out embryos with abnormally low IQ to couples in the U.S. undergoing assisted reproductive technologies. And, Hsu predicts that screening to rank intelligence at the embryonic level will be available in the next ten years. In fact, not everyone in the scientific community agrees with the prediction and many regard it as genetics run amok and a potential ethical nightmare. For more than two decades couples undergoing IVF have been able to screen their embryos for chromosomal defects, both chromosome copy abnormalities (e.g., Down Syndrome, Turner Syndrome) and single gene problems (e.g., cystic fibrosis, spinal muscular atrophy). And, although many other traits, such as appearance and intelligence and predisposition for certain diseases are known to be inherited, these genes are distributed in hundreds of regions among the 24 pairs of chromosomes (polygenic), and therefore it has been impossible to screen for these traits. However, during the past several years, screening of huge databases of the various genes leading to traits has been possible, thereby allowing for calculation of “polygenic risk scores,” which give the relative likelihood of an individual’s having a particular trait or disease susceptibility. Hsu’s is the first company to take embryo screening from black and white into the many shades of gray. Presently, prediction of the smartest embryo is not possible but Genomic Prediction projects that once high-quality genetic data from approximately one million individuals becomes available, (anticipated within five to 10 years), it may be able to predict IQ to within about 10 points. Hsu is reluctant to state that screening for high intelligence would be ethically justified, saying: “Let me just decline to answer that at the moment.” Admittedly, this technology is highly controversial; however, that does not mean it could not gain acceptance in the future, Hsu said, suggesting parallels with the reaction to IVF in the 1980s. “The IVF pioneers … were called monsters, Frankenstein doctors; it was predicted that these babies would have health problems,” he said. “I am actually reassured by that. IVF is completely normalized now. Everyone who is pointing their finger [at Genomic Prediction] now should go back and read those articles.” Thu, 30 May 2019 00:00:00 Fertility to Futility: Treatment When Prognosis Is Very Poor, Or Worse CRM Orlando The great percentage of patients who present for fertility services have a chance of having a baby and their prognoses range from excellent to poor. Less commonly, the likelihood for success is very poor to almost zero. While most couples set limits (emotional, financial, age-related) to their treatments, others do not and find great difficulty in stopping treatment, even with a nearly nonexistent chance for success. In such scenarios where the patient desires to continue treatment despite overwhelming odds, the clinician faces an ethical dilemma in the continuation of care. When do the known risks, or even side effects, of the patient’s desired treatment(s) outweigh the benefits (the exceedingly small chance for a baby)? And, how are misunderstandings and disagreements between patients and physicians in these regards best handled? A recent journal article in Fertility and Sterility from the American Fertility Society’s Ethics Committee provides an opinion on fertility treatment when the prognosis is very poor or futile ( Certainly, open communication between the patient and physician is essential for preventing and/or resolving conflict and patient education, according to the latest medical literature, as well as psychosocial examination of motives and values are important in the worst prognosis cases. Even so, there may be times when a patient insists on continuation of therapy, not willing to stop treatment or to consider alternative means for developing a family. The Ethics Committee recommends the development of patient-centric policies for each IVF center to enable clinicians to make the best, evidence-based decisions. There may be cases in which the clinician ethically refuses to provide further care. In addition, there may be rare occasions when provision of treatment in the futile case yields a psychological benefit; however, in most situations, therapy in futile cases cannot be justified medically or ethically. Every patient must be part of the dialogue of the informed consent process, with a clear discussion of the indications, risks, side effects, potential benefits, and treatment alternatives. Thu, 16 May 2019 00:00:00 What about Uterine “Receptivity”? CRM Orlando Much is being said and written about endometrial (uterine lining) receptivity in the in vitro fertilization (IVF) setting, and especially in the context of the failed IVF cycle. Endometrial receptivity is one of the critical aspects of the complex process of embryo attachment, invasion, and successful implantation. The endometrium is a hormonally-responsive, shag carpet-like tissue that undergoes dynamic growth and developmental changes all within a single menstrual cycle. These proliferation and differentiation phases lead to a 3-6 day long “window of implantation,” or time of optimal receptivity, within the second half of the cycle, during which embryos are most likely to implant. Although this window of implantation has been suggested and studied for nearly seventy years, only relatively recently have more sophisticated techniques been applied to evaluating the endometrium. Abnormalities of the uterus (fibroid tumors, adenomyosis, polyps, inflammation of the endometrium) are frequently encountered and are thought to alter endometrial receptivity by interfering with endometrial molecular expressions that promote implantation. Ultrasound or magnetic resonance imaging studies, alone, may be inadequate to determine receptivity deficits in the context of anatomic abnormalities and molecular studies (e.g., Endometrial Receptivity Analysis, Endometrial Function Test) may be indicated. In known or suspected endometriosis, inflammatory marker testing (ReceptivaDX) may be a consideration. For the best success, anatomic abnormalities and endometriosis may need to be treated medically or surgically prior to IVF and care should be individualized and prospective with diagnostic and treatment options carefully discussed with patients. Such an approach is exceedingly important for the couple who has had multiple failed embryo transfers with high quality embryos. With 72-144 hours of potential receptivity, timing is not everything. In fact, endometrial functionality is more important than exact timing of embryo transfer and implantation. That is, implantation success is a matter of properly developed endometrial glands expressing the appropriate pattern of peptides, complex carbohydrates, and growth factors during a widely-opened window. There is much more to learn about endometrial receptivity, the signaling between endometrium and embryo, and implantation; however, strides have been made during the last decade in understanding this conundrum, the biggest question mark in IVF. Thu, 09 May 2019 00:00:00 IVF in Poor Responders: Mild Versus Conventional Stimulation CRM Orlando Relative to traditional treatments with higher dosages of hormonal medications, is mild stimulation of the ovaries for in vitro fertilization (IVF) better? Certainly, mild stimulation has potential advantages, including reduced cost per cycle, lower risk of ovarian hyperstimulation syndrome, and less physical and emotional demands on the patient. Based upon a medical literature search (766 studies of which 21 were included) the American Society of Reproductive Medicine published a guideline: In patients expected to be poor responders with IVF (Age>40 years, poor response in prior IVF attempt, low AMH, elevated FSH, reduced antral follicle count), pregnancy rates are low, no matter which treatment plan is used. There is fair to good evidence that clinical pregnancy rates are not substantially different using mild stimulation protocols compared with conventional IVF in poor-responder populations. There is fair evidence that mild ovarian stimulation is cost-effective. In patients who are classified as poor responders and pursuing IVF, strong consideration should be given to a mild ovarian stimulation treatment plan (low-dose gonadotropins with or without clomiphene or letrozole) due to lower costs and comparable low pregnancy rates compared with traditional IVF stimulation protocols. In short, it may be time to reduce the dosages, the costs, the physical and emotional stress, the logistics, and where appropriate, the expectations for pregnancy among poor prognosis patients considering IVF. Thu, 02 May 2019 00:00:00 Ways to Improve Fertility CRM Orlando Oftentimes with respect to complex issues, even health-related, we like easy, self-help fixes. Just go to any online bookstore (or a bricks and mortar bookstore, if you can find one) and see a myriad of “DIY” titles such as “Three Steps to ______,” “Five Ways to ______,” “Seven Methods for ______.”  While there are not 3, 5, or 7 steps to conception, below are ten clinically-based means to boost fertility. Most are pretty simple, and some of these things your grandmother probably told you! 1: Timely intercourse It is best to have vaginal intercourse every two to three days throughout the cycle, with the most likely days including 3 days prior to ovulation to 3 days following ovulation. Commonly we recommend the usage of an ovulation prediction kit beginning around cycle day 10 of a 28 day cycle, with intercourse the evening that the test suggests ovulation as well as the next evening. 2: Maintain a healthy BMI What is the right weight to maximize the likelihood of conception? Generally it is a body mass index of between 19-25 kg/m2. If you do not know your BMI you can use this calculator from the National Institutes of Health: It is more difficult to conceive if one is overweight or underweight (in fact, more difficult if under than over). The fatty layer beneath the skin is the largest endocrine organ in the body, by far, and it makes hormones that have direct effects on ovulation and other reproductive functions. 3: Maintain sperm health Approximately 40% of couples who present to an infertility clinic have a male factor related problem as a primary diagnosis. Sperm concentration, motility and structural form are all important determinants of sperm health.  Men should also avoid being over- or underweight, and avoid tobacco, alcohol, excessive heat (tight underwear, hot tubs, saunas, steam rooms), and toxins (e.g. petroleum-based products, household cleaners, pesticides and herbicides). 4: Do not smoke In addition to known adverse effects on the lungs and cardiovascular health, a couple attempting conception should stop smoking due to the fact that smoking tobacco products increases oxidative stress (oxygen radicals) which damages both egg and sperm DNA. Ask your primary care physician about means to stop smoking (e.g., nicotine replacement therapy, Chantix, Zyban, e-cigarettes, hypnosis). 5: Good lubricants Although commonly used, water-based lubricants may not promote fertility! In fact, some water-based gels actually stun or kill sperm. Oil-based lubricants such as canola oil, olive oil, baby oil (Not butter!) are all good alternatives. If you do decide to use a product from the drugstore, please read the label to make sure you are not using something that may be contra-ceptive.   6: Drink alcohol minimally (if at all) Some recent studies from northern Europe have shown that even five bottles of beer per week can have definite adverse effects on sperm health and reproductive hormones. Excess alcohol in men can lead to decreased testosterone, increased sex hormone binding globulin and increased estrogen, as well as increased visceral fat (“beer belly”) with associated cardiovascular risks. In women, excess alcohol can lead to ovulation dysfunction, can increase testosterone and other androgens and can increase the chances for breast cancer. In general, men should probably have no more than four bottles of beer, or four 6 oz. pours of wine per week and women should have no more than three of either per week. With respect to mixed drinks, men should probably have no more than two and women no more than one per week. 7: Minimize caffeine intake Consuming 500 milligrams (about 5 cups) of coffee can affect male and female reproductive health. Animal studies reported in the British Journal of Pharmacology have found that the activity of fallopian tubes, which carry eggs from the ovaries to the uterus, can be undermined by regular caffeine intake, thus negatively affecting fertility. The recommended daily limit of caffeine is 200-250 milligrams daily while attempting conception and no more than 125 mg during pregnancy. First trimester miscarriage rates increase with greater than 150 mg of caffeine daily. 8: Prevent STDs Avoiding sexually transmitted diseases (STD) is recommended to protect general health and fertility. Chlamydia and gonorrhea can cause scarring in both women and men and adhesions in the fallopian tubes or vas deferens can lead to sterility. Condoms help as does monogamy! Before having sex with someone, make sure that she or he is verifiably STD-free and has been very recently tested. No proof, no sex.   9: Stop exercising excessively Daily aerobic exercise, achieving a heart rate of 70-80% of one’s target heart rate for 30 minutes daily is a good general recommendation; however, one should have a medical checkup before engaging in any new physical activities. More than five hours of vigorous exercise per week may lead to ovulation problems due to poor communication between the brain and the ovaries. Sperm production and function can also be impacted negatively by excessive exercise. 10: Beware of toxic chemicals Household cleaners, herbicides, pesticides, organosolvents, petroleum based products, anesthetic gases and other chemicals can decrease fertility. Certain professions are more likely to be exposed to harmful chemicals than others. These include but are not limited to workers in agricultural, pest-control, domestic cleaning, petroleum industry, hair styling, dentistry, anesthesia, and printing. Thu, 18 April 2019 00:00:00 For Polycystic Ovary Syndrome: Letrozole or Clomiphene + Letrozole? CRM Orlando In the most recent edition of Fertility and Sterility is an intriguing pilot study on the treatment of polycystic ovary syndrome (PCOS) by the excellent reproductive medicine specialists at the University of Iowa ( It is a randomized and controlled trial to evaluate whether a combination of letrozole and clomiphene results in higher ovulation rates than Letrozole alone in women with PCOS. The most common cause of lack of ovulation, PCOS is also the single most common endocrine disturbance of reproductive age women. Both letrozole (an aromatase enzyme inhibitor) and clomiphene citrate (a selective estrogen receptor modulator – SERM) are used frequently throughout the world as oral ovulation induction medications. Letrozole has emerged as the first line treatment of ovulation dysfunction in PCOS following another randomized trial that demonstrated higher ovulation rates and better live birth with lower twin rates. However, there is a frustrating lack of responsiveness by some patients following letrozole administration. Dr. Rachel Mejia and her colleagues proposed adding the old drug, clomiphene (FDA approved in 1967), with the newer medication, letrozole (used in PCOS since the late 1990s). The Iowa-based research team studied whether combination of both agents would provide a synergy that would be better than letrozole alone. Seventy participants were randomized; 35 received letrozole 2.5 mg plus clomiphene 50 mg cycle days 3-7 and 35 received letrozole 2.5 mg cycle days 3-7 for one treatment cycle. Women who received the combination therapy had statistically higher ovulation rates than women who took letrozole alone [27 of 35 (77%) versus 15 of 35 (43%)]. There were no serious adverse events or multiple gestations in either group and side-effects were similar in both groups. This relatively small study suggests that two-agent therapy is better than letrozole alone among PCOS patients and provides an inexpensive and safer alternative to injectable (gonadotropin) therapy in this patient population. This investigation did not look at live birth rates and until such a larger, randomized study is available, this dual therapy approach should be employed with some restraint. If live birth rates were to be shown higher for the letrozole-clomiphene combo, then dual therapy may supplant letrozole as the first line approach to PCOS ovulation problems. Thu, 28 March 2019 00:00:00 Cannabis: What You Should Know CRM Orlando Marijuana and its sister, hemp, are suddenly everywhere. Both are cannabis species and contain a class of compounds called cannabinoids. In fact, there have been more than 100 different cannabinoids identified, but the two most abundant and notable are tetrahydrocannabinol (THC) and cannabidiol (CBD). Marijuana and hemp are very different in cultivation, function, and application. Marijuana, of course, is used recreationally and medicinally but hemp is used in dietary supplements, plastics, fibers, clothing and accessories, and skin care products. Remarkably, hemp has been shown to have more than 2500 applications. Marijuana has high THC content (5-35%) whereas hemp has low THC content (<0.3%) and is therefore not psychoactive. Hemp cultivation requires minimal care and may be grown easily in most climates but marijuana must be grown in carefully-controlled conditions. It is important to note, however, that hemp contains high CBD that acts as an antagonist for hemp’s low THC content. CBD may have some mild anti-inflammatory, analgesic, and anti-anxiety properties (without any psychoactive properties whatsoever).   1. Be Careful with CBD. Most CBD oil in the United States has been imported with little quality control or quality assurance. Due diligence is important prior to purchasing!  Because CBD is found only in hemp’s leaves and flowers (not the seeds) hemp oil does not have much CBD unless it has been added. If you desire CBD you must look for “CBD” on the label not just “Cannabinoids.”  2. CBD Has Few Proven Medical Indications. Presently, CBD may be purchased in water, coffee, and candy and while there are many claims as to its health benefits, most claims have not been substantiated. Except for FDA approval of a CBD-derived drug for treating rare, severe forms of epilepsy, there are essentially no randomized, placebo-controlled clinical trials with CBD.   3. CBD May Interfere with Medications. The liver enzyme, cytochrome P450, which metabolizes many medications including antidepressants, anti-hypertensives and cholesterol-lowering drugs, may be blocked by CBD. That is, CBD may adversely affect the way medications work. If you are presently taking prescription medicines, please consult your health care professional before taking CBD.   4. THC has Few Proven Medical Benefits. In 2017, The National Academy of Medicine published The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research ( and the conclusions were as follows: There is conclusive evidence that cannabis reduces the nausea and vomiting associated with chemotherapy There is substantial evidence that cannabis modestly reduces chronic pain There is substantial evidence that cannabis reduces self-reported involuntary muscle contractions in patients with multiple sclerosis. The FDA has approved only three synthetic THC drugs: Cesamet (nabilone) and Marinol and Syndros (dronabinol)   to treat nausea and vomiting of chemotherapy.   5. Cannabis Has Risks! Like smoking tobacco, smoking marijuana introduces carcinogens and many other yet unidentified chemicals into the body. Although smoking marijuana has not been associated with an increased risk of lung cancer relative to non-smokers, there is an increased risk of chronic bronchitis as well as coughing and wheezing symptoms. Quality research has also shown that using THC impairs the ability to drive an automobile and to operate machinery.  Driving under the influence, whether alcohol or cannabis, is still very dangerous and DUI may have personal and legal consequences. The National Academy of Medicine found that THC usage may increase the risk of psychoses such as schizophrenia, with the highest risk among frequent users. Adolescent users also have a higher risk for psychotic disorders and people with a family history of mental disorders should avoid using cannabis. “Appropriate doses” differ from state to state. In Oregon a “dose” of THC is 5 mg, whereas in Colorado and Washington a “dose” is 10 mg. Dosage effects vary from individual to individual and 10-25 mg may lead to anxiety, hallucinations, nausea and vomiting. Due to slower absorption, it is easier to overdose with edible forms (candies, chocolates, lollipops, brownies) of THC than smoking or vaping. In short, there are real differences between marijuana and hemp but there are few medical indications for either THC or CBD. Well-controlled clinical trials are needed for the safe medicinal usage of these agents. Thu, 21 March 2019 00:00:00 Are Mosaic Embryos the Past and Future of IVF? CRM Orlando Not every embryo starts off containing 46 perfect chromosomes; some have “aneuploidy,” that is, too few or too many chromosome copies. Aneuploidy is common and affects as many as 80 percent of human embryos and because aneuploidy has been linked to decreased IVF success, miscarriage and certain genetic disorders, “mosaic” embryos, those with both normal and abnormal (aneuploid) cells, have not been considered the best embryos for IVF  transfer. Research published on March 4, 2019 in Genome Research from the Oregon Health and Science Center, one of the world’s best primate research centers, confirms that in a nonhuman primate model, embryos with mosaicism are able to adapt to their genetic abnormalities and continue into fetal development with healthy IVF outcomes. Using advanced time-lapse imaging and single-cell genetic sequencing techniques to accurately track the development of mosaic embryos of a rhesus monkey, Dr. Shawn Chavez and the Oregon team identified a unique relationship between mosaicism and two other well-known biological processes: cell fragmentation and blastomere exclusion. Following natural conception, as well as after IVF, the large embryonic cells formed by the division of a fertilized egg, are known as blastomeres, and these early blastomeres may break down into smaller pieces called cellular fragments. As blastomeres either divide normally or fragment, the embryo appears to able to have a “red light” signal, identifying which blastomeres have genetic abnormalities and stopping these cells from further development. By five to six days of development (the stage that an embryo implants into the uterus), these abnormal cells have been visibly excluded from the embryo, suggesting that mosaic IVF embryos could be considered for use in transfer with resulting developmental success and livebirth. This investigation has implications for human IVF and could positively impact IVF processes for humans in the near future. For example, in patients with only mosaic embryos available for transfer, these findings as well as previous human reports (e.g., Grifo and colleagues) suggest that in some cases, these embryos can result in apparently normal pregnancies. No doubt, prior to preimplantation genetic diagnostic testing, mosaic embryos were unwittingly transferred and, no doubt, some of the eight million IVF babies born since 1978 began as mosaic embryos! The team at the Oregon National Primate Research Center has ongoing research employing live-cell time-lapse imaging to better understand the relationship between aneuploidy, cell fragmentation and blastomere exclusion within the early embryo.   Reference: Brittany L. Daughtry, Jimi L. Rosenkrantz, Nathan H. Lazar, Suzanne S. Fei, Nash Redmayne, Kristof A. Torkenczy, Andrew Adey, Melissa Yan, Lina Gao, Byung Park, Kimberly A. Nevonen, Lucia Carbone, Shawn L. Chavez. Single-cell sequencing of primate preimplantation embryos reveals chromosome elimination via cellular fragmentation and blastomere exclusion. Genome Research, 2019; 29 (3): 367 DOI: 10.1101/gr.239830.118 Thu, 14 March 2019 00:00:00 High BMI and Risks in IVF CRM Orlando With the increasing prevalence of obesity in the United States, and with the associations between obesity and infertility (ovulation dysfunction, insulin resistance, androgen excess), more and more patients with obesity are seeking infertility care. With the obesity epidemic in this country the question of “When do surgical risks outweigh benefits?” must be asked. Perhaps an easier question to answer, however, is “To what degree are high Body Mass Index (BMI) patients at risk in the IVF (egg retrieval) setting?” A study just published from Harvard Medical School by Romanski and colleagues on class III (BMI 40-49.9 kg/m2) and class IV (BMI 50 or greater kg/m2) obesity attempts to answer the latter question. This was a five plus year-long study of 144 patients with BMI at 40 kg/m2 or greater compared to 1,016 age-matched women with normal, overweight, and obese BMIs. Serious complications were uncommon across all BMI groups, although minor complications (oxygen desaturation, requirement for oral/nasal airway, etc.) were more common among class III and class IV patients. As expected, obese patients in these two groupings also had more frequent diagnoses of gastroesophageal reflux disease, hypertension, diabetes, asthma, and sleep apnea. These patients were also more likely to require more intravenous sedation medications, have longer egg retrieval procedures and require transabdominal egg retrieval. The authors conclude that egg retrieval procedures can be safely performed in the outpatient setting for patients with BMI greater than 40 kg/m2; however, with the increased anesthetic requirements, longer procedure times and frequency of minor complications there should be “the presence of adequate personnel, training, and equipment to perform basic and emergency airway management.”   Reference: Thu, 28 February 2019 00:00:00 Folate for Fathers? The Effect of Paternal Folate Status and Embryonic Growth CRM Orlando It is well known that the folic acid status of the mother is of vital importance to normal embryonic and fetal growth, with folate deficiency resulting in neural tube and other defects of development. Although the association between maternal folate consumption and fetal growth has been amply studied, much less is known about the paternal diet and fetal health. In the February 2019 edition of Fertility and Sterility, a leading journal in reproductive medicine, is a study by Dr. Jeffrey Hoek and colleagues from Erasmus MC, University Medical Centre Rotterdam, the Netherlands regarding the association between folate status in men and the growth of embryos. This prospective study involved 511 singleton pregnancies, 303 of which were spontaneously conceived, and 208 followed in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and measured paternal folate levels as well as embryonic growth at 7, 9 and 11 weeks of gestation using 3-D ultrasound and a virtual reality system. The results were divided into four groups (quartiles) and showed that low and high paternal folate levels are associated with reduced embryonic growth trajectories in pregnancies which were conceived spontaneously. The third quartile of paternal folate levels had the highest embryonic growth; however, there was no relationship observed between paternal folate status and embryonic growth among the IVF/ICSI pregnancies. This research from Rotterdam is the first to link paternal folate levels with growth of the embryo and although the authors underscore the importance of a father’s folate status, they do not specifically recommend folate supplementation for men. (Interestingly, only 8.1% of the men in the study used folate supplements with and increasing number of men using supplements from quartile 1 to 4.) This study demonstrated that there can be too much of a good thing with decreased embryonic growth with the highest folate levels. This study makes it clear that the nutritional status of the father plays a role in fetal growth; however, much work remains to be done along these lines before recommendations for paternal folate supplementation may be made. At this point the best advice may be to eat a healthy, well-rounded diet, rich in whole grains and fresh vegetables and fruits (Choose My Plate:   Reference: Hoek J, Koster MPH, Schoenmaker S, et al: Does the father matter? The association between the periconceptional paternal folate status and embryonic growth. Fertil Steril 111:2, 270-278. Thu, 21 February 2019 00:00:00 Children Born Following Assisted Reproduction: No Overall Increased Risk of Cancer CRM Orlando In a study of 47,690 children published February 4, 2019 in Human Reproduction, a highly-regarded reproductive medicine journal with world-wide circulation, children born after assisted reproductive technology (ART) do not appear to be at greater risk of developing cancer than other children. This is a landmark study because there has been conflicting evidence in this regard and the size and duration of this investigation are unparalleled in other such research. (The children in this study were followed for an average of 21 years.) This paper from the Department of Epidemiology in The Netherlands Cancer Institute, Amsterdam, is the first study to look at the long-term cancer risk in ART children compared to those in the general population or who were conceived naturally by sub fertile women. The possibility exists that difficulty in conceiving could be a factor that influences the risk of cancer in their offspring. Of the 47,690 children included in the analysis, 231 developed cancer. After adjusting for confounding factors (age and the parental cause of subfertility), the overall long-term risk for cancer was neither increased in the ART-conceived children compared with naturally conceived children from sub fertile women, nor when compared with the population at large. The cancer risk, however, was somewhat increased, although not statistically significantly, in children conceived after two commonly used fertility treatments: intracytoplasmic sperm injection [ICSI] or from embryos that had been frozen before being thawed and transferred. In addition, there was a slightly increased, but statistically insignificant risk of lymphoblastic leukemia and melanoma. These data must be interpreted cautiously in that the numbers of cancers in these groups were small, and these findings may be due to chance. Researchers analyzed data from a large, nationwide study of sub fertile women (the OMEGA study) who were treated in one of 12 Dutch fertility clinics between 1980 and 2001. They also collected data on the offspring and the information was linked to data on the incidence of cancer from The Netherlands Cancer Registry between January 1989 and November 2016. Of the 47,690 children born alive, 24,269 were conceived by ART, 13,761 were naturally conceived and 9,660 were conceived naturally or with the help of fertility drugs, such as ovarian stimulation medication, but not by ART. Of the 231 cases of cancer occurring among all the offspring, there were 31 cases of lymphoblastic leukemia and 26 cases of melanoma. Although only hypothetical, some fertility treatments might induce genetic alterations that increase the risk of melanoma and leukemia. Clearly, further research with larger numbers is needed in this regard. Although these results provide reassuring evidence that children conceived as a result of fertility treatments do not have an increased risk of cancer after a median follow-up of 21 years, as more children are born following ICSI and embryo cryopreservation, the long-term cancer risks of these techniques should be studied in larger numbers of children. (In fact, this same research group is expanding their study to include more than 30,000 ART-conceived children born in more recent years. It will include children born following ICSI and/or embryo cryopreservation.) Journal Reference: Mandy Spaan, Alexandra W van den Belt-Dusebout, Marry M van den Heuvel-Eibrink, et al:. Risk of cancer in children and young adults conceived by assisted reproductive technology. Human Reproduction, 2019; DOI: 10.1093/humrep/dey394 Thu, 14 February 2019 00:00:00 Welcome Orilissa? CRM Orlando In 1977, Doctors Andrew Schally and Roger Guillemin shared the Nobel Prize for the discovery of Gonadotropin Releasing Hormone (GnRH), the brain hormone that causes the pituitary release of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH lead to menstrual events, including ovulation, in the female, and sperm production in the male.  GnRH is a small, ten amino acid-long protein and shortly after its discovery, investigators were substituting some of its amino acids to make GnRH-like (or GnRH agonist) drugs that would have a longer half-life and that could modulate reproductive function. In 1985, Leuprolide (Lupron™, AbbVie) was approved by the FDA and this injectable medication has been a mainstay in the treatment of endometriosis, uterine fibroids, early puberty, breast cancer and prostate cancer, as well as in treatments for IVF. A distinct disadvantage of GnRH agonists has been that they take 7-10 days to ”turn off” FSH and LH production and, in fact, there is an initial increased release of these pituitary hormones which can actually worsen the condition being treated. Anticipated since the early 1990s have been GnRH antagonists, agents that would act immediately in suppressing FSH and LH production. Antagonists were developed by changing the part of the GnRH peptide that binds the pituitary receptor such that it was not activated. Since the early 2000s, injectable antagonists Ganirelix and Cetrorelix have been available for the same indications as Leuprolide, but are mostly used throughout the world in IVF treatment plans to inhibit premature ovulation of the eggs. In July 2018, the FDA announced the approval of elagolix (Orlissa™, AbbVie) a non-protein, oral GnRH antagonist for treatment of moderate to severe endometriosis pain. Although it is the first new endometriosis treatment in over a decade, it is uncertain whether elagolix represents an advantageous option or is it just one more arrow in the therapeutic quiver. The FDA phase III trials and twelve month long extension studies showed improvement in menstrual pain as well as nonmenstrual pelvic pain for both the 150mg once daily and 200 mg twice daily preparations of elagolix compared with placebo. For example, in the extension study, 75-78 percent, 67-69 percent and 58-60 percent of women taking the 200mg twice daily dose reported improvement in menstrual pain, non-menstrual pelvic pain and painful intercourse, respectively. Other potential uses of elagolix include other estrogen-dependent diseases, oral contraception, post coital contraception, male contraception, and all non-contraceptive uses of oral contraceptives.   The annual cost for elagolix for one year is approximately $10,000, which if not altogether prohibitive, certainly limits its prescription. By working directly with insurance companies, however, AbbVie, the manufacturer, has taken action to make the medication more affordable. Elagolix has demonstrated efficacy for endometriosis-associated pain and certainly represents another tool in the armamentarium; at this point, however, it remains unclear whether this new oral antagonist offers improved long-term patient satisfaction, safety and efficacy relative to continuous oral contraceptives, progesterone-like agents, and the depot form of Leuprolide. It is also critically important for healthcare providers to know which endometriosis patients will benefit from combined treatments, including surgical, medical, and physical therapies and other multidisciplinary pain management techniques. In short, Yes! We heartily welcome Orilissa to the world of reproductive medicine and perhaps most exciting may be the myriad indications (other than endometriosis) for which it may be used. Thu, 07 February 2019 00:00:00 Gene-swapping in Human Eggs and Sperm Can Increase Mutations in Children CRM Orlando When parents pass their genes down to the next generation, their children receive shuffled or remixed versions of their own chromosomes. According to a recent, high-precision study of the DNA of more than 150,000 people in Iceland, that reshuffling of the chromosomal deck can increase the chances that the child’s DNA will also mutate in certain locations. The findings of this study may help the understanding of mutation rates in humans and perhaps how quickly we are changing as a species. One’s total genetic makeup, or genome, consists of long strands of double-stranded, helical DNA, which codes for genes using the four chemical letters of the genetic alphabet. Approximately three billion pairs of letters, or “base pairs,” coil into 23 pairs of chromosomes in almost all of one’s cells. Each chromosome contains thousands of genes, strands of DNA that code for various types of proteins.  Egg and sperm cells each have 23 chromosomes (one-half of the chromosomes of other cells) and arise from specialized cells called germ cells. However, before a germ cell splits, each chromosome exchanges a piece of itself with its partner chromosome in a process called “crossover,” or recombination. That is, sequences of DNA cross over between the chromosomes in a pair. Due to this “gene swap,” children do not have the identical chromosomes of their parents. Recent data have revealed that crossovers may affect the rates at which individual genes mutate. Using a genetic data set of 155,250 Icelanders, researchers at deCODE Genetics, a biotechnology company based in Reykjavik, have created the most detailed map yet of the relative locations of genes of the human genome. By looking at the differences in parent and child DNA, the researchers were able to trace both crossovers and mutations in DNA as it passed from parent to child. Although prior genetic maps revealed the locations of specific features to within thousands of DNA base pairs, the new map pinpoints the location of a feature to a segment of DNA about 700 base pairs long. As reported in the January 14, 2019 edition of Science, the team found that mutations occurred much more often near crossover sites. In stretches of DNA within about 1000 base pairs of where crossovers had happened, mutations were roughly 50 times more likely than in the whole genome on average. And the farther from a crossover site a stretch of DNA was, the fewer the mutations. Previous investigations have shown similar relationships between crossovers and mutations but in considerably less detail and in far smaller sample sizes. Crossovers that occur when parents’ eggs and sperm cells are created are not random, and they make mutations more likely in certain areas of DNA, making these mutations less random as well. This suggests that there is more than randomness contributing to genetic diversity. Interestingly this study also demonstrated that parents’ ages matter: for each year older that a mother or father is when their child is born, the number of mutations in the child’s DNA will increase by about 0.38 and 1.39 respectively. Further, a mother’s age also affects the number of crossovers a child will inherit. For older mothers, the egg cells that eventually become children tend to have more crossovers than the egg cells of younger mothers. Aside from findings about crossover and mutation frequencies, the researchers from Iceland identified several specific genes that may be associated with the rate or location of crossovers beyond the genes already known. In summary, this work suggests that understanding how mutations occur can help biologists study how human genetic diversity happens and may yield insights into mutation-caused diseases as well.     Reference: doi:10.1126/science.aaw7896 Thu, 31 January 2019 00:00:00 Acupuncture Does Not Improve IVF Birth Rates CRM Orlando Among the most frequent questions that our patients ask are those regarding the complementary, Traditional Chinese Medical techniques of acupuncture.  Several previously published meta-analyses (quantitative statistical analyses of separate studies to test the pooled data for statistical significance) have shown no benefit of acupuncture in the IVF setting. Another such study of over 800 Australian and New Zealand women undergoing acupuncture treatment during their IVF cycle has confirmed no significant difference in live birth rates relative to controls. The findings published some months ago in the Journal of the American Medical Association (JAMA) support recent guidelines from the American Society for Reproductive Medicine and the previous, high-quality meta-analyses. The researchers from NICM Health Research Institute (NICM), Western Sydney University, Flinders University, UNSW Sydney, University of South Australia, University of Adelaide and Greenslopes Private Hospital studied the effects of acupuncture administered prior to and following an embryo transfer (ET). Performed in 16 IVF centers in Australia and New Zealand, the randomized clinical trial involved 848 women aged 18 to 42 undergoing an IVF cycle using fresh embryos between June 2011 and October 2015, in which participants were given either acupuncture or a sham acupuncture control (a non-insertive needle placed away from the true acupuncture points). The results showed the rate of live birth was 18.3 per cent among participants who received acupuncture versus 17.8 per cent who received the sham acupuncture control, a non-significant difference. The authors concluded that while a short course of acupuncture may statistically be no better than sham at improving live birth and pregnancy outcomes, a psycho-social benefit (relaxation, stress relief, increased sense of wellbeing) from acupuncture was reported by some women undergoing IVF.       Reference: Caroline A. Smith et al. Effect of acupuncture vs sham acupuncture on live births among women undergoing in vitro fertilization: a randomized clinical trial. JAMA, 2018 DOI: 10.1001/jama.2018.5336 Thu, 24 January 2019 00:00:00 Eating a Diet Rich in Fiber and Whole Grains Is Associated with Reduced Risk of Various Diseases CRM Orlando In a study published in the prestigious British journal, The Lancet, earlier this month, nearly 40 years of data from observational studies and clinical trials revealed the health benefits of eating a high fiber diet (at least 25g to 29g or more of dietary fiber daily). The study was commissioned by the World Health Organization to inform the development of new recommendations for optimal daily fiber intake and to determine which types of carbohydrates provide the best protection against non-communicable diseases and weight gain. The researchers included 185 observational studies containing data that relate to 135 million person years and 58 clinical trials involving 4,635 adult participants. They focused on premature deaths from and incidence of coronary heart disease, cardiovascular disease and stroke, as well as incidence of type 2 diabetes, colorectal cancer and cancers associated with obesity: breast, endometrial, esophageal, and prostate cancer. The authors only included studies with healthy participants, so the findings cannot be applied to people with existing chronic diseases. The results suggest a 15-30% decrease in all-cause and cardiovascular related mortality when comparing people who eat the highest amount of fiber to those who eat the least. Eating fiber-rich foods also reduced incidence of coronary artery disease, stroke, type 2 diabetes, and colorectal cancer by 16-24%. Per 1,000 participants, the impact translates into 13 fewer deaths and six fewer cases of coronary artery disease. In addition, a meta-analysis of clinical trials suggested that increasing fiber intakes was associated with lower bodyweight and cholesterol, compared with lower intakes. Most people worldwide consume less than 20 g of dietary fiber per day. In 2015, the UK Scientific Advisory Committee on Nutrition recommended an increase in dietary fiber intake to 30 g per day, but only 9% of UK adults manage to reach this target. In the US, fiber intake among adults averages 15 g a day. Rich sources of dietary fiber include whole grains, vegetables and fruit. These findings provide compelling evidence for public health guidelines to focus on increasing dietary fiber and on replacing refined grains with whole grains. This dietary change reduces incidence risk and mortality from a broad range of significant diseases. “The health benefits of fiber are supported by over 100 years of research into its chemistry, physical properties, physiology and effects on metabolism. Fiber-rich whole foods that require chewing and retain much of their structure in the gut increase satiety and help weight control and can favorably influence lipid and glucose levels. The breakdown of fiber in the large bowel by the resident bacteria has additional wide-ranging effects including protection from colorectal cancer," said Professor Jim Mann, a coauthor of the paper.     Reynolds, A. et al: Carbohydrate quality and human health: a series of systematic reviews and meta-analyses. Lancet, Jan 10, 2019. Thu, 17 January 2019 00:00:00 Endometrioma-related Infertility: Surgery or IVF? CRM Orlando Endometriosis, and perhaps especially intra-ovarian endometriosis, is associated with infertility. The classic endometrioma or “Chocolate cyst” represents a benign ovarian cyst lined with uterine lining-like cells which contains viscous, old blood. They occur in 20-40% of patients with endometriosis and tend to distort normal ovarian anatomy and induce a chronic inflammatory reaction. This local inflammation can decrease the total amount of viable ovarian tissue and may diminish egg reserve. In the IVF setting women with endometriomas have higher cancellation rates and a lower number of eggs retrieved than those without endometriomas; however, the live birth rates are similar in the two groups. That is, although the numbers of eggs and resulting embryos are fewer, the embryo quality and implantation rates are not substantively different. Patients with endometrioma-related infertility may be offered surgery, surgery then IVF, or IVF directly as modes of treatment. Risks of endometrioma surgery include but are not limited to the skill of the surgeon, possible surgical complications, negative impact on ovarian reserve, possible incomplete excision with recurrence, delay in IVF treatment, and costs. The risks of IVF without prior endometrioma surgery are possible progression of endometriosis, cycle cancellation, challenging egg retrieval, fewer eggs retrieved, endometrioma infection, follicular fluid contamination, peritonitis, and undiagnosed ovarian cancer. In short, the decision for or against surgery prior to IVF must be carefully considered and individualized with baseline ovarian reserve testing (AMH, Cycle day 2-3 FSH and estrogen levels, and antral follicle counts) and associated pain levels important variables in the decision-making process. For example, the younger patient with presumed endometriosis-related pain and excellent reserve is a better candidate for pre-IVF endometrioma surgery than the older patient without pelvic pain and diminished ovarian reserve. It is along the disease continuum, and between these two patient types, that there are infinite shades of gray.                                                                                                                      Reference: In part after Donnez, J: Thu, 10 January 2019 00:00:00 Genetic Carrier Screening: What You Need to Know CRM Orlando Our DNA contains two copies of each gene — one inherited from one’s mother, and one from one’s father. While these genes pass along family characteristics like hair- and eye color, they also may pass on inherited conditions. Such inherited conditions are caused by mutations, or changes in the genes, and as long as only one copy of the gene contains a mutation there are usually no associated symptoms. Historically, genetic carrier screening for select disorders has been offered to patients of certain ethnic groups or has been limited to a few conditions, e.g., cystic fibrosis, spinal muscular atrophy and fragile-X, and this is still the approach offered by many reproductive specialists. However, for several years at the Center for Reproductive Medicine (CRM) we have recommended  expanded genetic carrier screening (ECS) for all patients due to the fact that of the 176 conditions for which we screen, most people carry at least one mutation. Usually this only becomes an issue if both patient and partner have a mutation in one copy of the same gene. In this situation, even though neither has any symptoms, there is a 1 in 4 chance for each pregnancy that a child will be affected by the condition associated with the gene (autosomal recessive disorders). While some of these autosomal recessive diseases are relatively benign, others are life-threatening. In addition, there are a few conditions where only the mother needs to carry a mutation for her children to be at risk (X-linked genetic disorders). The ideal time to assess genetic carrier status is prior to conception so that all reproductive options may be considered. These options would include preimplantation genetic diagnosis, where a few cells from a day-5 embryo may be biopsied and used for diagnosis, or usage of donor eggs or donor sperm. If one decides upon ECS, as opposed to ethnicity-based screening, there must be appropriate counseling as to the pros and cons as well as to the limitations of testing. There should also be the willingness for one’s partner to be tested if there are one or more mutations identified. Further, there should be the provision for posttest counseling, including comprehensive consultation with genetic counselors. Due to recent advances in throughput and lowered costs, ECS has become a valid option over traditional limited or ethnic screening and there is a progressively increasing screening panel for increasingly rare disorders. Such technological strides must be seen in context, however, and may be a double-edged sword. Thu, 03 January 2019 00:00:00 Endometriosis Treatment: Time for “Precision Medicine?” CRM Orlando Endometriosis – a condition where uterine lining tissue grows outside of the uterus – affects approximately 10% of reproductive-aged women, 45% of infertility patients, and 80% of women with chronic pelvic pain. The associated pain can be significant and even debilitating. The first-line treatment for women with endometriosis-related pain is hormonal and specifically progestin (progesterone-like) therapy. A recent study published in the Journal of Clinical Endocrinology & Metabolism from Yale University School of Medicine has shown that the effectiveness of progestin therapy depends on whether a woman's endometriosis-related lesions have the progesterone receptor (PR) present. The investigators tested the endometriotic lesions of 52 women who had undergone surgical evaluation for endometriosis at Yale New Haven Hospital for their PR status and there was a significant association between PR status and responsiveness to progestin therapy. Those whose endometriotic lesions were PR-positive responded considerably better to the progestin therapy, while those whose lesions were PR-negative found little to no relief from progestin therapy alone. The research team concluded that knowing the presence or absence of PRs may help in the development of new, individually-targeted, precision-based approaches to treating endometriosis. First author, Dr. Valerie Flores, stated, "Receptor status in endometriosis could be used in a manner analogous to the use of estrogen/progesterone receptor status in breast cancer for tailoring hormonal-based regimens." A targeted approach to endometriosis management may avoid some of the present “trial and error” methods involved with therapy. This work is the first step in the right direction toward precision medicine in treatment of endometriosis. Further work should focus on other hormonal receptors on endometriotic lesions and ultimately, perhaps the patient’s genome with respect to specific hormonal and other therapies. Reference: Valerie A Flores, Arne Vanhie, Tran Dang, Hugh S Taylor. Progesterone Receptor Status Predicts Response to Progestin Therapy in Endometriosis. The Journal of Clinical Endocrinology & Metabolism, 2018; DOI: 10.1210/jc.2018-01227 Thu, 27 December 2018 00:00:00 Perhaps the Slipperiest Slope CRM Orlando Some years ago a patient and her husband, both Ivy League-educated professors at a local university, presented to my office stating that they desired a “male heir.” They wanted him to be a least six feet two inches tall, dark-haired with blue eyes, athletic, and highly intelligent. It was explained to them that such Brave New World technology was not available and, even if it were, the ethics of developing such a ‘designer baby” would be questionable, at best. Three weeks ago, He Jiankui, a United States-educated Chinese physicist with training in bioengineering, reported that he had altered a gene in human embryos, before having them transferred into the mother’s uterus, with the goal of making the babies resistant to infection with H.I.V.Breaking with longstanding scientific tradition, He has not published the research in any scholarly journal and did not share any information on his specific materials and methods. Although genetic engineering of human embryos is banned in many countries, the Chinese researcher claims that he had created the world’s first genetically modified babies, born November 2018. Certainly his technique involved “CRISPR” (pronounced “crisper”, which stands for Clustered Regularly Interspaced Short Palindromic Repeats),  a bacterial defense system that forms the basis for CRISPR-Cas9 genome editing technology. This system can be programmed to target specific sequences of genetic code and to edit DNA at precise locations. With these systems, researchers can permanently modify genes in living cells and organisms and, in the future, may make it possible to correct mutations at precise points in the human genome in order to treat genetic causes of disease. Time will tell whether the recent CRISPR claims from China will prove fictional or factual; however, to mix a metaphor, the Rubicon has been crossed and our reproductive medicine stands at the top of what may be the slipperiest slope. Thu, 20 December 2018 00:00:00 What about Vaccines? CRM Orlando Cold and flu season is once again upon us and some of the most frequent questions that we hear during the fall and winter months among our female infertility patients are “Should I get a flu shot?” and “Is the flu shot safe?” and “What about other immunizations?” It would be best, of course, if all immunizations were completed prior to fertility care to protect against potentially serious infections, to avoid transmission to the baby during pregnancy, and to provide passive immunity to the newborn. Although most vaccines are safe, even during pregnancy, many physicians are reluctant to immunize patients due to unrelated but possible, coincidental events such as miscarriage or birth defects. Those vaccines which should not be given during pregnancy are measles, mumps and rubella (MMR), chicken pox (varicella), and herpes zoster. All others are recommended, especially if other risk factors exist. The following immunizations are recommended of women of reproductive age: Influenza, Tetanus, diphtheria, pertussis (Td/Tdap), Varicella, Human papilloma virus (HPV), MMR, Pneumococcal, Meningococcal, Hepatitis A, and Hepatitis B. For complete guidelines please see the Centers for Disease Control web site: ( It is important to know one’s immunization history, and especially one’s Rubella and varicella status, before becoming pregnant. In short, the answers to the above queries are: “Yes, please do get a flu shot.” “Yes, the flu shot is safe.” “Ideally, all immunizations should be current prior to becoming pregnant.” Thu, 13 December 2018 11:00:00 Sons of Fathers Who Smoke Have 50 Percent Lower Sperm Counts CRM Orlando Although numerous studies have linked maternal smoking during pregnancy with reduced sperm counts in resulting sons, a recently published investigation from Sweden has shown that men whose fathers smoked at the time of pregnancy had half as many sperm as those with non-smoking fathers. This effect was found to be independent of nicotine usage by the mother. Of 104 young men (age 17-20), those with fathers who smoked had a 41 percent lower sperm concentration and 51 percent fewer sperm than men with non-smoking fathers. This finding was after adjustment for the mother's own exposure to nicotine, socioeconomic factors, and the sons' own smoking. In fact, regardless of the mother's level of exposure to nicotine, the sperm count of the men whose fathers smoked was much lower. Cotinine is a metabolite from nicotine and a marker which can be measured in the blood. By measuring the level of cotinine, the team in Lund, Sweden was able to determine whether the parents themselves smoke or whether they have been exposed to passive smoking. This is the first study to link the father's smoking habit and negative changes in the son's sperm count; however, other studies have previously shown links between fathers who smoked and various health outcomes in children, such as birth defects. As opposed to the maternal egg cell, the father's sperm cells divide continuously throughout his reproductive lifetime and the percentage of genetically mutated sperm doubles approximately every eight years. Most newly occurring mutations come from the father and there are number of studies between advancing paternal age and a host of complex diseases. Tobacco smoke contains many substances that cause new mutations; therefore, it is certainly possible that at the time of conception, the sperm have undergone mutations and pass along genes that result in lowered sperm quality and quantity in the sons. Amazingly, children of fathers who smoke have been reported to have up to four times as many mutations in a certain repetitive part of the DNA as children of fathers who do not smoke. Certainly additional research is necessary in regard to tobacco usage and human reproduction.                                                                                                                            Reference: Jonatan Axelsson, Sally Sabra, Lars Rylander, Anna Rignell-Hydbom, Christian H. Lindh, Aleksander Giwercman. Association between paternal smoking at the time of pregnancy and the semen quality in sons. PLOS ONE, 2018; 13 (11): e0207221 DOI: 10.1371/journal.pone.0207221 Wed, 05 December 2018 11:00:00 Follow-up of Children Born After Preimplantation Genetic Diagnosis CRM Orlando Preimplantation genetic diagnosis (PGD) offers couples at risk for transmitting genetic diseases an alternative to prenatal diagnostic testing (chorionic villus sampling or amniocentesis). Couples opting for PGD must first undergo IVF treatment to obtain embryos for genetic analysis. Typically the peripheral, placental-generating (trophectodermal) cells of blastocysts (day 5 embryos) are biopsied and analyzed for a specific genetic defect or a chromosomal abnormality. In the current edition of the Journal of Assisted Reproduction and Genetics is a study from the Netherlands that looked at the safety of PGD from 1995-2014. The primary focus was on the congenital malformation rate as well as misdiagnosis, birth parameters, perinatal mortality and morbidity. A secondary focus was: “Is PGD a justifiable tool in prevention of heritable diseases?” The authors reviewed 439 pregnancies in 381 women that resulted in 364 live born children. The modes of inheritance in this study were as follows: autosomal dominant (39.1%), chromosomal (27.6%), X-linked (17.5%), autosomal recessive (14.8%), and mitochondrial (0.9%).  Nine children (2.5%) had major malformations and this percentage is consistent with other PGD registries and comparable to the prevalence reported by the European Surveillance of Congenital Anomalies. There was one misdiagnosis resulting in the miscarriage of a fetus with an unbalanced chromosome pattern and 20% of the children were born premature (< 37 weeks) and less than 15% had a low birth weight. One child from a twin, one child from a triplet, and one singleton died at 23, 32, and 37 weeks of gestation respectively.   It should be noted, because this study includes the early years of PGD, that older genetic analysis techniques were employed and only one or two cells of the embryo were biopsied. Presently, comparative genomic hybridization (CGH), a fantastically more sensitive method, is used to analyze the 5-8 cells of the biopsy. More biopsied cells mean more DNA available and increased accuracy of the diagnosis. This study also did not include preimplantation genetic screening for abnormal chromosome copy testing, commonly used in IVF for patients with advanced reproductive age, recurrent miscarriage history and failed IVF implantation(s). The conclusion of the study is that overall, the risk on major malformations in PGD children seems comparable to children born after IVF-ICSI, as well as to the risk reported in naturally conceived children. Data on pregnancy duration, birth weight, perinatal mortality, and hospital admissions in the PGD population, especially in the singletons, appear to be similar to the published data on naturally conceived children. In conclusion, PGD does not seem to be associated with an increased risk for adverse birth outcome when compared to naturally conceived children. Indeed, PGD does seem to be an important and justifiable technique for avoiding transmission of genetic diseases.   Reference: Heijligers, M., van Montfoort, A., Meijer-Hoogeveen, M. et al. J Assist Reprod Genet (2018) 35: 1995. Wed, 28 November 2018 00:00:00 Stress Reduces Fertility CRM Orlando Although up to 25% of women and 21% of men of reproductive age in the US and Canada report daily psychological stress, few studies have investigated whether there is an association between stress and decreased fertility in the population at large. In a study recently published in the American Journal of Epidemiology by Amelia Wesselink and colleagues at Boston University School of Public Health (BUSPH), higher levels of stress were indeed associated with lower likelihood of conception for women, but not for men. The study did not show a definite cause and effect relationship, but a strong association The study included women (4,769) and men (1,272) who did not have a history of infertility and had not been trying to conceive for more than six menstrual cycles. The researchers measured perceived stress using the 10-item version of the perceived stress scale (PSS), a survey designed to assess how uncontrollable, unpredictable, and overwhelming an individual finds her or his life circumstances. The items referred to the previous month, with five response choices ranging from 0 (never) to 4 (very often), up to a total of 40, with a higher total score indicative of a higher level of perceived stress.  The PSS was completed by both partners at baseline, and women also completed the PSS every two weeks at follow-up visits. (The baseline questionnaires also included demographic and behavioral factors, including but not limited to ethnicity, household income, diet, sleep, and frequency of sexual intercourse.) In general, baseline PSS scores were approximately 1 point higher among women than men, with the average follow-up PSS scores among women remaining fairly constant over the 12 months of the study. Women with PSS scores of at least 25 were 13 percent less likely to conceive than women with PSS scores under 10. This association was stronger among women who had been trying to conceive for no more than two menstrual cycles than among women who had been trying for three or more cycles prior to participating in the study. The association was also stronger among younger women (under 35 years old). The authors suggested that, if, in fact there is a causal relationship between higher levels of stress and lower pregnancy rates, it may be due in part to decreased intercourse frequency and increased menstrual cycle irregularity. No association was noted between men's PSS scores and the likelihood of conceiving. Interestingly, however, couples in the study were about 25 percent less likely to conceive when the man's PSS score was under 10 and the women's was 20 or higher. “Stress discordancy” between partners resulted in fewer pregnancies!  A K Wesselink, E E Hatch, K J Rothman, J L Weuve,  Aschengrau, R  J Song, L A Wise. Perceived Stress and Fecundability: A Preconception Cohort Study of North American Couples. American Journal of Epidemiology, 2018; DOI: 10.1093/aje/kwy186 Wed, 21 November 2018 00:00:00 Consulting Dr. Google: What Fertility Patients Should Know CRM Orlando Infertility? “Hormonal problems”? Endometriosis? Miscarriage? … While it is certainly tempting to search the Internet for health-related questions, it must always be remembered that surfing the web, or consulting “Dr. Google” is never a substitute for actual medical care. It is obvious that a search engine cannot take the place of a detailed medical history, a thorough physical examination, appropriate laboratory and diagnostic testing, and informed consultation performed by a board-certified physician; however, several patients daily tell me that they have done their “research” on the Internet, with many having diagnosed and treated themselves! Not infrequently, patients present with photocopies of a number of scholarly journal articles as evidence of their Internet search to argue for or against their diagnosis, treatment plan, or other convictions. There is nothing wrong with checking a search engine for things medical or surgical. For example, last year, I was having excruciating lower back pain and I turned to PubMed, Google Scholar, and other organizational and educational Internet sites for articles on treatment. Although my medical training to the point of residency was focused on neurosurgery, I did not presume that my reading of a few journal articles on laminectomy could replace the vast study and experience of a well-respected neurosurgeon. When physicians seek medical care, they ask their respected colleagues for recommendations. When I was looking for a back surgeon, I asked neurosurgeons, orthopedic surgeons, and anesthesiologists: “Who would you see if you needed lumbar back surgery?” Another good method for selecting a provider is to check those physicians who are on “Best Doctors” and “Top Doctors” lists. Although for thirty-three years we have seen many hundreds of physicians as patients at the Center for Reproductive Medicine, curiously, not once has a physician ever told us of their “research” on the Internet or challenged our diagnoses or treatments based upon a web search. Since most of us do consult with Dr. Google, at least occasionally, the following tips may result in the best quality information: Know the Source. (Everyone is not an authority.) In the order of sources, please consider:   branches of the Federal Government (.gov), a non-profit institution (.org), a professional organization (.org), a health system (.edu), a commercial site (.com). There is a big difference between a blog that states, "I did IVF and transferred four embryos." and one that says, "This page on in vitro fertilization was developed by healthcare professionals at the American Society of Reproductive Medicine." Be Skeptical: There is a lot of snake oil for sale on the Web! If the claims sound too good to be true, they probably are. Beware of claims that one treatment will cure a variety of conditions, or that it is a "breakthrough," or that it relies on a "secret ingredient." Use caution if the site uses sensational, sales-pitch-like writing. A web site for healthcare consumers should use simple language, not medical or technical jargon. Get multiple opinions. Check several respected web sites. Always look for the evidence. Rely on valid research, not opinion. Look for the credentials of the author, whether an individual or an organization. For example, "Written by IVF Blogger, Jane Doe," or "Copyright 2018, Society of Assisted Reproductive Technology." Consulting Dr. Google: What Fertility Patients Should Know Look for dates on articles. Reproductive medicine is a rapidly changing field and information just several years old may not be the current practice. Beware of commercial bias. Who or what organization is funding the site?  Determine if the site is supported by public funding, donations or by commercial ads. All ads should be labeled as “Advertisements.” Be wary of a particular drug or procedure being highlighted throughout a particular web site. Always protect your health information. Confidentiality is critically important.  What is the site’s "Privacy Policy?" Read the privacy policy to see if your privacy is being protected. If, for example, the site says, "We share information with companies that advertise on this web site," then your information is not private. Everywhere you step in the web leaves a digital footprint! If there is a registration form, carefully consider the questions that you must answer before you can view further content. If you must provide any personal information (such as name, address, date of birth, gender, social security number, bank account number, credit card number), please refer to their privacy policy to determine what they can do with your information. Finally, if one has a healthcare concern, after consultation with the virtual physician, Dr. Google, she or he should see an actual board-certified, well-respected physician and get a “second opinion!” Thu, 15 November 2018 00:00:00 Egg Freezing to Avoid “Panic Parenting” CRM Orlando A new study published in Human Fertility suggests that most single women who freeze their eggs for non-medical reasons (“social freezing”), are doing so to avoid “panic parenting,” that is, entering into unstable relationships to have their genetically-own children. Professor Lorraine Culley and Dr. Kylie Baldwin of the Centre for Reproduction Research at De Montfort University interviewed 31 women (average age 37) who had frozen their eggs to preserve their reproductive options. The participants were asked why they had chosen to do this, how they regarded the experience, and the quality of information they had been provided about the probability of eventually having a baby with frozen-thawed eggs. Twenty-six of the participants were single, and the lack of a partner, or having a partner not willing to commit to parenthood, was the most common reason for elective egg freezing. Some found the process as a stress-reliever and others felt that they had short-circuited the proverbial “biological clock,” allowing them time to find a suitable partner. Many considered egg freezing as an “insurance policy,” and hoped to conceive naturally with a future partner, never needing to use their frozen eggs. A number of women in the group found the process emotionally trying and would have much preferred pursuing motherhood with a committed partner. Disconcerting is the fact that the clinical information available to these women was deemed to be inadequate. Nearly all the participants reported that the clinics from which they sought help were unable to provide an estimate of the likelihood of a future live birth with cryopreserved eggs. In particular, the physicians did not provide a detailed discussion regarding freeze/thaw procedures and the women were not given clinic- or age-specific success rates. For many years, the Center for Reproductive Medicine in Orlando, Florida has been providing fertility preservation for women and men (elective “social freezing” and cancer patients).and eEvery effort is made to provide a thorough and compassionate informed consent process with discussions of indications, risks, potential benefits, complications, emotional and financial costs, as well as age-specific and clinic-specific success rates. Thu, 08 November 2018 00:00:00 In IVF Is Fresh or Frozen Embryo Transfer Better? CRM Orlando Although Louise Joy Brown, the first IVF baby, turned 40 years old this year, the science of IVF is still in its formative stages. Research questions continue to arise, and one current controversy is whether transferring a fresh versus a frozen-thawed embryo gives the a better chance for a healthy baby. In a study of nearly 83,000 IVF patients recently published in Fertility and Sterility, there was no easy answer, and the better technique may depend upon how many eggs and how many embryos are available. Many IVF clinics have adopted a “Freeze All” policy for all embryos; however, according to this study from Duke University, freezing may be advantageous only for women who produce 15 or more eggs. Birth rates in these “high responder” patients were higher with frozen-thawed transfers, FET, (52%) vs. fresh transfers (48%). But women who do not produce as many eggs, that is, 14 or fewer, do better with fresh transfers than FET. This study was large but did have a couple of limitations: the data were was from the 2014-2015 SART Registry, and practice patterns have continued to evolve since that time,  and the study did not assess why patients opted for FET over fresh transfer. More research is clearly indicatedneeded, but it may be stated with certainty that no two IVF patients are exactly alike, and each patient deserves a thoughtful, individualized treatment plan. Thu, 01 November 2018 00:00:00 Caffeine, Alcohol, Smoking and IVF Success CRM Orlando Among infertility patients, caffeine, alcohol and tobacco are perceived as the top three modifiable lifestyle factors which may be detrimental to IVF success. A recent review from the Harvard School of Public Health and Harvard Medical School summarized the available studies on these three factors with respect to reproductive outcomes among couples undergoing IVF treatment. Of the five studies on caffeine usage and IVF outcomes, only one found a significant impact on caffeine intake on live birth rate following IVF. The scientific literature on this topic is limited and observational but does not support a link between low or moderate intakes of caffeine and poorer IVF outcomes. In addition, there waserelittle few data available regarding heavy caffeine users. With respect to alcohol consumption, several studies assessed observed negative effects on IVF outcomes, including fertilization, embryo quality, and implantation. Wine, beer, and liquor intake during the year before IVF treatment do not appear to have an effect on outcome; however, current or short-term consumption of alcohol around the time of IVF appears to have negative impact. It is recommended that women refrain from alcohol usage immediately before IVF treatment and throughout pregnancy. Lastly, various well-conducted epidemiologic studies have consistently and clearly demonstrated that women who are current smokers have worse IVF outcomes, including lower egg counts and quality, lower implantation, clinical pregnancy, and live birth rates. Smoking cessation should be encouraged in the weeks prior to beginning IVF treatment. Further research is clearly indicated needed regarding caffeine and other modifiable lifestyle factors. Thu, 25 October 2018 00:00:00 Progesterone: Shots, Rings and Gels CRM Orlando Supplementing the second part of the IVF or FET cycle (luteal phase) with progesterone is a universal and beneficial practice. The gold standard option, against which all other routes of administration are compared, is intramuscular progesterone in oil. Previously, the Center for Reproductive Medicine was one of eight centers that participated in a randomized, controlled trial of 800 patients comparing the efficacy and safety of aqueous subcutaneous progesterone with vaginal progesterone for luteal phase support of IVF, and the subcutaneous route was found to be similar to the vaginal, (Hum Reprod. 2014 Oct 10; 29(10): 2212–2220). Presently, vaginal progesterone (Crinone™ and Endometrin™) is also a commonly employed route; however, the progesterone vaginal ring (Milprosa™) is a novel means for luteal support with advantages of controlled release with less frequent (weekly) dosing. The Center for Reproductive Medicine is one of fifteen centers participating in a phase III FDA clinical trial involving Milprosa. It is a prospective trial regarding the clinical safety of the progesterone vaginal ring in women undergoing IVF procedures and is sponsored by Ferring pharmaceuticals. The two inch in diameter silastic ring releases progesterone into the vaginal circulation and in previous studies has been proven to be a safe and effective alternative for luteal support in IVF. Among others, the end points of the current study include ongoing pregnancy rates, miscarriage rates, and vaginal bleeding. It may be that in the not too distant future, the one and one-half inch long intramuscular progesterone injections could be a practice relegated to IVF lore. These daily injections into the gluteus muscles are given for up to eight weeks duration and are often considered by patients as the very worst part of the assisted reproductive technologies. Tue, 16 October 2018 00:00:00 Planning for Pregnancy Randall Loy While most couples who are seen at Center for Reproductive Medicine (CRM) Orlando are in good to excellent health, this is certainly not always the case, and being in less than optimal health may have serious consequences for both mother and baby. At the initial visit to CRM there will be considerable preconceptional counseling and planning such that the couple has an opportunity to assess their health and to make any necessary lifestyle modifications. This brief blog is intended to highlight some of the major steps toward a healthy pregnancy. First, meet with your Reproductive Endocrinologist and Infertility specialist for assessment of your health. A personal (and family) medical history relative to your conception plans will be taken and a physical examination will be performed. To best benefit from this particular visit it is helpful to anticipate the following topics of questioning:   • Personal or family history of chronic medical problems • Personal or family history of birth defects or developmental delays • Current or recently used medications • Current and past method(s) of birth control, if any • Previous pregnancy history including spontaneous or elective abortions or ectopic pregnancies. • Immunization history; Dates and results of pap smears and mammograms • Diet, Exercise, Tobacco and Alcohol history • Previous sexually transmitted infection(s)   The answers to these questions form the foundation of diagnostic testing and treatment. After the medical history is taken, the fertility specialist will perform a physical examination. The exam often involves a pelvic ultrasound and may detect medical problems that could require treatment prior to conception. For example, problems such as abnormal Pap smear, uterine tumors or ovarian tumors, and breast or thyroid masses which should be addressed before pregnancy. After the physical examination, the following tests (and perhaps others) may be recommended: Semen analysis, uterine cavity evaluation, ovarian reserve testing, thyroid function screening, screening for diabetes, genetic carrier screening (e.g., for cystic fibrosis, spinal muscular atrophy, fragile X, etc.), sexually transmitted diseases, complete blood count with differential, and immunity for rubella and varicella. If there are preexisting medical conditions, there may be other tests or consultations recommended before commencing fertility treatment. The couple’s lifestyle can impose risk for pregnancy attainment and/or maintenance. Weight: When planning to conceive, it is best to reach a healthy weight (Body Mass Index, or BMI of 18.9-24.9 kg/m2) before pregnancy. Excessive weight can increase the incidence of infertility, miscarriage, diabetes and high blood pressure, as well as cesarean section.   In addition, being underweight markedly increases chances of infertility and of delivering a low birth weight baby. Diet: A balanced diet with appropriate amounts of protein, complex carbohydrates and healthy fats plays a major role in fertility. A lifestyle with frequent snacks and meals featuring colorful vegetables and fruits will be recommended and a diet rich in sugars and simple carbohydrates is to be avoided. Exercise: Daily aerobic exercise and resistance training 3-4 times weekly, before and during pregnancy, can increase the likelihood of having a fit, comfortable gestation, while decreasing risks of excessive gestational weight gain, hypertension and diabetes. Tobacco, Alcohol and Illicit Drugs: Smoking tobacco or marijuana, drinking wine, beer or liquor, and legal or illegal drug usage may decrease fertility and can be harmful to the baby. Both partners should discontinue all such usage prior to conception. Exposure to second hand or third hand (tobacco residue and dust on clothes and carpets) has also been related to increased risk of asthma in the baby as well as more frequent respiratory infections and sudden infant death syndrome (SIDS). Toxins: Many chemicals, including some household cleaners and petroleum distillates are not to be used without gloves and adequate ventilation during pregnancy and certain other toxins as well as radiation in sufficient exposure can lead to congenital defects. Preexisting Conditions: In general, any preexisting medical problem (e.g., diabetes, hypertension, thyroid disease) needs to be controlled prior to pregnancy. Treatment may involve your CRM physician working in concert with your primary care doctor or other medical or surgical specialist.   The above is a very elementary primer on planning for pregnancy. Please be sure to bring any specific questions to your provider at Center for Reproductive Medicine. Thu, 11 October 2018 00:00:00 Timing May Be Everything: A Study on Sperm Quality Suggests Diminished Period of Abstinence CRM Orlando Recent clinical research from Doctors Da Li and XiuXia Wang of Shenyang Hospital, published in the journal Molecular and Cellular Proteomics, shows both sperm quality and reproductive outcomes are improved when semen is provided after just 1-3 hours of abstinence. The prevailing conventional wisdom in reproductive medicine is that limiting sexual activity between conception efforts can improve chances of pregnancy success. This research involved nearly 500 couples to determine if decreasing abstinence time could change their success rates. Prior studies from this lab had shown that semen produced shortly after ejaculation (within approximately three hours) had faster and more motile sperm than if abstention had been several days. Uncertain, however, was why the sperm changed and if the changes seen affected fertility. To understand these questions, semen samples were studied for volume and motility after either several days or after just one to two hours abstention. As had been observed previously, the sperm from short periods of abstinence did not have abnormally low volume and also moved faster. The protein makeup of the semen samples was then investigated using a laboratory technique called mass spectrometry, and there were significant molecular differences, as well, with the majority of the affected proteins involved in cell adhesion, a function necessary for sperm binding to the egg cell. Other involved proteins in the semen involved those that combatted oxidative stress (reactive oxygen species, ROS). The inference is that the longer sperm exist between ejaculations, the more vulnerable they become to DNA damage by ROS, which could impair their ability to form a viable embryo. The team also ran a study of the approximately 500 couples undergoing IVF treatment at the Shenyang fertility clinic to determine if there were differences in success rates.  Men in the control group provided semen samples after several days of abstinence; however, men in the experimental group had three or fewer hours of abstinence before providing samples. IVF was performed as usual with the two sample types, with the live birth rate in the control group about 30 percent and approximately 40 percent in the experimental (shorter abstinence) group. Dr. Li plans further research to investigate differences in post-translational protein modifications that his lab saw between the types of semen samples. "This is a very new field," said Li. Indeed, this is a novel area of reproductive research with profound implications for present clinical practice.     Journal Reference: Zi-Qi Shen, Bei Shi, Tian-Ren Wang, Jiao Jiao, Xuejun Shang, Qi-Jun Wu, Yi-Ming Zhou, Tie-Feng Cao, Qiang Du, Xiu-Xia Wang, Da Li. Characterization of the Sperm Proteome and Reproductive Outcomes within VitroFertilization after a Reduction in Male Ejaculatory Abstinence Period. Molecular & Cellular Proteomics, 2018; mcp.RA117.000541 DOI: 10.1074/mcp.RA117.000541 Tue, 02 October 2018 00:00:00 In Brief: Boxers! CRM Orlando Although the link between the type of men’s underwear and fertility has been regarded by many as an old wives’ tale, folklore, or urban legend, the largest study to date has concluded that men who wear looser-fitting (boxer) shorts have higher sperm concentrations than men who wear tighter undergarments. The investigation, conducted by Dr. Lidia Mínguez-Alarcón and colleagues at the Harvard School of Public Health, studied 656 men in the Massachusetts General Hospital (Harvard) infertility clinic and not only looked at semen concentration but reproductive hormones and sperm DNA damage. Recently published in the journal Human Reproduction, the researchers also found that men who wear boxers had lower levels of follicle-stimulating hormone, FSH, compared to men who most frequently tight-fitting underwear.  (FSH is the pituitary hormone that stimulates sperm production.) These findings certainly suggest that FSH is elevated to compensate for the damage from increasing temperatures within the scrotum and decreasing sperm concentration. Men who wore boxer shorts (53% of the study population) had a 25% higher sperm concentration, 17% higher total sperm count, 33% more swimming sperm in a single ejaculate and 14% lower FSH levels than men who did not usually wear boxers. All of these differences were statistically significant, even after adjusting for potentially confounding variables, such as body mass index, physical activity, hot baths and Jacuzzis, tobacco usage and the year the sample was taken. There were no significant differences in other reproductive hormones or damage to the DNA of the sperm. It is important to note that it is not possible to prove from this study that the type of underwear causes the difference in semen quality and FSH levels, only that that there is a strong association between them. Definitive proof is not possible from this study because other factors that might affect scrotal heat, such as the material and fit of trousers worn and underwear fabric type, could also affect the results. Dr. Mínguez-Alarcón suggested, "Since men can modify the type of underwear they choose to wear, these results may be useful to improve men's testicular function." Reference: Lidia Mínguez-Alarcón, Audrey J Gaskins, Yu-Han Chiu, Carmen Messerlian, Paige L Williams, Jennifer B Ford, Irene Souter, Russ Hauser, Jorge E Chavarro. Type of underwear worn and markers of testicular function among men attending a fertility center. Human Reproduction, 2018; DOI: 10.1093/humrep/dey259 Tue, 25 September 2018 00:00:00 Are Pears Healthier than Apples? CRM Orlando According to a new study published in the journal Frontiers of Immunology by researchers at the University of California, Riverside, it's healthier to be a pear than an apple! As we age, we tend to accumulate fat: women experience fat build up around the hips, yielding a pear shape, and men have increased abdominal fat resulting in an apple shape. In this study, male and female mice were fed a high fat diet but only male mice experienced changes in the reproductive system (low testosterone and reduced sperm count) as well as response of the immune system in the brain, or neuroinflammation. Females were unaffected and this study suggested that they were not affected because of the protective effect of ovarian estrogen as well as other factors. Dr. Djurdjica Coss, the study leader, stated, “The findings, derived from the mouse study, are likely to have applications in humans.” Much like humans, mice on high-fat diet develop metabolic syndrome — a collection of endocrine problems that includes Type 2 diabetes and insulin resistance. Obese men have decreased testosterone (associated with lowered sperm production, fatigue, decreased libido and less muscle mass and strength). Similarly, obese male mice demonstrated nearly 50 percent decreases in testosterone and sperm count, and analogous to humans, obese female mice showed abnormal ovulation patterns, contributing to decreased fertility. Obesity is a likely a factor in the increased incidence of infertility in the United States. Now, more than 30 percent of people are obese (BMI > 30 kg/m2), and more than two-thirds are overweight (BMI 25-30 kg/m2). Also similar to humans, female mice deposit fat differently than their male counterparts. Females deposit fat right below the skin, while males accumulate fat deeper, within the body's visceral region, which may affect internal organs. Even in women, however, when fat overwhelms the subcutaneous storage capability, it then accumulates in the abdominal region, resulting in neuroinflammation. Another fascinating finding reported in this study is that macrophages, (large, engulfing peripheral white blood cells), cross the blood-brain barrier — the protective barrier that prevents most compounds in the blood from entering the brain. This infiltration of macrophages into the brain occurs in addition to the activation of immune cells within the brain. "We know the immune cells secrete cytokines, which are inflammatory markers, in the blood. It's possible these cytokines travel in blood from the fat tissue and activate the immune cells to cross the blood-brain barrier," Coss said.   Journal Reference: Nancy M. Lainez, Carrie R. Jonak, Meera G. Nair, Iryna M. Ethell, Emma H. Wilson, Monica J. Carson, Djurdjica Coss. Diet-Induced Obesity Elicits Macrophage Infiltration and Reduction in Spine Density in the Hypothalami of Male but Not Female Mice. Frontiers in Immunology, 2018; 9 DOI: 10.3389/fimmu.2018.01992 Tue, 18 September 2018 00:00:00 IVF Chances Increased with 18-20 Eggs CRM Orlando There has been a longstanding question in reproductive medicine: “How many eggs does it take to maximize IVF success?” There has been the desire to find the “sweet spot,” the appropriate balance between success and safety. A recent dissertation from the Sahlgrenska Academy in Sweden showed that the likelihood of childbirth following IVF increases if 18 to 20 oocytes are collected. The fact is, however, IVF clinics do not collect 18-20 eggs in most of their infertility patients (with an average number of eggs being in the 10-15 range). This suggests, of course, that more than one IVF stimulation cycle, with oocyte or embryo cryopreservation, may be necessary to achieve such success. Some previous investigations involving fresh embryo transfers have suggested the optimal “egg count” in IVF is approximately 10 eggs with greater ovarian stimulation thought to increase side effects and complications, including ovarian hyperstimulation syndrome. Further, these studies have not included subsequent frozen-thawed embryo transfer success. The present study analyzed data from the national Swedish registry from 2002 -2015 and looked at the relationship between the number of eggs collected, cumulative delivery rates and serious complications. The findings included that cumulative IVF success increased up to 18-20 eggs and then leveled off and that the risks of complications remained relatively low at this same number of eggs, increasing at higher numbers. These results can serve as the basis for how ovarian stimulation in the IVF setting may be better designed in the future to achieve just the right balance between efficacy and safety.Have you been trying to conceive without success? Contact us today to schedule a consultation with Dr. Loy or another of CRM Orlando's fertility doctors. Tue, 11 September 2018 00:00:00 6 Tips for Making the 2 Week Wait Bearable CRM Orlando The two-week wait between ovulation and your expected period is often fraught with anxiety, impatience and so many “what-ifs.”  These emotions can make it seem as if the two week wait goeson forever. Luckily, the fertility experts of CRM Orlando in Orlando, Florida are here to help!  In our latest infographic, our team offers some pointers to get you through this wait as peacefully as possible. Waiting isn’t fun for anyone. For those TTC, the two-week wait to see one line or two can be torture.  Emotions run amok and can easily take over in a negative way. If you have any additional questions or are looking for support during this time, we are here for you. Please don’t hesitate to reach out our team at CRM Orlando. Mon, 13 August 2018 00:00:00 Physician Spotlight: Dr. Sejal Dharia Patel CRM Orlando When Dr. Sejal Dharia Patel joined CRM Orlando in 2008, both the city and our fertility clinic were very different. At the time, they were a team of just three infertility doctors who were unable to offer many of the advanced services available today. The city of Orlando was much smaller as well – now it has grown to become “a burgeoning center for healthcare, innovation, and new businesses.” CRM Orlando has grown in that time as well, boasting a team of over 8 infertility specialists that are able to offer a wide array of services, including elective egg freezing, fertility preservation, genetic testing of embryos, and relationships with one of the largest donor egg banks in the world. Better, More Specialized Treatments for Patients The field of reproductive endocrinology has changed tremendously as well. “When I started practicing we were doing more surgeries to correct reproductive abnormalities,” says Dr. Patel. “We would utilize medications and inseminations for multiple cycles and utilize in vitro fertilization as a last option based upon cost and the relatively low success rates.” Now, Dr. Patel and the team of infertility specialists at CRM Orlando are able to create targeted treatment plans customized to each patient’s unique situation. This has allowed her to give her patients a higher chance of success while keeping the cost of infertility treatment as low as possible. Dr. Sejal Dharia Patel believes that in the future, treatments will become even more specific to each patient, enabling them to “figure out which medications or treatment approach will be the most effective based upon a patient’s genetics, receptivity, and metabolism.” This will help patients achieve their dreams of family in a much more efficient way, and in a much shorter time frame. A Patient Centered Approach As much as our fertility clinic, Orlando, and especially the field of infertility treatments have changed, there is one thing that has remained the same: the deep connection Dr. Patel has with each and every patient she sees. She recalls one particular couple whose infertility struggle touched her deeply. After two years of struggling with unexplained infertility, they realized that IVF at CRM Orlando was their last hope. Unfortunately, “In vitro fertilization was not financially an option for them.” They had given up for 6 months, before Dr. Patel gave them the call that would change their lives. “We then call them when our office had a research study that paid for the cost of IVF. The couple was in tears they were so hopeful to have a chance to start their own family. They diligently followed every step. They underwent the IVF cycle and conceived their beautiful son. Every year I receive a Christmas card with a note of thanks and I realize how important our role is to be compassionate, to think outside the box and to never give up.” This is a lesson she hopes to pass on to others struggling with infertility. “Always have hope. The technology exists, the providers genuinely care and it is only a matter of time before you will start your family. Sometimes you have to think outside of the box.” Have you been trying to conceive without success? Contact the team at CRM Orlando and schedule a consultation with Dr. Patel today to have your best conceivable chance of growing your family. Thu, 28 June 2018 00:00:00 Know the Facts: 4 Things to Know About Fertility Dr. Sejal Patel Is it ok to have a glass of wine or a cup of coffee when we are trying to have a baby? Should we have relations every day or every other day? Questions like these will get many different responses when asked to friends and family and create more confusion for a couple trying to start their family. In my 15 years practicing reproductive medicine, these are the most common questions I have had and thought, I may try to provide some data to the questions quietly asked between couples or friends or sought on the internet.  So what are the facts (From the ASRM)?  What is the chance that I will get pregnant in 6 months? Monthly fecundity defined as the ability to conceive monthly is approximately 15-20%. Approximately 80% of couples will conceive in the first 6 months. For the remaining 10-15% this will occur in the subsequent six months. If after a year of no success, don’t give up, although the rates are low, there is still a 3% chance of pregnancy monthly. Am I too old to get pregnant?  In women, pregnancy rates start to decline subtly at 27 years of age, but decline significantly at 35 years of age. With a decrease in pregnancy rates, you will see an increase in miscarriages with increasing age. In women after the age of 35, we normally recommend they visit a feritlity doctor if they have been trying to conceive for at least 6 months (as compared to the traditional 12 months in women under 35). In men, there appears to be a subtle decrease at 40, which declines more significantly at 50. So you should be reassured that it is not too late, but the earlier the better. How often should we have intercourse?  This question has a multifaceted answer. The simple answer is everyday around the time of ovulation. If you are using a ovulation prediction kit, this would be relations on the first day of the positive sign, the day after and the day after that. If you are not using ovulation prediction, it would be starting the day of cervical mucus thinning. Ideally, intercourse is most efficient if it occurs a day or two just before ovulation. However, having intercourse everyday can create stress over time. Data shows that pregnancy rates decrease significantly when intercourse is reduced to once weekly, however, there is a small difference between every day and every other day.  After intercourse, should I rest in one position for 15 minutes or do anything specific?  There is no evidence that resting after intercourse will facilitate sperm delivery. Sperm placed into the cervix can be found anywhere from 2-15 minutes later in the fallopian tube. The sexual position also doesn’t matter. Although there is data that sperm is facilitated more efficiently during orgasm, there is no relationship to fertility.  We hope these answers have helped. In our next blog, we will look at lifestyle changes that can be made to improve your fertility. Have you been trying to conceive without success?At CRM Orlando, fertility specialists are here to answer your questions.  Contact ourOrlando are fertility clinics to schedule a consultation with Dr. Sejal Patel by requesting an appointment today. Thu, 21 June 2018 00:00:00 Fertility Diet: The Best Foods for Boosting Fertility [infographic] CRM Orlando When it comes to achieving and maintaining a successful pregnancy, diet plays an important role. While eating certain foods and avoiding others won't guarantee that you'll be able to successfully achieve a pregnancy, the right diet can improve your chances. Here, the fertility experts of CRM Orlando in Orlando, Florida go over which foods can give you a better chance of building the family of your dreams. If you are interested in learning more about starting a fertility diet, contact the fertility specialists of the Center for Reproductive Medicine in Orlando, Florida at 800-343-6331 or request an appointment. Tue, 22 May 2018 00:00:00 Diet and Fertility: Foods that Can Impact Chances of Fertility Issues CRM Orlando If you’re trying to conceive, chances are that you’ve read an article or two about a fertility superfood or supplement. While the majority of these claims have little to no scientific evidence to back up the results, eating a balanced and nutritious diet that avoids things like refined sugars, excessive alcohol, and trans fats can help improve your chances of conception. So what does the ideal diet look like for couples trying to conceive? Here, Heather Doerr, ARNP of CRM Orlando in Orlando, Florida goes over what to eat (and what to avoid) to give women trying to conceive their best chance of success. Pile Your Plate with Fruits and Veggies You’ve heard it hundreds of times – Americans need to eat more fruits, vegetables, and whole grains to maintain a heart healthy diet. But upping your intake of greens doesn’t just decrease your risk of heart disease – it can also improve your chances of successfully achieving a pregnancy. According to Nurse Practitioner Doerr, “Studies examining the effects of lifestyle on fertility have shown some promising data regarding dietary modifications and improved outcomes. Men and women who choose to eat more fruits, vegetables, and whole grains tend to have better fertility.” But why are fruits and veggies so good for fertility? The answer may lie in antioxidants, compounds that reduce oxidative stress or damage. Sperm and eggs are particularly sensitive to the damage caused by free radicals as oxidative stress has been associated with decrease sperm and egg maturation, fertilization, embryo development, and pregnancy. [i]   So are all fruits and veggies created equal on the antioxidant front? Not quite. While all fruits and vegetables contain antioxidants, berries pack the biggest punch. Soy is also a great source of antioxidants (and a great plant based protein!), along with dark chocolate – so feel free to indulge in a square or two every now and then. Say Yes to Healthy Fats Not all fats are created equal. While those trying to conceive should avoid monosaturated trans fats (which have been proven to increase ovulatory dysfunction), research has shown that a diet rich in omega-3 fatty acids have been shown to help semen and egg quality[ii]. For women undergoing fertility treatment, a diet rich in omega-3 fatty acids is even more important as it has been shown to increase blood flow - an important factor in ovarian stimulation and egg quality. The best way to work omega-3’s into your diet? Nurse Practitioner Doerr of CRM Orlando says around 8oz of smaller species of fish each week is the way to go. Fish such as salmon, tilapia, haddock, and trout contain an abundance of omega-3 fatty acids without exposing you to the increased levels of mercury often found in larger fish such as mackerel and big tuna. Putting it All Together If you think these recommendations look familiar, it’s because they’re very similar to the Mediterranean diet – and with good reason. According to Nurse Practitioner Doerr of CRM Orlando, findings reveal that following the Mediterranean Diet can positively impact your levels of folate, B6, the fluid surrounding a woman’s eggs, and omega-3 fatty acid intake, with one study even showing that following the Mediterranean Diet can increase your chances of pregnancy by up to 40%![iii] While following a healthy lifestyle that includes a Mediterranean-style diet doesn’t guarantee that you’ll be able to get pregnant, it can help create the right environment for conception. If you have been trying to conceive for one year without success (or 6 months if over 35), contact us at CRM Orlando to schedule a consultation with one of our fertility experts by calling us at 800-343-6331 or requesting an appointment today! [i] Ahmadi, Bashiri, Ghadiri-Anari, & Nadjarzadeh, 2016 [ii] Salas-Huetos, Bullo, & Salas-Salvado, 2017 [iii] Mmbaga & Luk, 2012 Tue, 08 May 2018 00:00:00 All About Egg Freezing: Know the Facts [Infographic] CRM Orlando More women than ever before are looking to postpone pregancy to pursue their personal and professional goals. Luckily, scientific advancements in the freezing and thawing protocols for eggs have made elective egg freezing a viable option for women who would like to maintain their ability to have children later in life. But how common is elective egg freezing, and what is the process like? Get the answers to  your questions in our infographic below. If you are interested in learning more about freezing your eggs, contact the fertility specialists of the Center for Reproductive Medicine in Orlando, Florida at 800-343-6331 or request an appointment. Tue, 10 April 2018 00:00:00 4 Ways Sleep Impacts Fertility CRM Orlando Between work, family, and personal obligations, getting enough quality shuteye is difficult for over 30 percent of Americans. For couples struggling with infertility, the stress of undergoing fertility treatments can make getting enough sleep even more difficult. But for women trying to achieve a pregnancy, a lack of sleep could be sabotaging their chances of success. Here, the fertility experts of the Center for Reproductive Medicine in Orlando, Florida discuss the four ways poor sleeping habits can impact a woman’s ability to conceive.   1.  Sleep Patterns Impact Your Hormones Shortchanging yourself on sleep doesn’t just impact your mood and productivity, it also influences the hormones a woman secretes throughout her cycle. For women trying to conceive, getting enough quality sleep has a positive effect on the hormones a woman produces during her cycle. Getting in your recommended 7-8 hours each night can improve your levels of progesterone, estrogen, Leptin, and Follicle-Stimulating Hormones (FSH) – all of which are crucial to achieving and carrying a pregnancy.   2. Light Pollution & Egg Quality Several studies have shown that the blue light from our electronics are keeping us from getting enough sleep. But the blue light from your gadgets isn’t just keeping you from sleeping well, it can also be negatively impacting your ability to get pregnant. The blue light emitted by your electronics suppress melatonin, a key hormone that both helps you sleep and protects your eggs when they are close to ovulation. Without adequate melatonin production, your egg quality can suffer and make achieving a pregnancy more difficult.   3. The “Infertility Shift” is aptly named If you work the night shift and are trying to conceive, you may want to consider changing your schedule. The night shift has gained a reputation as the “infertility shift,” due to the higher rates of infertility among women who work nights. But why? Studies have shown that working the night shift can disrupt your circadian rhythm, causing hormonal imbalances, lower estrogen levels, and irregular menstrual cycles. These changes can all make it more difficult to both achieve a pregnancy, and carry a pregnancy to term.   4. Get Your Z’s During IVF For women undergoing IVF, getting enough quality sleep is even more important. According to the American Society for Reproductive Medicine’s study, women with low quality sleep had lower rates of fertility than those getting adequate rest. If you’re undergoing IVF, make sure to get 7-8 hours of quality sleep each night to give yourself your best chance of success.   Fixing Your Sleep Patterns While most women will find that they have at least one habits that negatively impacts the quality of their sleep, most are relatively easy to fix. In order to improve sleep quality and increase their chances of getting pregnant, women should: Get 7-8 hours of sleep every night. Put away computers, phones, tablets, and other electronics at least an hour before bedtime. If you work night shifts, ask your employer if you can change your schedule. If your schedule can’t be changed, ask your employer if it would be possible to adjust the lighting.   If you’re trying to conceive, it is important to get enough quality sleep in order to improve your chances of success. While it can be difficult for couples with infertility to squeeze in those hours, doing so can help improve your chances of conceiving and building the family of your dreams. If you’re having difficulty achieving a pregnancy and would like more information on the fertility options available to you, call the fertility specialists at the Center for Reproductive Medicine at 800-343-6331 or request an appointment today. Thu, 15 March 2018 00:00:00 PGT: Everything You Need to Know CRM Orlando For couples going through fertility treatments, it can seem like you’re picking up a whole new vocabulary full of acronyms – IUI, FSH, AMH. If you and your partner are considering IVF, there’s likely another term you’ve heard: PGT, or pre-implantation genetic testing. But what is PGT? And when is it a good idea to have it done? The experts of the Center for Reproductive Medicine are here to answer your questions about pre-implantation genetic testing as part of IVF.   What is PGT? Pre-Implantation Genetic Testing is a technique in which tests an embryo prior to implanting it in the uterus. Once the egg is fertilized, the embryo is allowed to develop in the lab for five days before a few cells are removed for genetic testing. The embryos are then frozen while the cells are being tested. After the results of the genetic testing come back, the couple can decide which embryos would be best for transfer to the uterus, hopefully resulting in pregnancy. When should PGT be done? While deciding to have a baby is a happy and exciting time for most couples, for those with a family history of genetic diseases the decision can be incredibly stressful. For this reason, it’s suggested that couples with a family history of genetic disorders undergo pre-implantation genetic testing to prevent them from passing on the disease to their children. Some things PGT tests for include: Translocations of genes, which can cause birth defects or miscarriage Huntingtons disease Marfan syndrome Recessive genetic diseases, like Tay-Sachs or Cystic Fibrosis X-linked genetic diseases Abnormalities in the number of chromosomes Some patients also use PGT when they’d like to choose the sex of their child for family balancing reasons. What if family medical history is a mystery? Some men and women, for a variety of reasons, may not know their family medical history. Others may know the medical histories of their parents (even grandparents), but may not know of any issues with earlier generations. Because some genetic diseases are recessive, it’s possible that these individuals may carry the gene for diseases such as Cystic Fibrosis. It there are any gaps in your knowledge of your family’s medical history, conducting genetic testing on yourself can bring to light any possible genetic issues that may cause them to consider PGT.   Talk to your fertility specialist If you have been trying unsuccessfully to achieve and carry a pregnancy, there are multiple things to consider when deciding if a specific fertility treatment is right for you. To learn more about PGT and all of your fertility treatment options, contact the fertility specialists of the Center for Reproductive Medicine in Orlando, Florida at 800-343-6331 or request an appointment. Tue, 06 March 2018 00:00:00 Keeping the Romance Alive: Ideas for Couples #TTC CRM Orlando For couples struggling with infertility, it can be difficult to keep the romance alive. All of the stress, frustrations, and disappointments these couples face on their path to parenthood can take a toll on any relationship. But taking a break from focusing on your fertility issues to reconnect with your partner can help strengthen your relationship and reduce infertility-induced stress. So how can couples keep the romance alive? The team at the Center for Reproductive Medicine in Orlando, Florida is here with some tips on ways to spend some quality time with the one you love on any day of the year.   Press pause on fertility talk When you’re struggling with infertility, it can start to feel like it’s taken over your whole life. For couples dealing with all of the testing, monitoring, and lifestyle changes associated with fertility treatment, it starts to seem as if it is all that you and your partner talk about. Try taking a break from the fertility talk and instead take the time to talk about anything but your fertility struggle.   Spice things up If you’re looking to inject some romance back into your relationship, interrupting your routine can be just what the doctor ordered. Spice things up by trying something new together. Whether it’s a new activity you’ve been wanting to try or a place you’ve been dying to go, experiencing something new with your partner can help deepen your connection and reinvigorate your bond.   Get away for a while Whether it’s a day trip nearby or a full-fledged vacation, getting away for a while can help you and your partner broaden your horizons, discover new places, and give you something new to talk about. Getting out of town can also help you recharge – relaxing with your partner on a getaway can help give you a break from the constant stressors in your daily life.   Work up a sweat together The couple that sweats together, stays together! Spend some quality time with your partner on hiking trails, in a yoga class, or on a long bike ride. Exercising together doesn’t just help you stay in shape – it also helps deepen couple’s emotional bond and improves communication skills.   Give back Practicing gratitude can help couples cope with the stress that comes with struggling with infertility. One of the best ways to show your gratitude? Giving back. Take some time to share the love with those in need by volunteering at a nursing home, animal shelter, or other local non-profit. If you’re struggling with infertility and would like more  information on infertility treatments for you and your partner, contact us at 800-343-6331 or request an appointment here. Tue, 13 February 2018 00:00:00 The Link Between Heart Disease & Infertility CRM Orlando If you’re undergoing treatments for infertility, chances are you’re aware of the links between diseases such as diabetes and STIs and infertility. But there is another chronic illness that has links to infertility that may not seem so obvious – Heart Disease. While there is no evidence that one causes the other, there is a strong correlation between men and women who struggle with infertility and develop heart disease. The fertility experts of the Center for Reproductive Medicine are here to go over the connection between heart disease and infertility – and what you can do about it.   Infertility May Be a Red Flag for Health Issues Studies have not shown that infertility, or treatments for infertility, causes heart disease. Instead, infertility can act as a canary in the coal mine for future health issues. Men and women struggling with infertility face an increased risk of developing chronic conditions later in life. Men, in particular, face a greater risk of developing diabetes, heart disease, and substance abuse problems if they are also infertile. Additionally, the extensive testing couples undergo when starting fertility treatment provides valuable information about their current overall health and potential future concerns. Many individuals don’t realize they’re at risk for a metabolic disease until they undergo a full fertility workup. For more information on the connection between heart disease and infertility, contact the fertility experts at the Center for Reproductive Medicine in Orlando, Florida.   PCOS Impacts Your Health in Many Ways PCOS (Polycystic Ovary Syndrome) is a common cause of infertility among women, causing menstrual issues, problems ovulating, hair loss, insulin issues, acne, and even depression. But PCOS doesn’t just impact your fertility. Women with PCOS also tend to have higher rates of high blood pressure, high cholesterol, and high blood pressure – all of which are risk factors for heart disease. If PCOS goes untreated, it can have long term consequences for a woman’s health. If you think you may have PCOS and would like to learn about your treatment options, schedule an appointment with the Center for Reproductive Medicine in Orlando, Florida today.   Make Some Lifestyle Changes Armed with knowledge of the link between infertility and heart disease, it’s important for men and women to take some steps to help mitigate their risk of developing long-term health issues. One of the best steps you can take to decrease your chances of developing health issues is to change your lifestyle. Embracing a heart healthy diet, exercising regularly, and learning how to manage your stress are all great ways to lower your risk for heart disease, improve fertility, and increase overall wellness and health.   While there is a link between infertility and heart disease, the fertility testing many infertile men and women undergo can provide them with valuable information about their general health. Schedule an appointment with one of our specialists today by calling us at 800-343-6331. Mon, 05 February 2018 00:00:00 Paying for Fertility Treatment: Options to Make it More Affordable CRM Orlando For couples diagnosed with infertility, one of the biggest issues they face is how to pay for treatment. Even though one in eight couples struggles with infertility, very few insurance plans cover the full cost of fertility treatment, leaving couples scrambling to figure out how to pay out of pocket for a variety of procedures and medications that can run into the thousands. While it may feel overwhelming, there are options available to patients looking to make fertility treatment more affordable. The experts at the Center for Reproductive Medicine in Orlando, Florida have a variety of programs and partnerships that can help patients struggling with infertility pay for treatment.   Navigating Insurance Coverage While few insurance plans cover the full cost of fertility treatment, many insurers will cover some tests and procedures. Many insurance plans the Center for Reproductive Medicine contracts with cover things such as diagnostic testing and initial consultations, reducing at least some of the cost for patients. The key is to understand what is covered under your plan. Take the time to reach out to your insurance provider and find out exactly what is covered under your plan – and what isn’t. Want to know if your insurance plan is contracted with the Center for Reproductive Medicine? Contact us today.   Multi-cycle Discount Programs For patients planning to undergo In vitro Fertilization (IVF), the associated costs can add up quickly - especially since there is a strong likelihood that you will need more than one cycle in order to achieve a pregnancy. To help patients looking to minimize their costs while increasing their chances of bringing home a baby, the Center for Reproductive Medicine offers multi-cycle discount programs through our Attain IVF program. This will give patients a reduced, set cost for two or more cycles of treatment.   Third-Party Financing Managing the cost of fertility treatments can seem out of reach for patients who can’t afford to pay for their treatment up front. At the Center for Reproductive Medicine, we offer multiple healthcare-specific financing options for patients through our exclusive partners. Our programs can cover everything from medications to retrievals and transfers. Many lenders also offer low- or no-interest plans. Learn more about our lending partners today.   Grant Programs There are a variety of grant programs available to couples struggling to afford fertility treatments. RESOLVE, the national infertility association, provides information about a variety of nonprofit organizations that provide financial assistance to infertility patients throughout the country. These grants usually won’t cover the full cost of treatment, but they can significantly reduce the cost to patients.   Whether you pay for your fertility treatment through your insurance plan, using discount and grant programs, financing, or a mix of all of the above, the fertility specialists of the Center for Reproductive Medicine have a team of financial counselors available to help patients with questions about how they can make fertility treatment more affordable. If you are struggling with infertility and would like additional information on our programs, contact us at 800-343-6331. Mon, 29 January 2018 00:00:00 10 New Year’s Resolutions for Your Fertility Journey CRM Orlando As we’re approaching the end of the year and the beginning of a new, you can breathe.  You did it.  You survived the holidays despite the emotional ups and downs that infertility can cause this time of year.  And now, with the excitement of a new year, there are new possibilities and hope for what this year will bring.  It’s a great time to start things off with a fresh outlook, make some adjustments, and take control over the things that will help create a positive impact on our everyday lives.  These New Year’s Resolutions for your fertility journey will help you do just that. Break Up with Dr. Google. Put the computers and mobile devices down!  There are several reasons that this is important.  One…it takes up way too much time, and two…the information you’re finding is more than likely going to make you more scared and confused than you were before you started the search.  You know we’re right.  Stop the search, and call your doctor instead.  Give Yourself Permission to be Selfish. You don’t have to be the people pleaser all the time.  Give yourself permission to skip a baby shower, the kid’s birthday party, a friend’s gender reveal celebration or any other event that is going to cause pain.  Also give yourself permission to not feel guilty for doing so.  Do Not Blame Yourself.  When you’re going through something like infertility, it’s easy to place blame on yourself.  Do not do this!  Whether you think you ate the wrong way, drank too much, or waited too long to start trying.  Whatever it is, this way of thinking will not do you any good.  This struggle is not your fault. This is a time to love yourself and to be kind to yourself – all of which can only help your chances of conceiving. Choose Your Words Wisely.  What does this have to do with a positive outlook on fertility?  “A person’s life is largely reflected by the words spoken from his tongue.” This suggests that every time you speak, you are potentially affecting your future.  Huh?  Sure, it sounds silly, but why not give it a try?  It can’t hurt to eliminate negative words and phrases that cause pain and replace them with positive words instead.  Take Care of You.  No, this doesn’t mean you have to stop being a good friend, wife, daughter, but it does mean that YOU need to focus on YOU.  Do the things you love or find new activities to boost your mental well-being.  Read more books, meditate, invest in regular massages, and surround yourself with people that make you happy.  Take Better Care of Your Body.  Getting pregnant starts with a healthy body, so take good care of yourself physically (It’ll help with the emotional stuff too.)!   Educate yourself on healthy foods, and include them in your diet.  Get active – walk, hike, join the gym.  Even pampering yourself falls into this category– go to the spa, get a facial or a massage or even a new hairdo.  Start a New Hobby.  Break the routine that fertility treatments can bring.  Does counting the days of your cycle over and over sound all too familiar?  You need a distraction to this cycle, and a new hobby will give you that.  Maybe take that art or cooking class you’ve always wanted to try, volunteer at a charity, or even dance classes with your partner– anything that makes you feel happy and fulfilled.  Share Your Story.  Even if you’re the silent type, the worst thing you can do is go through this process alone. Sharing your story is a powerful way to push through. You may find support in people who you would have never thought of. You need them and they may need you, but you don’t know until you open up.Connect - whether it’s by starting a blog, joining a support group, or chatting with a group of friends.  Stay Positive & Keep Trying.  Ugh, not this phrase again!  We get it.  It’s one of the most annoying things you can hear, BUT when you remain positive, you feel better, have a healthier outlook – all of which can only help your chances of becoming pregnant.  Let Go of Bitterness, Jealousy, and Anger.  Easier said than done, of course, but try your hardest to not let these feelings rob you of your own peace and happiness.  Again, this affects your mood, stress levels, and has a negative impact on your emotional well-being – none of which is good for baby making.  In addition to these resolutions for your fertility this year, you should also find a doctor you love. Throughout this process, you need to surround yourself with people who care.  This starts and ends with a fertility doctor and practice that offers compassion for their patients and knowledge and expertise of the fertility process. CRM Orlando can be that for you. For information or to schedule a consultation at either of our successful fertility clinics in Orlando, FL or Celebration, FL please give us a call at (800) 343-6331. Thu, 21 December 2017 00:00:00 Quiz: How Should You Make This a December to Remember? Center for Reproductive Medicine Orlando De-stressing is key when you’re #TTC… but is that realistic during the holidays? You bet. Take our fun & quick quiz to identify the best chill-out tactics for you! Powered by Wed, 06 December 2017 00:00:00 Leading Orlando Fertility Center Announces the Grand Opening of a New Comprehensive State-Of-The-Art Facility CRM Orlando ORLANDO, FLORIDA---NOVEMBER 20, 2017 – The Center for Reproductive Medicine (CRM) is proud to announce the opening of its new 16,000 square foot office in Central Florida at 1500 South Orlando Avenue, Winter Park, Florida 32789.  Committed to excellence, CRM has been treating patients throughout Florida for infertility-related issues since 1985 and was the first IVF (In Vitro Fertilization) program in the State of Florida. "We are genuinely excited to open our remarkable flagship office, providing the very latest advancements in fertility treatments.  Within our new, comprehensive state-of-the-art facility we will add some additional services and continue to provide the compassionate, personalized and affordable care that has made us Central Florida’s first choice for reproductive medicine, ” said Dr. Randall Loy, Medical Director and Managing Partner for CRM. During the past 32 years CRM has experienced tremendous growth and the new facility is designed to meet the needs of all their patients.  The new facility houses an all-inclusive fertility treatment center with a passionate, dedicated, and large, on-site physician, clinical, embryology, laboratory and administrative team.  A few highlights of the new facility include: A CAP- and COLA-accredited (College of American Pathologists and Council on Laboratory Accreditation) as well as CLIA compliant (Clinical Laboratory Improvement Amendments) and newly-equipped Endocrinology and Andrology laboratories offering extensive diagnostic testing A greatly expanded IVF lab with comprehensive services, including IVF, ICSI, Egg freezing, Fertility preservation, Preimplantation Genetic Screening (PGS) Increased space in all exam rooms (complete with new ultrasound machines), consultation rooms, and patient areas A leading edge, women’s’ care surgical center that is AHCA-accredited (Agency for Healthcare Administration) On-site x-ray procedures. “The new office is a very impressive facility, designed to meet the needs of our patients and staff, in a warm and comfortable environment,” added partner Dr. Sharon Jaffe, CRM’s Third Party Reproduction Director. Directed by partner, Dr. Sejal Patel, CRM also has a beautiful office located in Celebration, providing convenient access to comprehensive fertility treatments throughout Central Florida. About the Center for Reproductive Medicine Center for Reproductive Medicine (CRM) is a leading IVF (in vitro fertilization) and infertility center in Orlando and Central Florida. Founded in 1985, CRM was the first IVF program in the State of Florida. CRM’s infertility specialists are named among the top fertility doctors nationally by a variety of publications, and are leaders in IVF, egg freezing, egg donation, ICSI (Intracytoplasmic sperm injection), male infertility and PGD (preimplantation genetic diagnosis).  CRM is known for providing compassionate patient care, individualized treatment plans, and the most cost-efficient options, giving its patients every conceivable chance for success. Providing fertility services throughout Central Florida, CRM is the largest infertility and reproductive practice in the mid-state. Visit Mon, 20 November 2017 00:00:00 How to Have a Healthy Holiday While Trying to Conceive CRM Orlando It’s that time of year again for parties, parties, and more parties!  This also means it’s time for lots of food, food, and more food (Oh, and don’t forget the drinks!).  While there’s nothing wrong with enjoying the festivities, it’s important to keep your normal, healthy lifestyle in check – especially if you and you’re your partner are trying to get pregnant.  Here’s why…. Being overweight has been known to have devastating effects on fertility and can cause abnormalities in hormone levels in both men and women that can have a negative effect on eggs and sperm.  Not to mention, it also puts the cardiovascular system in overdrive, promotes pre-diabetic and diabetic states, and increases cholesterol levels.  While it’s certainly okay to treat yourself, just don’t completely derail your normal habits. Our fertility specialists recommend you follow these tips: Give that buffet table some thought, and make sure your diet includes a balance of lean proteins, healthy fats, and low glycemic index carbohydrates.  Avoid foods such as white bread, white potatoes, and sugared sodas.   *A low glycemic diet is important especially for women with PCOS who are prone to making high levels of insulin.  This includes foods such as vegetables, most fruits, oatmeal, peas, carrots, skim milk, and beans. Eat more often.  Really?!  Yes!  By eating smaller, more frequent meals each day instead of three large meals, you won’t be as hungry throughout the day and you’ll boost your metabolism.   Eat lots of lean proteins and healthy fats.  Proteins can include white meat chicken and turkey, lean cuts of red meat, nuts, beans, and tofu.  Nuts, avocado, and olive are excellent healthy fat choices. Why is this important?  Other than physical health benefits, protein and healthy fats make up essential hormones that influence brain chemicals to stimulate and create positive moods.  Stop the bad habits!  Don’t wait until the New Year; give up smoking (cigarettes and marijuana) and minimize alcohol intake.  A healthy lifestyle can help you and your partner to conceive. Exercise more frequently, and make it a priority.  Fitness does a body good in that it provides physical, mental, and emotional benefits.  It’s also important for men to exercise as it’s been proven to help sperm production.  If you’re heading to an event, eat a healthy meal before you go.  This will help you avoid unhealthy temptations and the dessert table! You can also bring a healthy dish for everyone to share. Get a good night’s rest.  Lack of sleep can throw off the natural cycles in a woman’s body, including ovulation.  Shoot for a minimum of seven hours of sleep each night even if it means leaving the party early. Are you struggling with infertility?  We can help!  For more information on our advanced fertility treatments and procedures or to schedule a consultation with one of our top physicians at our Orlando area location in Winter Park and Celebration fertility clinic locations, please call (800) 343-6331. Mon, 20 November 2017 00:00:00 Show Solidarity! Breast Cancer Awareness Events Near Orlando CRM Orlando October is National Breast Cancer Awareness Month, an important time of year that helps bring awareness to this devastating disease and emphasizes the importance of early detection.  Where there is pain, there is also hope, and there is so much we can do to contribute to this great cause.  The city of Orlando makes it easy to do just that with tons of fun events that honor Breast Cancer Awareness Month.  Here are some great options to ‘Think Pink’ and show solidarity with our Orlando sisters this month: Hands & Hearts Breast Cancer Outreach Benefit: Presented by Seminole Harley-Davidson, the 2nd annual fun-filled event features Vanessa-Echols along with breast cancer survivors and current fighters as they strut their stuff down the runway in the 2018 Harley-Davidson Pink Label Line.  Make sure to stay for the VIP party complete with small bites, a champagne toast, lots of prizes, great discounts on Motorclothes, and awesome music from DJ Jaywill. Seminole Harley-Davidson, October 14, 6pm to 9pm.  TWR Uncorked Breast Cancer Awareness Brunch:  This event presents a wonderful opportunity to celebrate life and sisterhood as well as honor those who have done so much to promote breast cancer awareness.  TWR Uncorked has a line-up of exciting guest speakers and a Live DJ.  The bottomless mimosas won’t hurt either!  All ticket sales and proceeds go towards the Susan G. Komen Breast Cancer Awareness Walk on Saturday October 21, 2017.  Ace Café Orlando, October 15, 11am to 4pm.  Pink Out. Dine Out. Rock Out.  With a donation of just $20, enjoy night filled with foods and signature drinks from a variety of restaurants from The Mall at Millenia and live music by The Frequency Band.  All proceeds from lanyard donations will benefit the Florida Hospital Breast Cancer Care Fund.  The Mall at Millenia, October 20, 6:30pm to 8:30pm.  Making Strides for Orlando: This American Cancer Society walk raises awareness and funds to ultimately save lives here in Orlando. This is a non-competitive 3 to 5 mile walk for anyone who has been impacted by breast cancer. Sign up for a team or donate today! Lake Eola Park, October 28, Registration begins at 7:00am.  Rock Your Rosé Cocktails for a Cause Party in Pink:  You know it’s a good party when the party is based on a specialty drink!  With a charitable donation, you can celebrate Breast Cancer Awareness month at the Blue Martini and enjoy entry into the raffle prize, their famous Pink Flamingo cocktails, and live music by Audio Exchange.  The Blue Martini Pointe Orlando, October 14, 8pm to 11pm.  At The Center for Reproductive Medicine, we will be celebrating Breast Cancer Awareness Month and raising awareness for this great cause.  For information on our fertility centers in Orlando, Celebration, or Lake Mary, please call us today at (800) 343-6331 or complete the request an appointment form. Tue, 10 October 2017 00:00:00 The Center for Reproductive Medicine is moving! CRM Orlando After 25 years and multiplied thousands of babies conceived at our present location, we are relocating and doubling in size to serve the Central Florida area better. Although we will just be a hop, skip, and jump away from where we are now in Orlando, our new address (1500 South Orlando Avenue/17-92) is actually in Winter Park. That’s right, Orlando Avenue in Winter Park! Near Florida Hospital. Near Winter Park shopping! Near Winter Park restaurants! (For you locals, our new building sits on the old “Pumpkin Patch,” so named because each autumn for many years the neighboring church has sold pumpkins on this 1.5 acre plot.)The new CRM is a two story facility with approximately 16,000 square feet. The first floor will be the “Orlando Avenue Surgery Center,” a surgical facility, with two operating rooms and one procedural room, where CRM physicians will perform all infertility and IVF-related procedures. The IVF labs will also more than double in size in the new facility and will occupy the first floor, as well. The second floor will house the clinical space, that is, consultation and examination rooms, the andrology laboratory, as well as nurses’ and physicians’ offices. Incidentally, the administration offices and call-center will be in a separate facility across the street from the building. With the new address have also come upgrades in laboratory and medical equipment. For example, new IVF and andrology work stations and new state-of-the-art ultrasound machines. And this is just the beginning…! The physicians and staff are really excited about our new digs and can hardly wait to show you. You are going to be very pleasantly surprised! Mon, 09 October 2017 00:00:00 What is the Best Diet for PCOS? CRM Orlando “PCOS (polycystic ovarian syndrome) is an endocrine disorder that affects over 7 million women.  That’s more than the number of people diagnosed with breast cancer, rheumatoid arthritis, multiple sclerosis, and lupus combined.”  – Louise Chang, MD September marks PCOS Awareness Month and presents an opportunity to raise worldwide public awareness of polycystic ovarian syndrome, a health condition that can affect a woman’s menstrual cycle, fertility, hormones, heart, blood vessels, and appearance specifically with obesity and issues with weight gain.  If you have PCOS and struggle with weight issues, here are some great PCOS diet and healthy lifestyle strategies.  Tip #1: Control Your Blood Sugar Many researchers believe that insulin (a hormone that controls your blood sugar, but also signals your body to store fat) is also linked to PCOS and is an underlying cause of weight gain.  It is common for women who have PCOS to have increased levels of insulin which appears to also increase the production of androgen.  With insulin resistance, your blood sugar levels rise in spite of high levels of insulin, and eventually, Type 2 Diabetes may result.  Positive changes in diet and exercise (including the ideas listed below) can postpone the development of diabetes and reduce the amount of sugary carbs that can result in weight-loss.  Cut out white breads, pasta, potatoes, cereals, certain fruits, and snack foods. Incorporate the following foods into your diet: nutrient dense, high-fiber carbs; foods high in protein such as lean meats and legumes; and foods containing healthy fats such as olive oil, nuts, and fish. Instead of eating three large meals each day, try several mini-meals throughout the day to keep you blood sugar levels even. Tip #2: Do Not Deprive Yourself A healthy diet should never mean starvation, and instead should involve a healthy, nutritious lifestyle.  There are so many ways you can incorporate delicious, healthy foods into your diet such as lentils, vegetables, lean meats, fruits, and so much more!  Check with your local health food store about tips on eating right or try some of the freshly made meals that you can take home without having to prepare yourself.  If you do like to cook, check out a cooking class that focuses on preparing healthy, nutritious meals. Tip #3: Exercise Regularly Living a healthy lifestyle must involve some form of regular exercise, and in order to burn serious calories, you should exercise every day!  Exercise if a perfect accompaniment to a PCOS diet, especially for women with PCOS and insulin resistance or type 2 diabetes.  Here are just a few ways exercise can help.  Regulate blood glucose levels Increases endorphins (the body’s natural opioids) Maintains a positive outlook Keeps the body trim and in good shape (especially for pregnancy!) Tip #4: Eat to Live.  Don’t Live to Eat. Some women use food as a reward for an accomplishment or go to emotional eating when they feel lonely or sad.  With a successful PCOS diet, you must evaluate your relationship with food and eat to live rather than live to eat.  Replace healthy snacks with junk food, and get help if you have an unhealthy relationship with food such as binge eating, purging, or starving yourself.  Tip #5: Ask Your Doctor about Metformin Metformin is a drug that was developed for type 2 diabetes and is often prescribed for obesity and PCOS. It can offer the following benefits for women struggling with weight issues causes by PCOS: Assist with weight loss Lower blood pressure Improve cholesterol Decrease levels of androgens Keep periods regular Improve sensitivity to fertility drugs Are you struggling with PCOS and trying to conceive?  The fertility specialists at CRM Florida can help.  Call us today at (888) 343-6331 to schedule a consultation at our Orlando, Lake Mary, or Celebration fertility centers. Tue, 19 September 2017 00:00:00 Dr. Sejal Patel Discusses IUI Dr. Sejal Dharia Patel What is an IUI? IUI is referred to as intrauterine insemination (IUI) and is a therapy where sperm can be placed past the cervix and into the women’s uterus around the time of ovulation. Naturally, sperm travels from the vagina, through the cervix and into the uterus prior to traveling to the fallopian tube to meet the egg. If they meet, fertilization will occur and an embryo will form. However, there are many barriers to this process, such a sperm traveling into the cervix and then traversing the cervix to reach the uterus. This is where intrauterine insemination can help. Male factor: Intrauterine insemination can be used when there is a male factor to the fertility picture. If there is a lower sperm count than expected, the sperm can be concentrated for placement directly into the uterine cavity. If the sperm have low motility, the motile sperm can be separated through a washing process (density gradient and centrifugation) and placed into the uterine cavity to have the best chance of moving into the fallopian tube. If there are antibodies or abnormally shaped sperm, these can be removed in the washing process. In addition, some men may have abnormalities to the reproductive tract like retrograde ejaculation where sperm are ejaculated back into the bladder. The sperm can be removed from the bladder, prepared and placed into the uterine cavity to help with conception. Cervical abnormalities: Intrauterine insemination can also be used when there may be abnormalities in the cervix. If the patient has had a LEEP or cone biopsy in the past to remove abnormal cervical cells, this procedure can remove a part of the cervix which contains the mucus glands to facilitate sperm movement into the uterine cavity. Intrauterine insemination will bypass this obstacle. In addition, sometimes the sperm and cervical mucus do not interact well and an intrauterine insemination can also address this issue. Donor sperm: Finally, intrauterine insemination can be utilized when undergoing intrauterine insemination using donor sperm. This is utilized when a male partner has no sperm or the sperm quality is too poor for in vitro fertilization. In addition, this can be used by single women or married same sex couples who want to start their family. Cryopreserved sperm: In some cases, men may preserve their sperm prior to cancer therapy, surgery or at a young age which can be utilized later via intrauterine insemination to help with conception. Collection: Sperm collection can occur via a number of ways. The most common is masturbation into a sterile plastic container. The collection can be done at home or in the office. If at home, the sperm must be delivered within 40 minutes of collection. The sperm may also be collected in a special sterile condom that can be obtained from our office at CRM. This collection method may result in a lower yield of sperm based upon the surface area of the condom. Men with retrograde ejaculation can also provide urine from which sperm can be retrieved for IUI. Sperm Preparation: An intrauterine insemination is performed around the time of ovulation. The partner will bring in a semen sample and the semen is separated from the sperm. Live sperm are then separated from nonviable sperm. The live sperm are then placed into a density gradient to separate the highly motile sperm from the others. The most directionally motile sperm are removed from the gradient and placed into fluid similar to the human fallopian tube for insemination. For the patient: Typically an intrauterine insemination is performed after placement of a speculum to visualize the cervix. Once completed, the cervix is rinsed of any mucus or debris. A fine catheter containing the sperm in human tubal fluid is then placed just past the cervix into the uterine cavity and once accurate placement is determined, the sperm sample is then slowly injected into the uterine cavity. The procedure should not cause significant pain or cramping, but occasional cramps or spotting can occur. Normally after the procedure, the patient is asked to rest in a supine position for 15 minutes. That evening, relations (unless using donor sperm) is recommended. Two weeks after the intrauterine insemination a urine pregnancy test is performed. Success rates: Success rates will depend upon the diagnosis, age of the woman and seminal parameters. If the age of the patient is advanced or the seminal parameters are lower than normal, pregnancy rates will be reduced. Overall, IUI as a treatment (not per cycle) yields a pregnancy rate of around 40%. Risks: Risks from an IUI are quite low. The chance of infection is rare. Other risks to the IUI include whether a woman is also taking additional medications which may increase her risk of multiples. IUI does not alone increase the risk of multiples. IUI is quite a successful therapy and should be reviewed as a potential option with your reproductive endocrinologist at CRM. Thu, 31 August 2017 15:13:00 4 Ways to Keep the Romance Alive During IVF Treatments Center for Reproductive Medicine in Orlando Sad but true, it should come as no surprise that couples going through fertility treatments, such as in-vitro fertilization (IVF), often struggle to keep the romance alive.  However, never is it more important to have a connection with your partner on both a physical and emotional level.  Here we offer different strategies on how to keep intimacy in the picture and on how to liven things up a little. Make Plans:  Even though we think the best sex is spontaneous, that’s not always the case.  Sex starts with our minds, so when we wait for spontaneity and don’t receive it, we’re often disappointed.  So give yourself something to look forward to, and put sex in your schedule! Take it up a notch and schedule a romantic date night with your partner (one where you both commit to not talking about your fertility issues), have some fun, go home (or stay at a hotel), and have some more fun! Go Outside Your Comfort Zone:  Most couples (yes, even the ones in the most romantic and sexual relationships) can get in a rut.  Throw fertility issues and timed baby-making into the mix, and it’s even worse.  So make a point to spice things up a little and add some excitement to that old routine.  Have a candle-light dinner with mood-enhancing scents or wear different types of attire.  The goal is to try something out of your comfort zone (even if it’s just a minor change) that will add a little zest to your love life.   Location, Location, Location: On one hand you’ve got love-making, and on the other, you’ve got baby-making.  A great idea is to designate one room in the house for one and another room for the other.  Another option is to book a hotel room or find a different location outside your home when you and your partner are looking for some extra romance.     The Ginger Jar Technique:  Take two jars, one for you and one for your partner, and put four to six slips of paper in each with different ways you’d like to feel appreciated, supported, and loved.  These do not necessarily have to be sexual (or they could be!).  For instance, if you love flowers, jot down, “Surprise me with flowers.”  Choose how often you want to take an idea out (daily or every other day), and do not tell your partner what you picked.  Then, when the time is right, surprise your partner with what he or she requested.  Think of this little exercise as planned spontaneity which, you never know, could put you and your partner in the mood! If you are struggling with infertility and would like to schedule an appointment at one of our fertility clinics in either Orlando, Lake Mary, or Celebration, please give us a call at (800) 343-6331. Wed, 23 August 2017 00:00:00 Quiz: What Romantic Activities Fit Your Personality? Center for Reproductive Medicine in Orlando IVF treatments are super relaxing … said no one ever. Reduce stress and help redicover the romance throughout IVF treatments. August is Romance Awareness month! How should you celebrate? Take our quiz to find out… Wed, 09 August 2017 00:00:00 The Role of Stress on Your Fertility Mayuri Nayee, RN, BSN, MSN Going through infertility can be a very stressful journey, and stress in return plays a negative role with fertility.  There are many fun ways to cope with stress and anxiety during this time whether it’s doing something as a couple, with your family and friends or with your close girlfriends. Websites such a Groupon always have amazing deals to help you with these fun things to do. Time to use those Travel PointsPlan a quick weekend getaway whether it’s in-state or out of state. Make it a girl’s weekend or a fun romantic getaway. Although traveling to the Caribbean’s and Mexico may seem like a lot of fun, we do not recommend it due to the Zika Virus.  Bring out the Van Gogh in youPainting class - A fun night with friends, family or a romantic date night with your loved one.  If you think you can’t paint, you’ll impress yourself with the masterpiece you walk out with.Pottery glass – get your hands all dirty while you try to make something that looks close enough to a piece of pottery, or you can simply opt for painting a professionally made piece of pottery. It’s all about the foodFood Truck night - take the evening off and enjoy a variety of food from all over the world. Most places are also pet-friendly.A nice classy dinner - make it a night to remember and spoil yourselves with some fine dining.Cooking class – learn to cook fun new recipes and engage in them together building a closer bond to each other.Farmers Market – Spend the day learning about some of the healthiest and organic local products at the Farmers Market.  Laugh it outComedy Club - Laughter is truly the best medicine. Visit a comedy club, and laugh till your stomach hurts.A new study by Israeli researchers has found that laughter might help women trying to become pregnant through in vitro fertilization. Arts, Culture and HistoryEvery city has a story to tell, so why not venture out and learn a bit more about your city. Visit local museums, botanical gardens, or go to an independent film theatre. Fri, 28 July 2017 13:00:00 Relaxation for Fertility: Romantic Orlando Staycations Center for Reproductive Medicine in Orlando Did you know that psychological factors such as stress and anxiety play a huge role in fertility?  While it’s a vicious cycle that is hard to overcome (um, you’re probably stressed because you’re trying to get pregnant), it is so important to remain positive, try your hardest to relax, and to avoid the depression and anxiety often associated with infertility.  Easier said than done of course, but a great way to let both your mind and body relax is to enjoy an adult-friendly, romantic staycation with your partner.   We’ve put a list together of Orlando hot spots that we think you’ll enjoy and that will help put you in the right frame of mind.  Check it out… Epcot Theme Park Epcot is known for its vast array of culture, historical exhibits, entertainment, shopping, and dining from 11 countries.  Here’s the fun part….you can travel the world in just a day and stop by each country to enjoy the cuisine and cocktails unique to each nation.  Sip avocado margaritas in Mexico, Veuve Cliquot in France, craft beers in Germany, and more.  As for eating, you have tons of options from fine dining to casual eateries.  If you time it right, take advantage of the Epcot Food & Wine Festival – a 6-week long event that features food and beverages from more than 25 countries.   Orlando’s Best Spas Orlando is not just known for theme parks and family-friendly attractions, but also for some of the best spas in Florida.  You’ve got plenty to choose from – Senses Spa at Disney’s Grand Floridian Resort, Mandara Spa at Loews Portofino Bay Hotel at Universal Orlando and the Walt Disney World Swan & Dolphin hotels, the Ritz-Carlton Spa, the Waldorf Astoria Spa, and Mokara Spa at Omni Orlando Resort at Championsgate.  For extra romance, book a treatment for two in one of the spa’s couples suites or private spa bungalows. Four Seasons Orlando You deserve to splurge, and the perfect place for that is the Four Seasons Orlando.  When you’re not enjoying world-class accommodations, relax in the 13,000-square-foot posh spa, play a round of golf, or swim in the adults-only infinity pool.  At the end of the day, dine at Capa – the hotel’s 17th floor rooftop steakhouse - while watching the fireworks display over Disney’s theme parks. B Resort & Spa The newly opened B Resort & Spa is a lifestyle hotel and a great adult-only option.  Complete with stylish decor and a casual, playful ambience, this hotel features a full-service Aveda spa, fitness center with tennis courts, and a fun BBQ restaurant – American Q – the perfect place to enjoy tasty bites and sip hand-crafted gin and whiskey cocktails.  Once your belly is full, head over to Downtown Disney (just a 10-minute walk away) for evening entertainment. Winter Park Village If you’ve never been to Winter Park village, you’re in for a treat!  Along the 10-block stretch in this charming neighborhood, you will find boutique shopping, trendy restaurants and bars, and a sprawling Central Park.  This Orlando-area gem is also home to the Morse Museum which features a magnificent Tiffany glass collection.  After you’ve shopped til you dropped, stop by one of the area’s top restaurants for delicious cuisine and hand-crafted cocktails. For information on any of our Orlando area fertility clinics or to schedule a consultation with one of our top-rated fertility physicians, please call us today at (800) 343-6331. Mon, 24 July 2017 00:00:00 Infertility: Staying Supportive of Each Other Through It All IVF Orlando Courage doesn’t always roar.  Sometimes courage is the quiet voice at the end of the day saying, “I will try again tomorrow.” – Mary Anne Radmacher Couples struggling with infertility not only have to deal with the stress of doctor appointments, procedures, and worst of all – timed intercourse, but are also subject to an emotional battle as well.  All of this will cause serious stress to the individual, but can also wreak havoc on a marriage.  However, this is a time when having each other to lean on is the most important.  The tips below offer insight on how to deal with the stress of infertility and how to support each other when it’s needed the most. Communicate.  One of the most important things you can do as a couple is keep the lines of communication open.  The challenge here is that you need to LISTEN to what each other is saying.  When one of you speaks, the other needs to remain quiet and focused on the conversation.  This is how you both will have a true understanding of each other’s feelings.  Counseling. Always remember that there is no shame in asking for help, and with counseling you have a safe space in which to communicate.  Counselors are especially great at guiding couples through healthy communication skills - a great way to work through the individual stresses of infertility.  Do your research because many counselors specialize in infertility counseling.  Be honest.  Being honest with each other is so important as you face the challenge of infertility.  Always let one another know how you are feeling and don’t sugar coat anything.  There’s no need for that as you’re both in this together.  At the same time, try your hardest to not be judgmental of each other.  Acknowledge that each of you has a right to feel the way you feel.  Stop the negativity.  Do your best to let go of all the negative thoughts and feelings that are a result of your infertility struggle.  Negativity breeds negativity, and can only make the situation worse.  No one is saying you must be Mr. and Mrs. Positive, but just remember that your situation is temporary and “This too shall pass.”  Take one day at a time, and shift your perspective to something more positive.  Go for a walk, do something you love, see a friend, or just simply treat yourself.  It will make a world of difference in how you view your current situation and will make for a much happier situation at home. Don’t forget to be affectionate.  Between timed intercourse and a world of stress, it’s no surprise that a simple form of affection can be forgotten.  Take a moment to share some affection with your spouse whether this means a simple hug, holding hands, a massage, or spontaneous sex (not timed!).  Touching will make you reconnect, and research has shown it’s a powerful source of healing.  If you and your spouse have been having problems conceiving and would like to schedule a consultation with one of our top physicians at one of our Orlando fertility clinics, please call us today at 800-343-6331. Mon, 26 June 2017 00:00:00 Dr. Randall A. Loy Discusses IVF and the Chances of Having a Baby Dr. Randall A. Loy IVF: What Are the Chances of Having A Baby?  Prior to the birth of Louise Brown, the first IVF baby, in 1978, there were few effective treatments for infertility.  During the past thirty years, due to various improvements in ovarian stimulation regimens and innovations of the technique (e.g., intracytoplasmic sperm injection or “ICSI” and preimplantation genetic screening or “PGS”), results have progressively improved and IVF has become the “gold standard” technique for the treatment of infertile couples. Even so, it usually takes more than one IVF cycle to be successful. Even among the most successful clinics in the U.S.: Approximately 50 percent of women under 35 will not get pregnant on their first IVF cycle. Nearly 60 percent of women ages 35 to 37 will not become pregnant during their first IVF cycle. Almost half of patients using donor eggs need more than one cycle of IVF to conceive. Before most couples commit to the process of in vitro fertilization, they have several questions: What are our chances of having a baby? How much will it cost? How long will it take? With IVF being applied for all indications of infertility, from tubal occlusion and endometriosis to male factor and unexplained causes, the probability of achieving a pregnancy varies widely. Other modifiers of IVF success include age, underlying medical conditions as well as lifestyle factors such as body mass index (BMI), tobacco, alcohol and other drug usage. Certain models have been developed to help calculate IVF success but perhaps one of the best for patients living in the United States comes from the Society for Assisted Reproductive technology (SART).  Various studies have demonstrated that when a couple commits to a course of treatment (multiple cycles) rather than to just one attempt they markedly increase their chance of success. Attain® IVF is an example of a group of bundled IVF cycle plans, called Multi-Cycle Programs that include multiple IVF cycles for a one-time, discounted fixed fee. Multi-Cycle Programs are designed to reduce stress about IVF costs and may provide a couple greater peace of mind that they have the best possible chance of success. Multi-Cycle Programs are administered by IntegraMed® Fertility and are offered exclusively at practices within their nationwide network, of which we are a member. There are over 40 fertility centers in their network and over 25% of all IVF procedures in the U.S. each year are performed by a network physician. In short, the answers to the above three questions are as follows: Variable. Consult your physician and the SART predictor Variable, depending upon clinic and services rendered. Between 1 and 3 months depending upon if IVF involves a “fresh transfer” or a “freeze all” embryos approach. Twenty-three years ago, my wife and I underwent three assisted reproductive technology cycles with the first two unsuccessful. Ultimately, we had three children from these techniques (and a surprise fourth by natural means!). It was a frustrating and challenging chapter in our lives. Indeed, IVF can truly be a proverbial “emotional roller-coaster;” however, if a couple persists, most will, by one means or another, make the transition from infertility specialist to obstetrician! Fri, 23 June 2017 09:14:00 Who Should Consider Egg Freezing CRM Orlando Egg freezing, or oocyte cryopreservation, is a process in which a woman’s eggs (oocytes) are extracted, frozen, and stored as a method to preserve reproductive potential in women of reproductive age.  It is a procedure that has been around since 1986, but has been growing in popularity over the past five years.  This is largely due to advanced technology which led the American Society for Reproductive Medicine (ASRM) to lift its “experimental” label for egg freezing in October 2012.  Since then, it’s been a growing trend especially for healthy, young women who are electively delaying childbearing for a variety of reasons.  Who is a candidate for egg freezing? There’s a variety of reasons a woman may want to consider egg freezing… Women undergoing cancer treatments such as chemotherapy and/ or pelvic radiation therapy that may affect fertility *According to the American Society of Clinical Oncology in the Journal of Oncology Practice, “Oncologists should address the possibility of infertility with patients treated during their reproductive years.  Fertility preservation is often possible, but to serve the full range of options, fertility preservation approaches should be considered as early as possible during (cancer) treatment planning.” Surgery that may cause damage to the ovaries Rise of premature ovarian failure because of chromosomal abnormalities (i.e. Turner Syndrome, fragile X Syndrome), or family history of early menopause Ovarian disease with risk of damage to the ovaries Genetic mutations requiring removal of the ovaries (i.e. BRCA mutation) To avoid freezing surplus embryos after an IVF cycle Fertility preservation for personal reasons that delays childbearing until a later age *As women age, the quantity and quality of eggs decline each year – dramatically declining after the age of 35 and leaving only a 5% chance of conceiving by the age of 40.  With egg freezing, a woman can serve as her own egg donor when she is ready to conceive later in life.  At the Center for Reproductive Medicine, we understand how important the decision is to freeze your eggs.  Should you decide to move forward with the procedure, our compassionate team of doctors will walk you through the process and be there for you every step of the way.  For more information on egg freezing or to schedule a consultation, please call our fertility office today at (800) 343-6331. Thu, 25 May 2017 00:00:00 Advanced Paternal Age Dr. Sharon B. Jaffe A woman who is trying to conceive and is older than 35 years old is considered "advance maternal age" due to the increased risk of pregnancy and the increased risk of abnormal eggs. But what about the male partner?  Is there an advanced paternal age that matters?  The answer is yes.  As a man ages, the quality of his semen parameters can decline.  Male sexual function can decline with age and there is an increased risk medical and urological problems that can further contribute to decreased male fertility. But, what patients are usually not aware of is that advancing paternal age is associated with an increased risk of a variety of congenital anomalies, genetic abnormalities and syndromes, including psychiatric and neurocognitive disorders such as autism spectrum disorder and schizophrenia  Although the increased risk to the offspring due to advanced paternal age is very low, it is important to be counseled about this by your physician.  Some physicians have raised the question "should younger men cryopreserve sperm to use later in life because of the decreased fertility and increase in certain diseases associated with advanced paternal age? "The fertility experts at the Center for Reproductive Medicine are happy to discuss this and any other concerns regarding your fertility journey so that we can give our patients every conceivable chance to become parents. Wed, 24 May 2017 00:00:00 Dr. Albert Asante Discusses PCOS Dr. Albert Asante Is it possible you have Polycystic Ovary Syndrome (PCOS)? If you have menstrual irregularity, infertility due to lack of ovulation, and/or progressive hirsutism (abnormal hair growth) since puberty, you should be evaluated for PCOS. So, what is PCOS? PCOS is a hormone imbalance disorder that affects 5% –10% of women in the reproductive age group; it is the most common endocrine disorder affecting women in the developed world. It is a condition in which the ovaries contain many immature follicles (egg-containing structures) that are associated with chronic anovulation and overproduction of androgens (male sex hormones). Features of PCOS PCOS is a heterogeneous syndrome with multiple and variable clinical manifestations. Symptoms may include irregular, absent or heavy menstrual periods, excessive growth of central body hair (hirsutism), hair loss (alopecia), acne, and infertility. More than 50% of women with PCOS also are overweight or obese, but that is not part of the definition. Causes and risk factors The cause of PCOS remains unknown. However, the familial pattern of PCOS with affected mothers and daughters implies a role for genetic factors. According to one clinical study, approximately 35% of mothers and 40% of sisters of women with PCOS are affected. How is PCOS diagnosed? Consistent with the fact that PCOS is a syndrome, no single test is available to establish its diagnosis. The diagnosis is based upon the combination of clinical, ultrasound, and laboratory features. The Endocrine Society recommends that the so-called Rotterdam criteria should be used to diagnose PCOS. Those criteria are based on finding two of the three cardinal features that characterize PCOS. The first is hyperandrogenism which is androgen excess and diagnosed either based on a clinical sign, such as hirsutism; this includes some mid-line body hair, primarily on the upper lip, chin, and midline between the breasts. Hyperandogenism can also be diagnosed on the basis of elevated circulating levels of androgens (male sex hormones). The androgen that is most commonly used is testosterone. The second cardinal feature is ovulatory dysfunction, and that usually manifest as oligomenorrhea or infrequent menstruation. Sometimes this is observed as secondary amenorrhea or total lack of periods for a while. The third sign is a characteristic of the appearance of the ovaries known as the polycystic ovary. The term ‘polycystic ovary’ is a misnomer because the ovary does not contain true cysts (of note, technically speaking, an ovarian cyst refers to a large, usually > 3 cm, fluid-filled sac). Rather, the ‘polycystic ovary’ contains a lot of very small follicles (each measuring less than 1 cm in size) that have failed to mature and ovulate. Common conditions that may mimic some of the signs and symptoms of polycystic ovary syndrome must be excluded before a diagnosis of PCOS can be conclusively made. Thus, women suspected of having PCOS will be screened for thyroid dysfunction, prolactin excess, and the onset of non-classical congenital adrenal hyperplasia. Long-term Health Consequences The potential health implications of PCOS are lifelong. Women with PCOS are at risk for metabolic syndrome. Metabolic syndrome is when women develop multiple risk factors for cardiovascular disorders. They are also at increased risk for prediabetes or overt diabetes, heart disease, cholesterol abnormalities, infertility and endometrial cancer. A cross-sectional study from the University of Pennsylvania demonstrated a significant increase in disordered eating and an associated decreased quality of life for women with PCOS. Screening for eating disorders, anxiety and depression in women with PCOS is therefore strongly recommended. Treatment Treatments vary according to the complaints or goals of the patient. Some patients may be concerned primarily with fertility, while others are more concerned about menstrual cycle regulation, hirsutism, or acne. Regardless of the primary goal, PCOS should be treated because of the long-term health risks such as heart disease and uterine cancer. Lifestyle Modification and Weight Loss Obesity commonly is associated with PCOS. Weight loss has been shown to improve the hormonal condition of overweight or obese PCOS patients. Although tempting, fad diets and diet pills have not been found to be effective, and in many cases, cause additional health problems. It is recommended that overweight or obese PCOS women should enroll in a weight-control plan or clinic. Increasing physical activity is an important step in any weight reduction program. Recommendations include three to four exercise periods each week with at least 30 minutes of aerobic exercise. Extreme cases of obesity that do not respond to behavioral modification, should be considered as candidates for bariatric surgery. PCOS Treatment for Women Who Do Not Wish To Conceive Hormonal suppression is the treatment of choice for PCOS-related hyperandrogenism. Unfortunately, however, if treatment is stopped, symptoms usually reappear. Birth control pills is the best hormonal treatment. Birth control pills decrease ovarian hormone production and help reverse the effects of excessive androgen levels. Other contraceptive formulations, including injections and implants of progestin can also be used to suppress ovarian hyperandrogenism. Spironolactone, alone or combined with birth control pills may be prescribed for patients with persistent hirsutism. Rarely, GnRH analogs may be used to decrease ovarian androgen production. Patients without hirsutism may take progesterone at regular intervals to ensure cyclic endometrial shedding, to prevent the development of uterine cancer. PCOS Treatment for Women Who Wish to Conceive For women with fertility as the primary and immediate goal, ovulation is induced with clomiphene citrate. Clomiphene is simple to use, is relatively inexpensive, and works well to induce ovulation in many patients. Approximately 10% of pregnancies with clomiphene are twins; triplets or more are rare. For women who consistently fail to ovulate after taking clomiphene (also known as clomiphene-resistant patients), the use of another oral medication, letrozole, may be considered. Recent studies suggest that pregnancy rates achieved with letrozole use are similar to clomiphene citrate. Letrozole is not approved by the FDA for induction of ovulation. If a patient does not respond to both clomiphene and letrozole, or if they fail to conceive after six ovulatory cycles, gonadotropins may be the next step. Gonadotropins are more expensive and have a higher incidence of side effects such as hyperstimulation (excessive swelling) of the ovaries and a higher rate of multiple pregnancy such as twins or triplets. In very rare cases, ovulation is not achieved with clomiphene, letrozole or gonadotropins, and ovarian surgery may be tried to stimulate ovulation, or patients may proceed to assisted reproductive technology, such as in vitro fertilization. In Summary PCOS can cause hirsutism, acne, irregular or heavy menstrual periods, lack of ovulation, and infertility. It also is associated with an increased risk of diabetes, uterine cancer, high cholesterol, and heart disease. Dealing with PCOS can be emotionally difficult. The good news is that significant advances have been made in both understanding and treating PCOS. If you are diagnosed with PCOS or suspect that you have PCOS, your goals and concerns can be addressed here at CRM, in a relatively short period of time, and treatment often is successful.   References Norman RJ et al. Polycystic ovary syndrome. Lancet. 2007 Legro RS et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013 Kahsar-Miller MD et al. Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS. Fertil Steril 2001 Wed, 26 April 2017 00:00:00 The History of Society and Infertility Throughout the Decades CRM Orlando The Centers for Disease Control and Prevention estimates that nearly one in every eight couples struggles to conceive. And while those odds may not bode well for reproduction, they should, at the very least, provide a kind of safety in numbers for those dealing with infertility related issues. Or do they? If history is any indication, infertility has always been – and remains – such a societal taboo that one survey recently found that more than 60 percent of respondents said they hid their infertility from family and friends, and nearly half didn’t even tell their mothers. Enter: National Infertility Awareness Week Because behind every failed cycle are women and men who have fought tirelessly with themselves and their infertility with daily injections, drugs, hormones, countless blood tests, surgeries and other procedures. Over the centuries – since the dawn of time, really – women who couldn't have children were given many hurtful names and labels that implied that infertility was a shortcoming, a weakness – and women usually suffered for it. Egyptian society treated difficulty with conception as an illness that had to be diagnosed and treated, with recorded documents discussing the treatment of gynecologic disorders. Ancient Greece also recognized infertility as a medical problem necessitating diagnosis and treatment. And where the Byzantine and the Middle Ages made little progress, the Renaissance provided many discoveries in anatomy, marking a period of scientific progress and advancements in the treatment of infertility. But despite the progress made during these times, infertility was almost always the cross of the woman to bear. It was her womb that remained fruitless, so the onus was hers, too. The 19th and 20th centuries, however, made tremendous advances in the diagnosis and treatment of infertility. Those centuries marked the discovery of fertilization – the union of an egg and a sperm – and 35 years after British scientists created the world’s first ‘test-tube baby.” Now, women struggling with infertility are recognized as patients instead of curiosities or the condemned. Little by little – and albeit slowly – the veil of taboo is lifting, encouraging more honest discussions about infertility, its causes, its diagnoses, and its treatments. At the Center for Reproductive Medicine, we want to join your discussions about infertility. We want to help shoulder the burden of your struggles to let you focus on what really matters: having the family you’ve always wanted. Call CRM in Orlando today at (800) 343-6331 to let us help give you every conceivable chance for success. Mon, 24 April 2017 00:00:00 National Infertility Awareness Week 2017 CRM ORLANDO National Infertility Awareness Week starts April 23rd and throughout the week you will see us promoting infertility awareness through social media and at our Orlando area fertility clinics.  The goal of NIAW is to bring awareness to a disease that affects over 7 million women worldwide.  The CDC tells us that  is 15% of couples in America. NIAW is a great opportunity for anyone affected with infertility to communicate a message of hope and understanding.                        Be part of a movement that wants to remove barriers that stand in the way of building families during National Infertility Awareness Week®. Download the facts HERE. Mon, 10 April 2017 00:00:00 Dr. Patel Discusses Oocyte Donation Dr. Sejal Dharia Patel Let’s talk about oocyte donation! Oocyte donation is one of the most successful ways to start or complete a family. Over the last 10-15 years, the number of women who are using donated oocytes has increased to over 1000 thawed donor egg cycles in 2012. For whom is donor oocyte recommended? Patients may have undergone premature menopause as young as 20 or they may have failed multiple IVF cycles related to a low number of eggs or poor quality eggs. Some patient may have a low number of eggs related to surgery from having an ovary removed or multiple surgeries for endometriosis. For others it may be a result of cancer therapy or age or being born with a low number of eggs. How are women who donate their eggs chosen? These women are usually between the age of 21-30. Most women know someone struggling with infertility and often times this is a motivating factor to donate their oocytes. Donors undergo rigorous screening, from genetic screening, mental health testing, a thorough history and physical exam, endocrine testing, toxicology screening and infectious disease testing. Once they have successfully completed all testing and have been provided informed consent, they undergo in vitro fertilization. In vitro Fertilization involves injectible medications to make multiple follicles which are “the shells that house the eggs”. Once their “eggs” are mature,  they are harvested.  These eggs are either frozen via vitrification for future use by a patient or they maybe freshly donated to a patient who is already undergoing endometrial preparation to receive the eggs. What is the difference between using freshly donated oocytes as compared to vitrified oocytes? In the past, most egg donation cycles were fresh. This meant a donor and the recipient would have their menstrual cycles synchronized and over the next 6-12 weeks the donor would undergo ovarian stimulation while the endometrium for the recipient was prepared for transferred. All of the oocytes created by the donor would be given to the recipient. However, if the oocytes were immature or poor quality or the donor had a complication the recipient would have to choose a new donor and go through the process and the cost again. The cost is usually 1.5 to 2 fold higher for fresh oocyte donation vs frozen oocyte donation. With frozen oocytes, the recipient chooses 6 mature oocytes from a donor of their choice (chosen based upon pictures of the donor as a child or adolescent).  As soon as the oocytes are selected, they are shipped to the patient’s clinic and the time from the start of the cycle until the pregnancy test is approximately 6 weeks as the only menstrual cycle to be regulated is that of the recipients. Pregnancy rates are the same between both modalities. What are egg banks? At the Center for Reproductive Medicine, we are part of a national frozen egg bank called My Egg Bank. The egg bank is a national consortium of clinics who all provide services for donors to donate their eggs but also care for recipients who require donor eggs to start their families. The oocytes or eggs from each clinic are made available to all patients within the egg bank. The advantage to a national egg bank is that there is incredible diversity of donors and there are very high standards for the clinics to maintain to be a part of the egg bank.  Oocyte donation is an incredibly safe and efficient option for many patients.  Please reach out to us at the Center for Reproductive Medicine, so that we can provide guidance or information to help you on this journey to parenthood. Tue, 24 January 2017 14:00:00 Quiz: How to Best Relieve Stress CRM Orlando We all know that for ultimate fertility we should stress less – but how? Enjoy this fun & informative quiz to help uncover your unique ultimate chilling technique. Mon, 23 January 2017 00:00:00 New Insights into Endometriosis Related Infertility Dr. Randall Loy Endometriosis is a chronic inflammatory condition affecting 8-10% of women in the general population and approximately 40% of infertility patients.  This enigmatic disease is associated with pain with menstrual periods, intercourse, bowel movements, urination and ovulation as well as with chronic pelvic pain and infertility.  While it has been known for some time that the free fluid within the abdominal cavity (usually in the pelvic “cul-de-sac”) in endometriosis patients may be hostile to eggs and sperm and may play a role in infertility, new evidence suggests that a another fluid may be detrimental to egg development and diminish the likelihood for conception. In a collaborative study performed in England, it was found that egg quality may be severely compromised in endometriosis by the fluid (follicular fluid) in which it develops. Published in Scientific Reports, the study found that the ability of the egg to mature normally was blocked by endometriosis, and that follicular fluid from women with endometriosis could seriously damage egg quality. Endometriosis was found to block egg maturation via increasing oxidative stress, that is, by generating Reactive Oxygen Species (ROS) in the egg, which damaged their DNA. This damage was significant enough to prevent normal egg maturation and fertilization. This in vitro study involved taking immature mouse eggs and incubating them in follicular fluid taken from patients who had known endometriosis. The researchers examined the amounts of oxidative stress generated relative to egg maturation. In short, they found that follicular fluid from women with endometriosis resulted in higher amounts of ROS. The study further suggested that perhaps the damage done to eggs by follicular fluid in these endometriosis patients could be prevented by antioxidants. Two antioxidants were analyzed in this regard: resveratrol and melatonin. Resveratrol, (found in the skins of grapes and berries) and Melatonin, (a brain hormone released during sleep), were added to the fluid and were shown to reverse the negative effects of follicular fluid. Oxidative stress (ROS) was decreased and more eggs matured normally. These research results are encouraging; however, more investigation is necessary before any specific recommendations may be made with respect to the types and dosages of antioxidants and/or other therapies. Journal Reference: Mukhri Hamdan, Keith T. Jones, Ying Cheong, Simon I. R. Lane. The sensitivity of the DNA damage checkpoint prevents oocyte maturation in endometriosis. Scientific Reports, 2016; 6: 36994 DOI: 10.1038/srep36994 Wed, 07 December 2016 00:00:00 Maintaining a Healthy Lifestyle During the Holiday Season Dr Randall Loy The holidays are here, and you know what that means – lots and lots of delicious, irresistible foods and drinks to enjoy!  While it’s tempting, it’s important to maintain a normal, healthy lifestyle – especially if you or partner are trying to get pregnant (Guys, this goes for you too!).  Weight gain is known to cause abnormalities in hormone levels in both men and women that can have a negative effect on eggs and sperm.  Being overweight also puts the cardiovascular system in overdrive, promotes pre-diabetic and diabetic states, and increases cholesterol levels.  So how does one keep it together even through the holidays?  Just follow these tips below… Eat more often.  It’s true!  By eating smaller, more frequent meals you stay full throughout the day and boost your metabolism.   Make sure your diet includes a balance of lean proteins (white meat chicken and turkey, lean cuts of red meat, nuts, beans, etc.), low glycemic index carbohydrates, and healthy fats (nuts, avocado, olive oil).   Eat protein at every meal.  Stop the bad habits!  This means no smoking and limiting your alcohol intake.  Exercise more frequently.  Men, this goes for you as well as exercise has been proven to help sperm production.  Men should stop taking male hormone enhancing drugs which routinely decreases sperm production.  A low glycemic diet is important especially for women effected with PCOS who are prone to making high levels of insulin.  This is because high level glycemic foods allow large swings in blood sugar, which in turn allow sustained elevations in insulin.  Insulin acts as a growth factor in the ovary and releases male hormones, thus lowering chances to conceive.  The Glycemic Index (GI) ranges from 1-100, and the most ideal foods have a GI range of less than 55.  This includes foods such as vegetables, most fruits (watermelon, bananas, and grapes have a higher GI range), oatmeal, peas, carrots, skim milk, and beans.  Examples of intermediate GI foods can include pasta, corn, and ice cream.  Avoid high GI foods such as white bread, white potatoes, and sugared sodas.  While it’s certainly a challenge to go light on the delicious foods and drinks during the holidays, maintaining a healthy lifestyle can have a positive impact on fertility in both men and women.  For more information on fertility treatment options or to schedule a consultation at the Center for Reproductive Medicine in Orlando, please give us a call at (800) 343-6331. Mon, 05 December 2016 00:00:00 National Breast Cancer Awareness Month: Egg Freezing & Fertility Preservation Options Prior to Cancer Treatments CRM Orlando Did you know that breast cancer is the most commonly diagnosed cancer in women and is the second leading cause of death among women?  Or that one in eight women in the U.S. will be diagnosed with breast cancer in her lifetime?   The statistics are startling, but where there is heartache, there is hope.  When detected early (at the localized stage), the 5-year survival rate is 98%.  In fact, there are over 2.8 million breast cancer survivors alive in the U.S. today!  That is why the month of October - National Breast Cancer Awareness Month – is a great opportunity to not only educate ourselves about the disease but to also bring awareness to our friends and family and stress the vital importance of early detection.  No woman should fight breast cancer alone, and every woman should be aware of the risk factors, symptoms, and steps to early detection, as well as the available options when facing cancer treatments.   One of the main concerns for women with breast cancer, especially for women in their reproductive years, is whether or not she will be able conceive after cancer treatments.  Both chemotherapy and radiation can often damage sperm or eggs, leaving many patients infertile.  Fortunately, egg freezing and fertility preservation are options that give women hope and the ability to conceive a child even after going through harsh cancer treatments.  At The Center for Reproductive Medicine in Orlando, Celebration and Lake Mary we understand the emotional stress that women go through when faced with cancer, especially when fertility may become an issue.  That is why we have partnered with the Fertile Hope, Livestrong ™ program to provide support and assistance for patients that have opted to freeze eggs or embryos prior to cancer treatment.  For more information about this great program, please click here.  If you would like to schedule a consultation to hear more about our egg freezing or fertility preservation procedures, please contact us at (800)343-6331.  Resources: Tue, 25 October 2016 00:00:00 Fertility Preservation: Elective Egg Freezing CRM Orlando You never know where life is going to take you, or perhaps the road you’re currently traveling doesn’t include the immediate desire to start a family, at least not quite yet.  Whatever the reason, more and more women are choosing to stop the biological clock and are opting for elective fertility preservation – a process that freezes eggs in order to have children later in life. As women age, the quantity and quality of eggs decline each year – dramatically declining after the age of 35 and leaving only a 5% chance of conceiving by the age of 40.  With egg freezing, a woman can serve as her own egg donor when she is ready to conceive later in life.  Reasons you may consider Fertility Preservation: Various medical reasons, including cancer treatment *According to the American Society of Clinical Oncology in the Journal of Oncology Practice, “Oncologists should address the possibility of infertility with patients treated during their reproductive years.  Fertility preservation is often possible, but to serve the full range of options, fertility preservation approaches should be considered as early as possible during (cancer) treatment planning.” The desire to start a family later in life Delaying child bearing for personal reasons Avoiding freezing surplus embryos after an IVF cycle At CRM in Orlando, fertility preservation has never been easier with our Egg Freezing Fertility Preservation package.  The first step of the process starts with a physician consultation that includes an in-depth discussion of the patient’s needs and expectations, as well as a detailed description of the procedure.  Once the patient decides to move forward, blood tests and a pelvic ultrasound are performed to assess the number of eggs in the ovaries.  The next step is ovarian stimulation - a two-week process that involves fertility hormone injections (gonadotropins) in order to produce more mature eggs than a typical cycle.  The physician will then determine the exact time to retrieve the eggs which soon after will be frozen and stored.  When a woman decides to attempt a pregnancy, the eggs are thawed, fertilized, and transferred into the uterus.  For more information on elective fertility preservation at our fertility clinics in Central Florida, please call CRM today!  Resources:,, Thu, 14 July 2016 00:00:00 Men’s Health Month: A Closer Look at Male Infertility CRM Orlando June is Men’s Health Month and is celebrated across the country to bring awareness of preventable health problems and encourage early detection and treatment of disease among men.  This month gives us a great opportunity to spotlight a condition that affects millions of men around the world and one of the toughest challenges a man can face - male infertility.  In about 20% of infertile couples, the man is the sole cause of the inability to conceive, and in another 30%-40%, he is the contributing factor.  This is why it is crucial for men to get tested for fertility as well as women.  By discovering male fertility issues early, the better the chances of nixing the problem sooner and achieving a successful pregnancy with their partner.   Most often, male infertility can be attributed to issues with making or moving the sperm.  However, even everyday activities can cause problems.  See below… Causes for low sperm count or abnormal sperm: Varicocele – an abnormal collection of bulging veins above the testicle (Good news! This condition accounts for 38% of male infertility cases and is the most correctable issue.) Undescended testicle Infections in the testicle, the prostate, or elsewhere in the body Chemotherapy or cancer Medicines such as anabolic steroids or anti-seizure medicines Genetic abnormalities Hormone problems Causes for sperm mobility issues: Retrograde ejaculation – semen ejaculates backwards into the bladder instead of out the penis Absence of the vas deferens (the main sperm pipeline) Obstruction anywhere in between the testicles and the penis Anti-sperm antibodies that attack a man’s own sperm on their way to the egg Daily activities that can affect the viability of sperm: Drinking more than 2 drinks per day Tobacco or marijuana use Hot baths and whirlpools Stress Taking testosterone or any over-the-counter androgen like DHEA While this information can be hard to swallow for men suffering from infertility, there is good news.   Most of these conditions can be reversed, HOWEVER, it is critical to have an evaluation by a physician and a treatment plan in place to achieve a successful pregnancy with your partner.  For information on male fertility testing at our Orlando area fertility clinics or to schedule a consultation, please give us a call today! Resources:,, Thu, 16 June 2016 00:00:00 10 Tips to Boost Your Mental Health IVF ORLANDO Since 1949, the month of May has been observed as Mental Health Awareness Month and an opportunity to educate millions of people about mental health through the media, local events, and screenings.  As part of the “big picture” when dealing with fertility issues and treatments, mental health is just as important as your physical health.  So as we head into summer, check out these ten tips that can help boost your mental well-being.  Start your day with a cup of coffee.  Studies show that coffee consumption is linked to lower rates of depression, but remember to stick to just one cup. If coffee isn’t your morning drink of choice, try a cup of tea instead.  Even the non-caffeinated stuff can do the trick.  Plan a vacation.  Did you know that when you have something to look forward to, it can boost your overall happiness for up to 8 weeks?  Go ahead, and book that vacation you’ve been daydreaming about! Get creative.  Experiment with a bunch of new recipes, start a DIY project at home, paint or even just color in a coloring book.  When your creative juices are flowing, your mind is focused and you tend to be in an overall happier place.  Laugh a little.  Laughter is a great way to ease anxiety, so hang with a friend that makes you laugh, see a funny move, read a silly book, or watch funny videos online.  We all have our own quirky sense of humor, so do whatever makes you smile. Dance!  Hit your favorite dance club or simply dance around the house while you do your housework.  Dancing reduces levels of cortisol (the stress hormone) and increases endorphins (the body’s feel-good chemicals).  Take a bath.  Give yourself the gift of a relaxing, warm bath at least once a week.  Add some Epsom salt to soothe aches and pains which in turn will boost magnesium levels and help with depression.  Incorporate omega-3 fatty acids into your diet.  Among their many benefits, omega-3’s have been linked to decreased rates of depression.  Fish oil supplements work, but you can also try adding foods like wild salmon, flax seeds, or walnuts into your diet.  Practice forgiveness.  Put the road rage aside and forgive the guy who totally cut you off.  Studies show that people who forgive have better mental health and are more satisfied with their lives. Go outside for a walk.  Whether it’s a stroll through the neighborhood or a walk in the park, research shows that being outside can increase energy levels, reduce depression, and boost your well-being.  Smile!  When you’re down, the hardest thing to do is smile.  We totally get it.  But keep this in mind, smiling can help lower your heart rate, calm you down, and help you have that all important positive mindset. If you would like more information about CRM in Orlando, please give us a call for more information or to schedule a free consultation.   Resource: Tue, 31 May 2016 00:00:00 #HaveAHeart During National Infertility Awareness Week Center for Reproductive Medicine April 24 - 30 is National Infertility Awareness Week which aims to spotlight a disease that affects over 7 million women worldwide. NIAW allows for anyone affected with infertility the opportunity to communicate a message of hope and understanding. Infertility is a personal journey that that could affect anyone at any age, but is also an experience that so many share.  Check out these facts below… Infertility impacts 1 in 8 couples of reproductive ages. One third of infertility issues are considered “unexplained” infertility. One third of infertility issues are attributed to males. Women between the ages of 20-24 have an 86% chance of conceiving after trying a year. As women age, this percentage gradually falls. Between the ages of 40 – 44, the chances decrease to 36%. CRM is showing our support with our #HaveAHeart campaign. The campaign promotes infertility awareness during NIAW through social media and at our clinics. You may noticed orange represented in our offices to show support for our patient community. The campaign uses the color orange (red = love, yellow=happiness), because it has represented infertility since ancient times. For more information how to become a part of the NIAW movement, click here. If you are struggling with infertility and would like to schedule an appointment with the fertility specialists at CRM, please contact us today. Wed, 27 April 2016 00:00:00 Endometriosis: What You Need To Know CRM Orlando You’ve probably heard of endometriosis, but do you know the signs and symptoms? The reproductive specialists at the Center for Reproductive Medicine (CRM) in Orlando outline what you need to know about this condition. Endometriosis happens when part of the uterine lining, or endometrium, attach to tissues outside of the uterine cavity. These endometrial lesions build up and break down each month, causing inflammation, cysts, and severe menstrual pain. Endometriosis is commonly misdiagnosed, but it is thought to affect over six million women in the US. It is difficult to diagnose in part due to lack of symptoms in most women. While other women will suffer from severe menstrual pain, even before or after their periods. It’s also common to have pain while using the restroom or during sex. Other symptoms could include feeling tired or nauseous, being constipated, or having diarrhea.To learn more about the disease, watch the video below by CRM's Dr. Randall Loy as he discusses the symptoms and causes of Endometriosis.  The worst sufferers could become infertile due to the disease, but endometriosis can be surgically removed or destroyed with a minimally invasive procedure. This makes it extremely important to schedule a consultation with a fertility doctor at CRM immediately if you are experiencing the symptoms mentioned. If it’s found early enough, laparoscopy could treat patients fully and they could go on to achieve pregnancy without any complications. Dr. Loy shares additional information in the second part of his video series on Endometriosis. Wed, 30 March 2016 00:00:00 Dr. Frank Riggall Discusses Ovulation Induction (OI) CRM Orlando The Center for Reproductive Medicine offers a host of treatments for fertility patients. Orlando’s own Dr. Frank Riggall discusses ovulation induction (OI) in the video below. This procedure stimulates the production of mature eggs to help women conceive naturally before more invasive procedures are tested. OI is used to treat infertile patients by assessing the cause of infrequent ovulation. Then doctors can provide the appropriate medication to aid in the development of mature eggs that will then be released. Dr. Riggall explains that the ideal candidates for OI include women who do not have regular menstrual cycles, or those with PCOS or hormonal imbalance. Fri, 29 January 2016 00:00:00 Fertility Struggles During the Holiday Season CRM Orlando With the holiday’s right around the corner, the physicians at the Center for Reproductive Medicine realize that for many infertility patients, it is a stressful time attending numerous holiday gatherings that include children and being asked questions regarding growing their family.  In light of this, we would like to share a few strategies to help you handle these scenarios during this holiday season. Prior to attending parties or events, you and your partner should come up with a response in case anyone asks about your plans to start (or expand) your family. This way you won’t be caught off guard and will be prepared with a thought out response. Remember if there is a particular event that you don’t feel comfortable attending due to questions that may arise, etc., feel free to skip it altogether. It’s totally acceptable to turn down a few invitations to have some time for yourself. Give your time to others. After all, it is the season of giving! It always feels good to volunteer in your community. Choose a cause that is near and dear to your heart that will take your mind off of your routine fertility treatment plan. If it’s too emotional to see pregnant women or small children, make holiday plans with friends who do not have kids, or take a vacation with just you and your partner! For additional information on coping with the holidays, see Dr. Loy’s video: “All I Want for Christmas is a B-A-B-Y: 7 Tips for Coping with the Holidays.” Our Orlando fertility center hopes that all patients enjoy the holidays. If you are struggling with infertility, CRM would love to help you expand your family for future holiday get-togethers. Contact us today! Tue, 15 December 2015 00:00:00 Smoking and Infertility CRM Orlando Did you know smoking could cause fertility issues? The Center for Reproductive Medicine in Orlando shares important stats about smoking and infertility. Wed, 25 November 2015 00:00:00 Cancer Patients Should Consider Fertility Preservation CRM Orlando The Center for Reproductive Medicine (CRM) wants to help cancer patients achieve their dreams of expanding their families. Possible side effects of cancer therapies include infertility, which is why the physicians at CRM provide expedited consultation appointments to those affected by cancer prior to treatment. Chemotherapy, age, and dosage of radiation will have an effect on the level of impact in your fertility. There are no guarantees relating to your fertility while going through cancer treatment, so our reproductive specialists recommend considering fertility preservation before you begin therapy. There are many options for men and women available at CRM to preserve fertility. Depending on your circumstances, you may want to consider in vitro fertilization, embryo freezing, egg or semen preservation, and more! CRM is a proud member of Livestrong’s Sharing Hope Program, which works to increase access of fertility preservation services to cancer patients. Contact us to learn more about Orlando’s most comprehensive program to preserve fertility! Mon, 16 November 2015 00:00:00 What You Need To Know About PCOS CRM Orlando In honor of PCOS awareness month, the reproductive specialists at the Center for Reproductive Medicine (CRM) want to share some important facts. PCOS is a common hormonal condition. It affects about 5-10% of women. There are many possible symptoms. You may notice acne, irregular periods, excessive hair growth, and weight gain all due to an increase of male hormones in women. It is treatable. Though irreversible, doctors can put you on birth control to regulate periods; metformin so you’re less likely to become diabetic; statins to prevent high cholesterol; and/or hormones to combat infertility. Women with PCOS can live a normal life with a variety of treatments. You need to adopt a healthy lifestyle. You may be able to lower the chance of long-term health conditions by eating a well-balanced diet and regularly exercising. If you are having trouble getting pregnant and think you might have PCOS, schedule an appointment with our fertility specialists at the Center of Reproductive Medicine in Orlando today. We can help you conceive the family you’ve dreamed of! Mon, 21 September 2015 00:00:00 4 Things To Know About Egg Freezing CRM Orlando Want to preserve your fertility for when the timing is right? Advances in technology and research now make egg freezing a viable option to delay starting a family! Recently, Time researched egg freezing and uncovered the following: In 2009, 500 women elected to freeze their eggs. In 2013, this number increased to almost 5,000. It’s also been predicted that by 2018, the number of women freezing their eggs will reach 76,000. A “quick-freeze vitrification” egg freezing process improved the success rates among live births from frozen eggs. There has been an increase in egg freezing information and gatherings that allows women to learn more about the process. It is becoming increasingly popular for businesswomen to freeze their eggs. This could be due to the fact that professionals likely have other priorities and wish to start a family later in life. The infertility doctors at CRM have made the fertility preservation process easier than ever. If you’d like to learn more about freezing your eggs, contact the Center for Reproductive Medicine in Central Florida today! Mon, 31 August 2015 00:00:00 Attain IVF Flex Plans Offers Patient Discounts CRM Orlando Did you know that it may take more than one IVF cycle to achieve a pregnancy and take home a baby? At the Center for Reproductive Medicine in Orlando, we understand and offer a special discounted plan to help! Attain® IVF Flex Plans provides patients with multiple IVF cycles for a set fee. IVF cycles can be costly and cause stress, so we highly recommend an Attain program for our patients with limited to no insurance coverage. If you plan on using your own eggs, consider the Core Plan. This plan allows for two egg retrievals and the transfer of all resulting embryos until you have a baby. The next option is the Refund Plan, which offers two or three egg retrievals, and the transfer of embryos until you have a baby. If unsuccessful, this plan provides peace of mind because you will receive a refund of up to 100%. If you will be using a donor egg, CRM offers an Attain IVF Flex Plan for Donor Egg Recipients that allows patients to pre-pay a fixed rate that is also refundable if unsuccessful. Be sure to schedule your initial fertility consultation today to get started. If your doctor then recommends an IVF treatment plan, notify your financial counselor that you are interested in Attain. Mon, 17 August 2015 00:00:00 Facts about Infertility Center for Reproductive Medicine The American Society for Reproductive Medicine, ASRM, has found that at least one in seven couples have fertility problems. The reproductive specialists at CRM in Orlando, Florida share these common issues that can trigger infertility. Infertility affects about 11% of the reproductive age population – that is approximately 6.7milllion women! 25% of women with fertility issues have irregular ovulation, while 12% do not have a “normal” BMI. Those who smoke have been proven to have decreased fertility. Women who smoke are more likely to miscarry. As much as 13% of infertile women may have cigarettes to blame. Women age 25-29 are 78% likely to get pregnant after trying for one year, this percentage decreases to 36% for women age 40-44. Only 3% of infertile couples need IVF or other advanced reproductive technologies. 85-90% can be treated with medications or simpler surgical procedures. Learn more facts about infertility here. If you have been trying to conceive for over one year, have a history of miscarriage, have irregular menstrual cycles, or have any of the other risk factors listed here, contact the Center of Reproductive Medicine to schedule an initial consultation. Mon, 27 July 2015 00:00:00 Male Fertility Myths CRM Staff In honor of Male Fertility Month, the reproductive specialists at the Center for Reproductive Medicine debunk common myths about male infertility. We’re sure you’ve heard them all, so we want to set the record straight to keep you focused on the things that actually will affect your fertility. Infertility is due to the female partner. About 35-40% of infertile couples have an infertile male partner. It’s important to remember that it is no one’s fault, and most infertility issues can be treated with the help of an experienced fertility doctor. Men can conceive at any age. Studies have shown that when the male is over 40, there is a slightly higher risk of miscarriage or chromosomal abnormalities. Consider fertility preservation if you are waiting to conceive later in life. Having more sex will help you conceive. This is only true if you time it correctly. Your partner can only get pregnant when she is ovulating, so have intercourse every other day during her most fertile window. You can continue your regular routine while trying to conceive. This will depend on your “regular” routine. If you are actively trying to conceive, you should avoid hot tubs and saunas as that can drastically increase your temperature and disrupt sperm count. You should also avoid keeping laptops on your lap as well as taking long distance bicycle rides because these activities can cause overheating. Lubricants should speed up sperm. On the contrary, many lubricants on the market today can interfere with sperm motility. Consult your doctor for safer alternatives. You cannot be overweight. While being obese can affect sperm production, many men don’t realize that being underweight also affects your fertility. So try to maintain a BMI in the “normal” range. You’re not getting pregnant because you aren’t relaxed. While extreme stress can take a toll on your overall health, everyday stressors shouldn’t affect your fertility. But if you are truly infertile, even relaxing won’t help. It’s a condition that requires medical treatment. We hope that these facts help you on your conception journey. If you remain unsuccessful after one year, visit one of our infertility centers in the Orlando area. Thu, 18 June 2015 00:00:00 May is Mental Health Awareness Month CRM Staff Infertility affects both men and women mentally, physically, and emotionally.  The ups and downs of the process can lead to high levels of stress, anxiety, anger, depression, marital problems, sexual dysfunction, and social isolation.  These unfortunate side effects make the process that much more difficult, however it’s important to get the support you need so your self-esteem and outlook on life remain as positive as possible.  The month of May is Mental Health Awareness month, and there’s no better time than the present to give yourself a mental check-up or a much needed mental health break!  Your mental health plays just as significant a role as your physical health, especially while you are in the process of trying to get pregnant.  In fact more and more research is being done to link stress and infertility with implications that stress may play a role in 30% of all infertility problems! While it is virtually impossible to go through the infertility process stress-free, there are many ways to manage the stress with relaxation techniques.  Here are some of the more popular methods for fertility patients… Acupuncture Aerobic exercise (may be reduced during treatments) Journaling Listening to music Massage therapy Meditation Self-help books Progressive muscle relaxation Support/educational groups Walking/ hiking Yoga When to Seek Help and Where to Find It There may come a time when simple relaxation techniques can’t ease the emotional pain of infertility.  Learn the warning signs of depression and never be afraid to seek help when it’s needed most.   For mental health resources, click on the RESOLVE’s (the National Infertility Association) Directory of Services.  If there is not a doctor listed in your area, talk to family and friends about referrals and check with your insurance company for doctors listed in your plan. Additional Resources The articles below provide great insight on coping with stress and helpful tips for stress relief during the infertility journey.  Relaxation and Stress Management for Infertile Women Coping with the Stress of Infertility Fact Sheet Coping with Infertility: How Family and Friends Can Help At CRM in Orlando, we understand the ups and downs of the infertility treatment process and are sensitive to our patient’s needs and concerns. Wed, 20 May 2015 00:00:00 National Infertility Awareness Week CRM Staff Infertility affects millions, 7.4 million women to be more exact, and leaves many feeling isolated and alone.  That is why RESOLVE, The National Infertility Association, has chosen the simple, yet powerful message “You are not alone” as this year’s theme for National Infertility Awareness Week, set to kick off April 19th.  Their goal is to bring much needed awareness so those struggling with infertility know there is a community of support when it’s needed most.  Here’s how we can all help spread the word and increase awareness… Take it to Social Media… Post a fact about infertility or family building options in your status update. Share RESOLVE’s Infertility Etiquette page on Facebook or Twitter. If you are comfortable, share your story.   Not only will you find support from loved ones, you may also inspire others. Share information about RESOLVE’s Advocacy Day and other RESOLVE events. Start a blog about your infertility journey. Get Educated… Learn more about infertility, its causes, and the available treatments. Sign up to receive RESOLVE’s quarterly newsletter to receive important information on infertility from the field’s most noted professionals and from the personal experiences of others. Get Political… Become a Grassroots Advocate and help build state advocacy infrastructure to fight anti-family bills in all 50 states.  Talk to your employer about the advantages to offering insurance coverage that covers infertility and adding adoption benefits for employees. Local Support… Volunteer to represent and support the local infertility community.  Become a RESOLVE sponsor to promote RESOLVE’s efforts to provide support, education, advocacy, and research.  You are not alone, and at the Center for Reproductive Medicine in Orlando, we are here to help!  If you have any questions about infertility or are interested in hearing about treatment options that are right for you, please contact us. Wed, 15 April 2015 00:00:00 All I Want for Christmas is a B-A-B-Y: 7 Tips for Coping with the Holidays Dr. Randall Loy How to answer the awkward questions, "When are you going to start a family?" OR " Why aren't you pregnant yet?" OR "When are you going to make me a Grandma?" -- you know, THOSE questions! Mon, 22 December 2014 00:00:00 Donor Egg Programs: The Center for Reproductive Medicine vs. Donor Agencies Dr. Randall Loy Several weeks ago a 44-year-old new patient from the North Florida who was interested in donor egg IVF asked, “Could you explain the differences between using your Center and using an donor egg agency? Are there any advantages in using an agency?” The second question was quicker. The answer was a resounding “No! There are no advantages whatsoever in using an egg donation agency. In fact, most such agencies add approximately $10,000 to the process without any extra benefits.” The answer given to the patient’s first question is as follows: Relative to most donor egg agencies which are relatively new, non-physician owned and operated “Internet companies,” the Center for Reproductive Medicine (CRM) in Orlando has served patients in the southeastern U.S and many countries for more than 29 years and is one of the leading infertility practices in the country. With six Board-certified Reproductive Endocrinologists, scores of nursing, laboratory and administrative staff, as well as a dedicated donor egg team, our three offices are strategically located to best serve patients throughout the region. Further, CRM is one of just four partners in My Egg Bank- North America, the world’s largest and most successful egg bank. Whether patients have advanced reproductive age, decreased ovarian reserve, premature ovarian failure or genetic abnormalities, we are able to give them a high chance for success using highly qualified and rigorously-screened young healthy donors. CRM Egg Donor Program: Hundreds of egg donors 100% Money back guarantee option Immediate availability FDA screened donors Comprehensive donor profiles Donor photos available Majority college educated Majority with proven fertility Excellent success rates Egg donor coordinators providing individualized care NO DONOR AGENCY FEES At CRM we understand that you have a number of choices. However, if you want experience, expertise, high success rates combined with affordable pricing, please contact Faith Young, Chief Donor Egg Coordinator, at 407 756-1580. Wed, 17 December 2014 00:00:00 Does Lifestyle Affect the Outcome of Infertility Treatment? Dr. Randall Loy Infertility is estimated to affect up to 15% of American couples and is a diagnosis that is often not covered by third party reimbursement. It is therefore especially important to understand the available and current information that certain lifestyle habits may adversely impact fertility, including the success of IVF/ICSI treatments. This brief report is based upon an article by Kristen Rooney and Alice Domar of the Domar Center for Mind/Body Health, Boston IVF, Beth Israel Deaconess Medical Center and Harvard Medical School.[1] The authors performed an extensive review of the medical literature of this summary article and focused on six aspects of lifestyle: body mass index (BMI) – high and low, exercise, diet including supplements, caffeine, alcohol, smoking, and antidepressant medications. BMI: Obesity is a universal problem with increasing prevalence. Obesity, defined as a BMI of 30 or greater, affects 14% of women in the world, and almost 300 million women over the age of 20 are obese. It is well known that obesity is associated with hypertension, heart disease and diabetes but it is also strongly associated with infertility (68% less chance to have a birth in the first IVF cycle than women who e not obese), miscarriage, preterm birth. Underweight women, usually defined as a BMI of less than 19 also have increased fertility problems and miscarriage rates. Although most research on the impact of weight loss does not show a positive relationship between weight loss and pregnancy in IVF patients, weight loss is associated with a higher spontaneous pregnancy rate. In morbidly obese women, bariatric surgery increases egg quality and quantity relative to obese women who do not undergo surgery. Exercise: Moderate daily aerobic exercise is associated with the highest pregnancy rates, no matter what the BMI. Diet/Supplements: Vitamin D supplementation may normalize the serum anti-Muellerian hormone (AMH) levels. Vitamin D, a steroid hormone, itself, may modulate testosterone activity, thereby having a positive influence on pregnancy outcome. Caffeine: The evidence on the relationship between caffeine and fertility is inconsistent but, in general suggests that higher caffeine intake may be linked to lower egg number, fewer good embryos, lower pregnancy rates in IVF patients and increased miscarriage rates. Alcohol: Alcohol should be avoided in IVF. Alcohol usage resulted in fewer eggs, lower pregnancy rates, and more than a twofold increased risk of miscarriage. Smoking: Smoking should also be avoided and is associated with infertility, pregnancy loss, and IVF failure. In general, smokers add 10 years to their reproductive age. Antidepressants: This class of medications increases risks of miscarriage, birth defects, preterm birth, newborn behavioral syndrome as well as other physical and neurological abnormalities in the baby. The authors concluded that lifestyle habits may have a significant impact on pregnancy rates in infertile women. Although adequate research in this area is lacking, there is evidence to support the above lifestyle modifications in infertile women. However, despite patient education efforts, studies in the U.S. and Europe have indicated that infertility patients do not follow the recommended lifestyle modifications. [1] Current Opinion in Obstetrics & Gynecology: June 2014 - Volume 26 - Issue 3 - p 181-185 Thu, 20 November 2014 00:00:00 The Maternal Age Effect: The Risks of Old Eggs Dr. Randall Loy Dr. Randall A. Loy considers pregnancy in women of advanced reproductive age. Mon, 17 November 2014 00:00:00 Donor Egg IVF (Ova Easy) Dr. Randall Loy Dr. Randall A. Loy discusses donor oocyte IVF and a VERY generous donor! Wed, 05 November 2014 00:00:00 IVF : Testing the Embryos (Preimplantation Genetic Diagnosis) Dr. Randall Loy Dr. Randall A. Loy sheds light on the diagnostic testing and genetic screening of embryos. Tue, 28 October 2014 00:00:00 Moderate Alcohol Consumption is Associated with Reduced Sperm Quality Dr. Randall Loy In the first study among healthy young men with detailed information on alcohol intake, modest regular drinking of alcohol could be playing a major role in the abnormal semen analyses reported. In a study published in the British Medical Journal on October 2, 2014, Professor Tina Jensen and colleagues reported on 1221 young Danish men, aged 18-28, recruited for compulsory military service between 2008 and 2012. As part of their medical assessment, the recruits were asked about total alcohol consumption in the week prior (recent drinking), usual drinking (habitual) and binge drinking. Semen and blood samples were obtained from the group to determine semen quality (volume, sperm concentration, total sperm count and percentages of motile and normal appearing sperm) and the concentration of certain reproductive hormones. The average alcohol intake in the week prior to assessment was 11 units among the men who average age was 19 and whose favorite beverage was beer. Almost two-thirds (64%) had binged and 59% had been drunk at least twice in the thirty days prior to assessment. Semen quality decreased with increasing recent alcohol consumption as well as binge drinking.  The higher the number of units drunk, the lower was the semen quality in terms of total sperm count and the percentage of sperm of normal size and shape. This was true after accounting for other lifestyle factors. The effects were present from five plus units per week and beyond; however, the effects were most apparent among men who drank 25 or more units per week. Total sperm counts were 33% lower, and the percentage of normal sperm forms was 51% lower among those who drank 40 units per week relative to those who drank between one and five units. Moderate habitual drinking was also associated with changes in reproductive hormones. Testosterone increased and its carrier protein (sex hormone binding globulin, SHBG) decreased with increasing recent alcohol intake. The authors of this observational study conclude with “given the fact that young men in the Western world have a high alcohol intake, this is a public health concern and could be a contributing factor to the low sperm count reported among young man. It remains to be seen whether semen quality is restored if alcohol intake is reduced, but young man should be advised that high habitual alcohol intake may affect not only there general but also the reproductive health.” Thu, 23 October 2014 00:00:00 IVF : Risks vs. Benefits (Baby!) Dr. Randall Loy Dr. Randall A. Loy discusses the risks of IVF procedures and IVF pregnancies Tue, 21 October 2014 00:00:00 Factors in IVF Success and Failure Dr. Randall Loy Dr. Randall A. Loy discusses reviews the various factors that contribute to a positive or negative pregnancy test result in IVF. Fri, 17 October 2014 00:00:00 First Baby Born after Transplantation of Uterus Dr. Randall Loy The world’s first baby has been born after transplantation of a uterus. This remarkable research, carried out at Sweden’s University of Gothenburg, was reported on October 5, 2014 in the British journalLancet and was headed by Mats Brännström, M.D., Ph.D.  Until this report, eleven human uterus transplantation (UTx) attempts had been performed worldwide but none resulting in live births. This uterine transplantation research began in 1999 and involved animal studies. In rodent models, the Gothenburg team studied rejection patterns of the uterine graft, immunosuppression to avoid graft rejection as well as pregnancies and live-born offspring after UTx. Nine women in the human study have received a uterus from living donors, mostly from close family members and friends. In two cases, the UTx was removed, one for an infection and the second for blood clots in the transplanted uterine vessels. Of the remaining seven, all have had menstrual function and have been attempting pregnancies via IVF using their own embryos. This extraordinary surgery is the first available treatment for absolute uterine infertility caused by either congenital absence of the uterus or the presence of a non-functional uterus. In 2013, a 35-year-old woman with congenital absence of the uterus (Rokitansky syndrome) underwent UTx with a uterus was donated by a living, 61-year-old woman. The recipient and the donor had essentially uneventful postoperative courses. The recipient's first menstruation occurred 43 days after transplantation and she continued to have regular menstrual cycles.  In vitro fertilization treatment of the recipient and her partner had been done before UTx and 11 embryos had been cryopreserved. The recipient underwent her first single embryo transfer one year after UTx, which resulted in pregnancy. She was then given immunosuppression using three different medications which were continued throughout pregnancy. Early pregnancy was confirmed in the spring of this year and the patient delivered via caesarean section at almost 32 weeks of gestation due to preeclampsia and fetal stress. A baby boy with normal birth weight for gestational age (3lbs 15 oz) was born. “The mother and child are both doing well and have returned home. The new parents are, of course, very happy and thankful,”  Dr. Brännström stated. This report is a major step forward in UTx can be a treatment for uterine factor infertility. In addition, the study demonstrates the feasibility of live uterus donation, even from a 61 year old donor! Thu, 16 October 2014 00:00:00 The Vitrification Evolution - Revolution Dr. Randall Loy Vitrification, or the quick freezing of cells and tissue, has been available for almost two decades but its relatively recent application to human eggs and embryos has revolutionized the world of IVF. “Vitrification” from the Latin vitreumfor “glass” is the cryobiology technique that instantaneously turns a solution into a solid without ice crystal formation. Upon quick freezing, human eggs, for example, become glassy- like in appearance and can then be stored indefinitely in liquid nitrogen at -321⁰ F. Upon thawing, the survival rates are high, relative to older “slow freezing” techniques, due to the much lower risk of damage to the eggs or embryos from ice crystal formation. (A bit of science: Upon thawing, ice crystals actually expand before they contact back as a solution and this expansion can rupture cells.) Vitrification has allowed for more “freeze all” IVF cycles in which all available oocytes or embryos are cryopreserved to be replaced in a subsequent cycle. The advantages of such an approach may be as follows: - Decreased risk of ovarian hyperstimulation syndrome (OHSS) - Decreased fetal (preterm birth and small for gestational age) and placental (previa and abruption) risks of a fresh transfer - Improved endometrial (uterine) receptivity in a subsequent, more natural cycle - The possibility of more aggressive ovarian stimulation for “fertility preservation” - Decreased multiple gestation (triplets and higher) rates - Easier logistics for third party reproduction, e.g., egg donation, gestational carriers. In fact, this quick freeze technique has made oocyte banks possible. Ask your Infertility specialist if vitrification may be appropriate for your case. Thu, 09 October 2014 00:00:00 IVF: Now in Four Flavors Dr. Randall Loy Dr. Randall A. Loy discusses various forms of IVF treatments. Tue, 07 October 2014 00:00:00 Third Party Reproduction: Many Ways to Make a Baby Dr. Randall Loy In the 1975 solo hit Fifty Ways to Leave Your Lover, Paul Simon’s lyric reads “There must be fifty ways…” and the chorus begins to enumerate the ways. With respect to third party reproduction, there are at least half that many ways to make a baby. The following is an intriguing list of most of the possibilities in the novel world of assisted reproduction and involves donors, recipients, hosts, intended parent(s) and carriers:  1 - Female Recipient using her own egg and anonymous sperm donor (own uterus) 2 - Female Recipient using her own egg and known sperm donor (own uterus) 3 - Female Recipient using anonymous egg donor (AED) and partner’s sperm (own uterus) 4- Female Recipient using AED and anonymous sperm donor (own uterus) 5- Female Recipient using AED and known sperm donor (own uterus) 6- Female Recipient using known egg donor and partner’s sperm (own uterus) 7 - Female Recipient using known egg donor and anonymous sperm donor (own uterus) 8 - Female Recipient using known egg donor and known sperm donor (own uterus) 9 - Female intended parent (IP) using her own eggs and partner’s sperm with gestational carrier (GC  or host uterus) 10 - Female IP using her own eggs and anonymous sperm donor with GC (host uterus) 11- Female IP using her own eggs and known sperm donor with GC (host uterus) 12- Female IP using AED and partner’s sperm with GC (host uterus) 13- Female IP using AED and anonymous sperm donor with GC (host uterus) 14- Female IP using AED and known sperm donor with GC (host uterus) 15 - Male IP using AED and own sperm with GC (host uterus) 16 - Male IP using AED and partner’s sperm with GC (host uterus) 17 - Male IP using AED and anonymous sperm donor with GC (host uterus) 18 - Male IP using AED and known sperm donor with GC (host uterus) 19 - Female IP using known egg donor and partner’s sperm with GC (host uterus) 20 - Female IP using known egg donor and anonymous sperm donor with GC (host uterus) 21 - Female IP using known egg donor and known sperm donor with GC (host uterus) 22 - Male IP using known egg donor and partner’s sperm with CG (host uterus) 23 - Male IP using known egg donor and anonymous sperm donor with GC (host uterus) 24 - Male IP using known egg donor and known sperm donor with GC (host uterus) 25 - Female IP using own eggs and partner’s sperm with intent to use a GC (host uterus) in the future. 25a - Either Fresh or Frozen The options are dizzying and most require FDA screening and eligibility paperwork. In many of the above cases it would be advisable for the intended parent(s) to have legal representation by a healthcare attorney well-versed in adoption, surrogacy and family law. “…it's really not my habitTo intrudeFurthermore, I hope my meaningWon't be lost or misconstruedBut I'll repeat myselfAt the risk of being crudeThere must be fifty ways….”  (Special thanks to Faith Young and Cassandra Fyotek at the Center for Reproductive Medicine in Orlando, Florida for helping with this list.) Fri, 03 October 2014 00:00:00 An Overview of IVF - Thirty Years of Test Tube Babies Dr. Randall Loy Dr. Randall A. Loy reflects on the history and the steps of the IVF process. Wed, 01 October 2014 00:00:00 Online Dating - Chemistry through Genetics. Can Gene Testing Result in the Best Match? Dr. Randall Loy Is there just one perfect match on the face of the earth for each of us? Are the matching parameters of the most popular online dating services enough or is it time to go to the ultimately personal level of DNA? Could a particular gene or group of genes and their expressions determine your predisposition for relational success? If a single “perfect partner” were available in some universal genetic data base, how much would or should such a service cost? How ethical would it be to use or to withhold such genetic information if it were an accurate predictor of success in love? The questions just keep coming! These and other “slippery slope” questions are receiving more attention in recent weeks since the launch of an easy to use genetic testing service to determine compatibility.Instant Chemistry and SingldOuthave joined forces to provide genetic matches to members. Instant Chemistry provides the genetic testing component and SingldOut in an online “D(N)Ating” service that operates under the LinkedIn networking site umbrella to provide “ultimate compatability testing.” Although not the first kids on the block with a genetic test for romantic matches, Instant Chemistry may have real, although very incomplete, science behind it. The direct-to-consumer salivary testing analyzes three Human Leukocyte Antigen (HLA) genes in the Major Histocompatibility Complex (MHC) on the short arm of chromosome 6. The MHC distinguishes us from an immune point of view and is very important in organ transplantation medicine. It seems also to be important in mate selection in lower mammals, e.g., mice, where the little rodents preferentially breed with partners with different MHC genes. Research is always a matter of mice and men, however, and things are not nearly so straightforward in humans. MHC data regarding mate selection among humans are insufficient, controversial and inconsistent. If there is a link with MHC in humans, it is probably mediated by our sense of smell, in that MHC expression is related to the perception of certain compounds in body odors such as sweat.  Clearly, there may be some role of MHC genes in romantic matches but the “science” does not support commercial MHC testing for such purposes at this juncture. Perhaps more to the point, Instant Chemistry also considers the Serotonin transporter gene (SERT gene). Serotonin is a neurotransmitter that is especially associated with emotional satisfaction and the sense of well-being and the most common antidepressants function by inhibiting the serotonin transporter function. Nerve cells communicate by chemicals like serotonin which serve as messengers between one cell and another. The serotonin transporter removes serotonin from the space between nerve endings and terminates its effects. Clinical studies have shown that changes in serotonin transporter metabolism appear to be associated with many different conditions, including depression and anxiety, romantic attraction and love, obsessive-compulsive disorder and certain phobias. Variants of the Serotonin transporter gene (SERT gene) may have greater or lesser satisfaction in romantic relationships than those with the normal SERT gene. Again, the science is woefully incomplete, with few and limited human clinical trials in this area. Although, these two companies have attempted to add another and intriguing echelon of sophistication to online dating, the prevailing clinical data do not support their efforts. However, there are genetic tests of other sorts already offered clinically to determine carrier status for scores of relatively common to rare genetic diseases (autosomal recessive disorders offered by Counsyl or Good Start). Maybe these tests and more involved and expensive single gene testing for disease predispositions will make their way onto online dating web sites during the next years. Such highly specific and personalized genetic information has far reaching implications for more than just romantic matches. With respect to relationships and finding the right match, indeed, we are somewhere between the brief classified ads of the last century and a brave new world with perhaps too much information! Fri, 26 September 2014 00:00:00 Robotic Surgery: Robots in the OR?!? Dr. Randall Loy Dr. Randall A. Loy discusses the role of robotic laparoscopic surgery in infertility. Wed, 24 September 2014 00:00:00 Center for Reproductive Medicine (CRM) participates in the Making Strides Against Breast Cancer 5k Center For Reproductive Medicine Staff October is National Breast Cancer Awareness Month. Each year, the Center for Reproductive Medicine (CRM) participates in the Making Strides Against Breast Cancer 5k and walks to show their support and to help raise money to fight for a cure. This year’s walk is on Saturday, October 25th at Lake Eola Park. To find out more information about this year’s 5k, please visit: Orlando Making Strides 5k Mon, 22 September 2014 00:00:00 Hysteroscopy Surgery Without Incisions Dr. Randall Loy Dr. Randall A. Loy explores hysteroscopy -- minimally invasive, intrauterine surgery. Fri, 19 September 2014 00:00:00 Emotional Aspects of Infertility Dr. Sejal Dharia Patel Infertility can be such a stressful journey for a couple. From the initial diagnosis to a long pathway of oftentimes empiric therapy, infertility can create a significant amount of stress on a patient and her partner’s physical and emotional well being. Stress So what is stress? Stress is a challenge to our body, minds and environment when we do not have the resources to cope with this stress. For an infertile couple, this may be the stress of the diagnosis and the realization that they may not be able to conceive naturally or not having the resources available, whether emotional, physical or fiscal, to attempt conception. This may also be the stress associated with the feelings of loss after multiple miscarriages or the loss and feeling of failure after a treatment cycle when the pregnancy test is negative. Physiologically, stress may cause a release of adrenaline which increases heart rate, blood pressure, respiratory rate as well as increasing blood flow to the major muscles in our body. In an acute event this is helpful; however, chronically, this may cause a loss in the body’s ability to regulate its inflammatory response, and in turn will lead to a variety of medical diseases—including depression. Most importantly, this may further exacerbate infertility and lengthen the overall journey to conception. The best and most thorough research to date has been on the relationship between female distress and in vitro fertilization (IVF) success rates. There have been 14 published studies that have looked at distress levels in women prior, or at the beginning of, an IVF cycle. These studies have been conducted worldwide. Ten of the studies showed that distress levels are indeed associated with decreased pregnancy rates. The more anxiety or depression the women experienced before undergoing IVF, the less likely they were to get pregnant. Stages of the emotional journey Emotionally, infertility encompasses a few stages that most patients will undergo, although each patient’s experience is quite different. Initially, most couples go through a process of denial. They rationalize out why - although it has been three years, they may not have truly “tried” and do not meet the diagnosis of infertility. Or why their initial treatments did not work. They are anxious to admit there may be a problem for which clinical guidance is needed. There are also feelings of anger. Many patients are angry because they may feel vulnerable, helpless or both, often projecting that anger onto friends who offer helpful advice or friends who are pregnant. They may have anger related to their partner or family, resulting in patients distancing themselves from family or friends, or events which remind them of children or their fertility, thereby weakening the support system they truly need. Some patients will go through a stage of bargaining or looking for hope, whether this is with a provider or with a particular aspect of therapy or promises of pregnancy, and could stem from guilt or shame. Ultimately, most patients enter a stage of acceptance where they will understand and embrace their diagnosis, their treatment plan and the possible outcomes. Coping with emotional challenges of infertility Having the knowledge that both stress and the infertility journey in and of itself can be an overwhelming process, it is helpful to know there are tools in the armamentarium of every patient to help them deal with the emotional challenges of infertility. 1. Relaxation response therapy – relaxation response is a state of deep rest and will counteract the impact of stress on the body. The relaxation response can be induced through a wide variety of relaxation techniques, including progressive muscle relaxation, deep breathing, meditation and imagery. Progressive muscle relaxation involves progressively tightening and then relaxing your muscles, either from head to toe or vice versa. Deep breathing involves breathing slowly from your belly, like sighing deeply. Meditation requires focusing on a word or phrase as you breathe. Finally, imagery can mean a variety of things, ranging from imagining a pleasant safe spot to focusing on your body. 2. Mind Body Program – An integrated program focusing holistically on the patient and originally penned by Dr. Alice Domar. Mind/body techniques include both physical and psychological skills. Physical skills include relaxation techniques, “mini” relaxation techniques and information on lifestyle habits which can impact fertility. Psychological techniques include cognitive restructuring, social support, coping with negative emotions such as anger and guilt, and self-nurturance. 3. Acupuncture – Acupuncture has been shown to help fertility by reducing the effects of stress and balancing the hormones. Some purported benefits include increasing blood flow to the uterus and ovaries, increasing the uterine lining, and decreasing uterine contractility. Most, if not all, the studies of acupuncture's effects on fertility have been looking at the effects of acupuncture on IVF patients. These studies suggest there may be positive effects, although this data is not conclusive. 4. Nutritional/Exercise therapy – Diet is an important aspect of stress management. It is best to cut down on or eliminate sugar, salt, saturated fats, white flour, chemical additives, alcohol and caffeine. Caffeine is a particularly strong offender, and you may be amazed how much more peaceful you’ll feel when you give it up, or at least cut down, on colas and coffee. Other important nutritional and exercise tips include: a)      Get plenty of sleep – many people need eight hours. b)      Allow time in your life for rest and recreation. c)      Get plenty of exercise. Not only does it relieve physical tension, but if it’s aerobic exercise like running or swimming you will actually metabolize norepinephrine and serotonin, the substances your body produces when you’re under stress. You will truly get rid of stress. Consider taking a yoga, exercise, or dance class. 5. Coping techniques – These may be varied depending upon a patient’s personality. However, some examples include: a)      Getting more information about infertility, therapy, and options b)      Give yourself the opportunity to cry and be angry c)      Give your partner the chance to heal and mourn differently than you do d)     Teach your support system how you would like to be supported and, most importantly, take the time to care for yourself during this journey. Ultimately, it is important to be aware of the stress infertility and its journey can cause. It is important to refocus on you and your partner. Utilize your support system when needed and train them to support you as it helps you best. Have tools such as relaxation techniques, exercise, and acupuncture available to you. Know that parenthood awaits whether naturally, through therapy or alternative means. Wed, 17 September 2014 00:00:00 Endometriosis: A Life-Changing Disease Dr. Randall Loy Could you have endometriosis? Do you have pelvic pain or are you experiencing difficulty in achieving pregnancy? If so, do not delay in seeking medical attention and go to a specialist who is well-versed in comprehensive endometriosis management. Carefully document your symptoms (e.g., pain location, quality, timing, activities affected, things that make the pain better or worse…) and take a log of your symptoms charted during the course of a menstrual cycle. Also provide your physician a descriptive narrative of how your life is being affected by your symptoms. Endometriosis is a chronic disease state that affects approximately 10-12% of women of reproductive age throughout the world. Almost half of women with infertility have endometriosis and common symptoms include pain with menstrual periods and/or intercourse, fatigue, heavy menstrual bleeding and daily pelvic pain. Various clinical studies have shown that endometriosis is a pervasive disease and affects all aspects of women’s quality of life and especially with respect to pain and psycho-social functioning. A 2013 systematic review of 42 studies on the social and psychological impact endometriosis which was funded by the UK Economic and Social Research Council [Hum. Reprod. Update (2013)doi: 10.1093/humupd/dmt027] found delays between symptom onset and diagnosis, uncertainty about the course of the disease after diagnosis, significant impact on quality of life and activities such as employment, energy, vitality, socializing, as well as physical and sexual functioning. In addition, to increased rates of anxiety, depression and emotional distress, there was a sense of loss of control over one’s life while dealing with chronic pain. Other feelings which were common among endometriosis sufferers were worry, isolation, guilt, helplessness, hopelessness and the inability to cope. This excellent review by Lorraine Culley and colleagues also highlighted some of the limitations in the materials and methods applied in the 23 quantitative, 16 qualitative and 3 mixed studies included in the analysis. No two studies were exactly alike with respect to methodology making comparisons difficult and resulting in serious information gaps in the literature. There exists a compelling need to study both the interventions of treatment and the ongoing support techniques for affected women and their families. In a corroborative study just published from Monash University in the Journal of Family Planning and Reproductive Health Care (2014; DOI: 10.1136/jfprhc-2013-100853). Lead author, Kate Young and collaborators found that women commonly experienced delays in diagnosis and were more likely to be diagnosed sooner if reporting infertility rather than menstrual issues. Delays were both patient- and physician-related. The study noted that women were often dissatisfied, frustrated and angry with the experiences with their physicians and had concerns regarding the effectiveness and side effects of prescribed medical and surgical treatments. As with the first study cited above, authors concluded that further research is necessary to better understand endometriosis among women of diverse cultural and ethnic backgrounds. Effective treatments are available for endometriosis, so do not delay seeking help from a specialist just because a well-intentioned friend or family member, or even a medical professional told you that “pain with periods is normal” or that “pain with sex is common” or that “just relax and you’ll get pregnant.” Endometriosis is a pervasive, even life-altering disease; therefore, be proactive and take control and, if you are suspicious, find out if you have it and what the best treatment and support options are. Mon, 15 September 2014 00:00:00 Minimizing the Risk of Multiple Pregnancy Dr. Randall Loy The risks of multiple pregnancies are well known and include intense nausea and vomiting, pre-term labor and delivery with the associated risks to the babies (e.g. cerebral palsy), low birth weight, pregnancy-induced high blood pressure, gestational diabetes, increased bleeding risks and cesarean delivery. Despite greater awareness of these and other complications, as well as recent advances in the world of IVF which have improved embryo implantation rates, many patients still insist on a two or three embryo transfer. During the last number of years efforts have been made to define the appropriate number of embryos to transfer in the IVF setting to maximize the chances for a successful single pregnancy while minimizing the risks for twins, triplets and higher order pregnancies. The goal is the single embryo transfer (SET). Recently published inFertility and Sterility(2014;102:345-347) by Zabeena Pandian and colleagues was a summary of theCochrane Reviewon the number of embryos for transfer in the IVF and ICSI setting.Cochrane Reviews( are careful reviews of primary sources of clinical research and are regarded as one of the ultimate standards in evidence-based medical practice. In their review, Dr. Pandian of Aberdeen Maternity Hospital in the United Kingdom, and coauthors considered 14 randomized controlled research studies comparing the number of embryos transferred in 2,165 women. In short, there were no statistically meaningful differences in pregnancy between two SET cycles (either fresh-fresh or fresh-frozen/thawed) compared with one cycle of double embryo transfer (DET). However, as one would anticipate, the multiple pregnancy rate was significantly reduced in the repeated SET group compared with the DET group – approximately 1-3% vs. 14%. There is also no doubt that the single SET cycle is less likely to result in pregnancy than a single DET cycle, approximately 24-33% vs. 45%. The authors’ conclusion is straightforward: repeated SET may well minimize the various risks of multiple pregnancy in the IVF setting without substantially decreasing the live baby rates. The goal of IVF, now, should be to replace the single best embryo into the best uterine environment. Maybe the title should have beenReady, SET, SET, Go! Thu, 11 September 2014 00:00:00 Laparoscopy: Of Belly Buttons and Band-Aids Dr. Randall Loy Dr. Randall A. Loy considers laparoscopy -- a minimally invasive surgical procedure to diagnose and treat certain infertility conditions. Tue, 09 September 2014 00:00:00 How Exercise and Weight Impact Fertility - Size DOES Matter Dr. Randall Loy Dr. Randall A. Loy discusses the right "zones" for exercise and weight to maximize conception success. Fri, 05 September 2014 00:00:00 Fresh or Frozen: Which Embryos Should Be Transferred? Dr. Randall Loy The IVF world is approaching a great fork in the road. Since the first IVF baby was born thirty-six years ago, there have been a number of such branch points along the way, including the means of stimulating follicles, egg retrieval techniques, culture media types, to ICSI or not to ICSI, as well as optimal egg- and embryo- freezing techniques. Although most of the past three plus decades have brought progressive small, iterative changes to the assisted reproductive technologies, certain turning points are momentous and dramatically change the course of IVF throughout the world. The fork in the road just ahead is whether embryos should be transferred to the uterus in the fresh IVF cycle or in a subsequent frozen-thawed (FET) cycle. Stated differently: Should we freeze all embryos and eliminate fresh embryo transfers? The thinking behind freezing all embryos with a future FET cycle is that the embryos are returned to a “more normal” or more physiologic uterine environment. That is, the embryos are transferred into an endometrium that has not been exposed to large amounts of gonadotropins – stimulating hormones such as Follistim, Gonal-F and Menopur. The rationale has been that such an FET cycle may result in better pregnancy rates and decrease risks such as low birth weight and prematurity. Indeed, a review of a compilation of studies published in 2012 revealed that FET pregnancies, when compared to fresh-transfer pregnancies, had significantly decreased risks of preterm birth, small for gestational age fetuses, low birth weight, perinatal mortality, placental abruption and placenta previa. The risks for congenital abnormalities and some other risks did not differ significantly. (1) With respect to FET transfers, there was an increased risk for large for gestational age fetuses as well as cesarean section. In fact, various clinical reports have verified better implantation rates and pregnancy rates with FET over fresh-transfer cycles. Certainly, freezing all unavailable embryos makes sense to decrease the risks of ovarian hyperstimulation syndrome (OHSS), and to allow for preimplantation genetic diagnostic screening or diagnosis. In the context of a rising progesterone level prior to egg retrieval, freezing all embryos is also a common practice. There has been a clear and rather sharp turn toward more FET cycles during the last eight years in theU.S.and, although promising, it is too early to prescribe “freeze all” cycles for all patients even at a given IVF center. Treatment must be individualized and based upon clinical parameters as well as emerging clinical studies. (Translation: We should slow down and consult our navigation system as we approach the fork in the road!) Sources: 1. Maheshwari A, et al. Obstetric and perinatal outcomes in singleton pregnancies resulting from the transfer of frozen thawed versus fresh embryos generated through in vitro fertilization treatment: a systematic review and meta-analysis. Fertil Steril 2012;98:368-77. Wed, 03 September 2014 00:00:00 Intrauterine Insemination (IUI) Dr. Randall Loy Dr. Randall A. Loy reviews the various aspects of therapeutic insemination. Thu, 28 August 2014 00:00:00 Vitamin D Levels and IVF Success Dr. Randall Loy Vitamin D may play various roles in human reproduction and several recently published studies indicate that vitamin D levels are predictive of implantation and ongoing pregnancy rates in in vitro fertilization (IVF). Vitamin D is really not a “vitamin” but a small family of steroid hormones that increase the  absorption  of  calcium, magnesium, phosphate, iron and zinc from the intestine and which also have effects on many other organ systems. Vitamin D is either consumed, as in certain fortified foods, e.g., dairy products, or synthesized from cholesterol in the skin, when there is sufficient sun exposure. A January 2007 article in the New England Journal of Medicine revealed that the majority of American women may be Vitamin D deficient. Receptors for Vitamin D are present in the human uterus, ovary and placenta and low levels of vitamin D in pregnancy are associated with pre-eclampsia, gestational diabetes and intrauterine fetal growth retardation. When bound to its receptor, the active form of vitamin D (calcitriol) seems to be involved in estrogen production and implantation. In fact, calcitriol may regulate several genes involved in implantation. A prospective study of 173 women undergoing IVF in Toronto revealed that women with sufficient vitamin D levels (> 75 nmol/L) had significantly higher pregnancy rates in IVF than women with insufficient levels (>75 nmol/L). Women with sufficient levels had a 52.5% clinical pregnancy rate compared to a 34.7% rate among those with insufficiency. [CMJ Open, 2013 Jun 28;1(2):E77-82]. Another investigation, published inHuman Reproduction, measured vitamin D levels in 388 patients who underwent IVF/ICSI and a single embryo transfer. Clinical pregnancy rates were significantly lower in women with vitamin D levels < 20 ng/ml compared with those with higher concentrations (41 vs. 54%). When controlling for all potentially confounding factors, vitamin D was independently associated with lower clinical pregnancy rates [HumReprod, 2014 Sep;29(9):2032-40]. In a newly published study from Milan, researchers found that women who had sufficient that levels of vitamin D (>20ng/ml) were significantly more likely to produce higher quality embryos and were more like to achieve a clinical pregnancy than women who were vitamin D deficient (<20ng/ml). This prospective study examined 154 women who were vitamin D deficient and 181 women who had sufficient vitamin D blood levels. The clinical pregnancy rates were 20% and 31%, respectively. Interestingly, a subgroup analysis showed that the group of women with the highest levels (>30ng/ml) had the highest chances of pregnancy (J Clin Endocrinol Metab2014 Aug 14:jc2014 1802). It does appear, then, based upon these and a number of studies between 2005-2010 that Vitamin D plays a key role in human reproduction, maybe involving embryo quality as well as at the uterine lining, where it may facilitate implantation of the embryo. Vitamin D is readily available, inexpensive and has few, if any side effects and may improve one’s fertility potential. However, there are no adequate clinical studies on vitamin D supplementation and IVF outcome. Tue, 26 August 2014 00:00:00 The Conception Diet Dr. Randall Loy Dr. Randall A. Loy discusses the foods to eat to increase your chances of having a baby. Wed, 20 August 2014 00:00:00 Binding “Mr. Right”: How Sperm Get into the Egg Dr. Randall Loy How do swimming sperm cells and ovulated egg cells recognize each other and bind together? Despite substantial research, this question has been somewhat of a mystery for the past thirty plus years. The answer,  just in, may be a certain protein in the egg shell or zona pellucida.  The zona pellucida (Latin, “clear zone”) is the outer egg layer that surrounds and protects the egg as well as the embryo until it hatches out as a blastocyst (day 5-6 embryo). This soft, glassy layer binds sperm, allows one to enter and then blocks out all others. It appears that sperm bind to specific sugars associated with a particular zonal protein. In the human there are four zonal binding proteins, known as ZP1, ZP2, ZP3 and ZP4. Sperm-egg binding abnormalities are especially seen among infertility patients and are thought to be a reason for unexplained infertility as well as failed ovulation induction and intrauterine insemination (IUI) cycles. In fact, approximately 8-10% of couples who have had three failed IUI cycles may have gamete binding abnormalities, especially if the semen count and/or percentage of normal forms are abnormal. Intracytoplasmic sperm injection (ICSI) has largely overcome this problem of binding abnormalities and should be a consideration in patients with unexplained infertility and multiple failed IUI cycles. A recent study inThe Journal of Cell Biology(June 2014 DOI:10:1083/jcb.20140025) recently identified the protein in the zonal pellucida that sperm recognize and bind: ZP2. In this investigation, sperm did not bind the zona pellucida if it was missing ZP2. The researchers from the National Institute of Diabetes and Digestion and Kidney Diseases also found that sperm could not bind eggs if ZP2 was missing a critical region near the beginning of the protein. The entry one sperm through the zona causes the release of an enzyme that severs ZP2 in that critical region, thus preventing other sperm from entering. In the IVF setting we sometimes see a failure of this mechanism, especially in pre-mature or post-mature egg cells, and two or more sperm gain access to the egg nucleus. The answer, then, to “How does one bind ‘Mr. Right?’” is ZP2! Mon, 18 August 2014 00:00:00 The Hysterosalpingogram (HSG) Dr. Randall Loy Dr. Randall A. Loy discusses the hysterosalpingogram and what not to do when the lights go out! Fri, 15 August 2014 00:00:00 Career Now, Baby Later - Freezing Your Eggs Dr. Randall Loy There comes a time in a woman's lifetime -- most commonly in her mid 30s – when the biological clock alarm begins ringing and ringing loudly. The average age of our patients at the Center for Reproductive Medicine is 34 years, which means, of course, that many patients are in their mid to late 40s. Oftentimes these patients have been pursuing education and careers and have not been on the “mommy track.” Then, whether secondary to their own clock or curious friends and family, the question arises: “If you’re going to have a baby then when?” This singular question can produce considerable internal and external stress and sometimes panic. Now there may be the solution: fertility preservation via egg freezing. Fortunately or unfortunately, men do not have the same biological clock or reproductive constraints. Although there are definitely changes in the fertility potential and sperm genetics in the older male, in the female, there is a precipitous decline of egg quantity and quality after age 37 and by age 42, there may be fewer than 1000 eggs left (of the 1 million endowment at birth). Of these remaining eggs perhaps 90% are genetically abnormal. For this reason, more and more of our patients are electing to preserve their fertility via freezing eggs. The average age of the patient who electively freezes her eggs is 37 and down from age 39+ just several years ago. Typically she has a great job and ample money and may or may not have found “Mr. Right” yet. Many patients feel that by freezing their eggs they have stopped the biological clock and can then enjoy their careers and/or do their due diligence in finding the right partner. The whole notion of being able to “freeze time” is actually liberating and may be the biggest single advance in reproductive medicine since the introduction of the birth control pill. Although egg freezing has been available for approximately 30 years, it has not been successful until recent times with the advent of vitrification, a flash freezing technique that produces a glass-like appearance of the egg. Formerly, the so-called "slow freeze" method produced ice crystal formation in the egg that frequently produced rupturing of the egg cell upon thawing. With vitrification, the freeze-thaw viability rate is greater than 90% in the best labs. What if a woman has already missed the window of opportunity to freeze her eggs and to preserve her fertility, e.g. >42 years of age? Then she may wish to use frozen eggs from an anonymous, young donor. The Center for Reproductive Medicine has great expertise in fertility preservation as well as Donor Egg IVF and is a partner in My Egg Bank, the world largest and most successful egg Bank. Egg freezing, whether for preservation of fertility or with the usage of a donor, provides a brand-new way of approaching life and a way to enjoy one’s career today with the option of babies tomorrow. Wed, 13 August 2014 00:00:00 Laboratory Testing: The Usual Suspects Dr. Randall Loy Dr. Randall A. Loy of the Center for Reproductive Medicine reviews the most common laboratory tests in reproductive medicine and the difference between a "Pheromonologist" and an Endocrinologist. Thu, 07 August 2014 00:00:00 Could Exposure to Plastics Today Affect Your Great Grandchildren? Dr. Randall Loy If you are having a difficult time becoming pregnant, some very common household plastics may be playing a role. Three plastics (phthalates) were found to increase time to pregnancy by 20% in couples in which the male partners had high urinary concentrations of monomethyl phthalate, monobenzyl phthalate and monobutyl phthalate. This study, from the National Institutes of Health (NIH) and other institutions, included 501 couples who were recruited to participate in the Longitudinal Investigation of Fertility and the Environment (LIFE) study. Published in Fertility and Sterility in February 2014, the authors looked at levels of Bisphenol A (BPA) and 14 different plastic-related compounds as well as the time it took for couples to achieve a conception. “Our study shows that exposure to certain phthalates can reduce the chance of conception for otherwise healthy couples,” said the study’s first author, Germaine M. Buck Louis, PhD of the National Institute of Child Health and Human Development. Phthalates are actually “plasticizers,” substances added to plastics to increase their flexibility, transparency and durability. Phthalates are everywhere: adhesives and glues, electronics, building materials, personal hygiene products, medical devices, detergents, packaging, children's toys, waxes, paints, printing inks, medications, food products, and textiles. BPA is a chemical used to make certain plastics such as the ubiquitous polycarbonate plastic. Clear and nearly shatter-proof, polycarbonate is found in baby bottles and water bottles, sports equipment, medical and dental devices, dental fillings and sealants, CDs and DVDs, eyeglass lenses and household electronics. Phthalates have hormonal actions and are known as “endocrine disruptors.” Plastics can counter androgens (“male” hormones such as testosterone) and levels of phthalates in infertile men are related to low androgen levels, low sperm counts, abnormal sperm forms and increased sperm DNA damage. It could be that phthalate levels in men adversely affect reproductive success by epigenetic effects (markers that turn genes on and off but do not affect DNA). If DNA is the hardware, epigenetic factors are the software that tell genes what to do and when.  A new study underway at the University of Massachusetts Amherst led by environmental health researcher Richard Pilsner seeks to understand if epigenetic modifications may be secondary to exposure to plastics. Epigenetic factors can be inherited on top of genetic (DNA) inheritance and are shaped by environmental exposure such as smoking, air pollution and toxins. Such environmentally-induced epigenetic modifications could be manifested for generations to come so it may be possible that those plastic water bottles today could affect one’s great grandchildren someday. Tue, 05 August 2014 00:00:00 Semen Analysis - Boyz Under the Hood Dr. Randall Loy Dr. Randall A. Loy considers the first test in the infertility diagnostic evaluation: the Semen Analysis (as well as ways not to provide a specimen!). Wed, 30 July 2014 00:00:00 What to Expect at the First Visit with an Infertility Specialist Dr. Randall Loy Dr. Randall A. Loy of the Center for Reproductive Medicine in Orlando, Florida discusses the first appointment with an Infertility Specialist (and one life-threatening question!) Tue, 22 July 2014 00:00:00 CDC Releases National Action Plan for Infertility Dr. Randall Loy Just this week, the Centers for Disease Control and Prevention (CDC) released the final version of its National Public Health Action Plan for the Detection, Prevention and Management of Infertility. It is a primer on infertility definitions and statistics as well as a white paper on "where do we go from here?" with respect to infertility.The National Action Plan, seven years in the making, identifies opportunities for reducing infertility in the United States. The CDC and non-governmental organizations, including the American Society of Reproductive Medicine (ASRM) worked together to draft the document. Written from a public health perspective, the goals of this effort are to better prevent, detect and manage diseases that lead to infertility.Ultimately, the National Action Plan is a call to action for Federal, state, and local agencies; associated scientists; health care professionals; insurance providers; employers; industry; nonprofit organizations; and organizations representing people with infertility.To learn more about infertility prevention, treatment and support, the National Action Plan is available at Fri, 18 July 2014 00:00:00 What is a Reproductive Endocrinologist? The Tale of Two Brothers Dr. Randall Loy Dr. Randall A. Loy of the Center for Reproductive Medicine in Orlando, Florida explores how an infertility specialist differs from an OB/GYN and how to choose the right doctor. Thu, 17 July 2014 00:00:00 Fertility Drugs Not Tied to Long Term Breast, Ovarian, and Uterine Cancer Risks Dr. Randall Loy The results of a large and 30 year-long follow up study presented on June 30, 2014 at the Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE) suggested that there is "little evidence" that the use of fertility medications used for stimulation of the ovaries increases the long-term risk of breast or other gynecological cancers. However, the prolonged usage of clomiphene citrate was associated with an increased risk of breast cancer in women who had used clomiphene for twelve or more cycles.Dr. Louise Brinton of the US National Cancer Institute was the principal investigator of this study involving 12,193 women who were treated for infertility between 1965 and 1988 at five sites in the United States. Follow up lasted until 2010, with evaluation based upon an extensive questionnaire and records from US death and cancer registries. A total of 9,892 women were followed for their cancer outcomes. Most previous studies which had suggested a possible link between fertility drugs and breast, ovarian and uterine cancers were small studies with shorter follow up periods and without adequate controls. Because of the size and long-term nature of this particular study, it has greater statistical power than previous such studies.Only 10% of this study population had been treated with gonadotropins [human menopausal gonadotropin (hMG) and/or purified follicle stimulating hormone (pFSH)] and most of these were in combination with clomiphene citrate. In the hMG and pFSH group there is no association with cancer risk except in those women who never conceived. In short, the Brinton study does not support a strong relationship between the usage of fertility drugs (mainly clomiphene citrate) and breast or gynecological cancers. Although this study is reassuring, further studies, mainly involving the usage of gonadotropins and especially in the IVF setting are certainly warranted. Tue, 15 July 2014 00:00:00 Coping with Infertility on Mother's Day Center For Reproductive Medicine Staff With Mother's Day 2014 nearly upon us, the fertility specialists at Center for Reproductive Medicine in Orlando want to remind you that this is a time to celebrate and hope for the new life yet to come, and not a time for despair.  Faced with a day that is particularly difficult to navigate on an emotional level, it is not always easy and is, in fact, hard for many who are coping with infertility to maintain a positive outlook.  We recognize this and it is our job as fertility specialists, not only to help you find a successful fertility treatment plan, but also to ensure you have the right tools to help you cope with the emotional stresses that accompany infertility. To help keep a positive outlook on your Mother's Day, we've put together a few tips and resources that we hope, will enable you to emerge Monday morning refreshed and smiling. Focus on Celebrating the People Who Have 'Mothered' You Over the Years Over the years, from the time you were a child through adolescence and on into your 20's and 30's, your mother, grandmother, aunts, and the other moms who held you accountable when your mom wasn't around to see, have all shaped you and contributed to the mom you will one day be.  Celebrate those who have prepared you for motherhood. Plan Ahead, Do Something Fun with Your Spouse Some of the best medicine is knowing you can lean on each other for support.  There are so many options for planning a fun day to celebrate each other, like hiking, taking a walk on the beach, packing a picnic lunch, or visiting a museum - most importantly, be generous with your time for each other. Join a Support Group There are many local and online groups that will create a supportive community to help see you through the day.  Support groups can meet your needs on many different levels, from knowing what comes next in treatment to knowing you're not alone. Know You Can Talk to Someone and Get Support The National Infertility Association has set up a RESOLVE HelpLine so that when you feel overwhelmed and alone, you know there is someone you can talk to. As you consider or continue fertility treatment options, we urge you to check out the RESOLVE website at or one of our previous blog posts Dealing with Infertility and Holiday Stress for additional tips and further reading on how to approach Mother's Day this year.  An infinite store of optimism awaits you! Fri, 09 May 2014 00:00:00 How to Deal with Unexplained Infertility Dr. Sejal Dharia Patel A negative pregnancy test again. My aunt went into the bathroom and cried for six hours. After every IVF cycle, we all grieved her loss of implantation; we grieved over her social isolation, and her depressed spirit. There was no happiness, only hopefulness after the transfer until the first spot of blood or the negative pregnancy test and then back to the bathroom for more tears.Infertility is depleting. It represents many losses, such as, the loss of fertility and reproductive ability, the loss of an embryo, the loss of a pregnancy with miscarriage, and/or the loss of a child and biological offspring with a stillborn or neonatal death. Thus, grief is a normal reaction. However, when the loss is of a potential, not an actual loss, the couple may not realize they are allowed to grieve. However, without the ability to grieve the impact on the patient and her partner can be grave: from social isolation, marital discord and ultimately depression.Infertility and miscarriages evoke emotional losses that are overwhelming to patients but may be classified into four main phases: the initial phase (shock, surprise, denial); the reactive phase (frustration, anger, anxiety, guilt, grief, depression, isolation); the adaptive phase (acceptance) and a resolution phase (planning for future solutions).As a patient undergoes the four main phases, influences of the event itself, the patient's personality, cultural factors and social support from close family and friends can all influence their grieving process and their ability to cope.Coping mechanisms will vary from patient to patient, however a few tips to keep in mind that will help as your transition through your four phases include1) Do not blame yourself-Negative thinking patterns can only make matters worse. Remember that infertility is not your fault. Concentrate on your future.2) Work as a team with your partner-Do not blame one another for the difficulty encountered3) Educate yourself-This will eliminate the unknown and the associated speculation.4) Set limits on how long you are willing to try and decide on what you are willing to pay. This will help you and your provider create a customized plan for you that help you reach your goals.5) Get support from professionals and others with infertility problems to help you through your infertility journey. Programs such as the Mind-Body Program through Alice Domar, PhD have been shown to improve outcomes.6) Feel comfortable avoiding activities which are focused on pregnancy or births (i.e. baby showers)7) Balance optimism and realism-Realize that infertility is a journey. For most there is success, however, for some there is not and one should be prepared.8) Take care of yourself by pursuing other interests.As you look to the community to help and support you, look for psychologists who have experience in infertility counseling. Take the time to look for support groups where you can relay your experiences, learn from others and create a support structure with those who understand. Finally look to books to help.One resource is Alice Domar's book on Conquering Infertility, which provides some guidance on what they need most from stress relief, support and hope. Another great resource is "I never held you: Miscarriage, Grief, Healing and Recovery by Ellen Dubois and Dr. Linda Backman.For my aunt, in her last IVF cycle, she conceived and nine months later, a beautiful baby girl. However, the crying, the guilt and the anger my aunt and I never forgot. Mon, 04 March 2013 00:00:00 Dealing with Infertility and Holiday Stress Dr. Randall Loy The holidays are all about family gatherings, religious observances, shopping, parties, entertaining, familiar traditions and high expectations but the "hopes and fears of all the years" inevitably bring stress. The other family members with babies and friends with their children and the not infrequent, painful question "When are you two going to have a baby?" are separate and additive stressors. Many infertile couples feel marginalized or incomplete and suffer in silence. Signs of this stress may include feeling anxious, worried, irritable, and, possibly, sad or depressed. Some might experience eating or sleep disturbances, or other physical complaints such as headache, fatigue, muscle tension and abdominal pain and there may be the urge to self-medicate with excess alcohol or drugs.Seven Tips for Couples Coping with Infertility During the Holidays:1. Dignify your feelings. It is normal to feel sadness or grief. You should express your feelings to loved ones and it is OK to cry. Opening up to others and telling your story is good for the heart. Let your family and friends know what you need from them.2. Simplify. Do not be concerned with others' expectations of you. You do not have to attend every holiday function to which you are invited, especially if there will be pregnant women or children present. Invest your time wisely.3. Maintain Boundaries. You do not have to disclose the details of your infertility journey to anyone who asks. Have a standard answer prepared for the sincere, inevitable question about your beginning a family. If you feel uncomfortable with further infertility questioning, change the subject of the discussion or excuse yourself to get more food or beverage. Decide how you will respond to the children and babies at the parties and family gatherings you will attend.4. Remember the Reasons for the Season. Recall what the holidays have meant to you and what you are celebrating. Think of less fortunate others and how can you can focus on them and their stories, their pain, their problems. Helping others will help you. Consider what you have enjoyed in past holidays and invest your energies in those activities. Participate in those rituals that have the most meaning to you and your family.5. Make New Friends: Socialize with friends who do not have children. If being around the children among your family and friends is too difficult you may want to take a year off from the usual traditions and take a holiday vacation. Consider a ski trip or cruise with other couples from your support group, or a mission trip with your church or synagogue.6. Take A Breather. While spending time with people who really care about you, take some time for yourself. Take at least undisturbed 15-30 minutes per day alone to refresh. Find something that reduces your stress (meditation, prayer, exercise, soothing music, a pet, deep breathing) by clearing your mind. Attend religious services and community gatherings (concerts, plays, tree-lighting ceremonies). If stress becomes overwhelming, get professional help. Speak to your physician, mental health counselor, minister, priest or rabbi.7. Develop a Plan for the New Year. All of the festivities will soon be over and January 2, 2013 will be here. Decide that you will avoid the post- holiday let down by daily aerobic exercise and a healthy lifestyle. Make some clear decisions regarding your fertility care for the new year and consult with your doctor to discuss your action plan.One final word about the holidays. There may, in fact, be well-meaning family and friends who will breach etiquette and who will give infertility advice, e.g., "Just relax!" or "You need to take these fertility supplements I heard about" or "I've been 'researching' infertility on the internet, have you tried taking _____?" Politely tell them that you are already seeing an infertility specialist and that they will be among the first to know when they can buy you some baby booties! Thu, 15 November 2012 00:00:00