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Exercise, Weight and Fertility:
Couples
with infertility often wonder
if lifestyle habits might compromise
their fertility. Two important
lifestyle factors, weight and
exercise, can affect fertility.
Low
weight or weight loss can lead
to a decrease in an important
hormonal "message"
that the brain sends to the
ovaries in women and testes
in men. This hormone, gonadotropin
releasing hormone (GnRH), is
produced in the part of the
brain called the hypothalamus.
The release of GNRH leads to
the release of the hormonal
messengers LH and FSH (the gonadotropins)
by the pituitary gland. LH and
FSH are critical for the development
of eggs in the ovaries and sperm
in the testes. The degree to
which weight loss affects fertility
will vary. In mild cases, the
ovaries may still -produce and
release eggs, but the lining
of the uterus may not be ready
to receive a fertilized egg
because of inadequate ovarian
hormone production. In more
severe cases, ovulation does
not occur, and menstrual cycles
are irregular or absent. In
men, low weight or weight loss
may lead to decreased sperm
function or sperm count. If
low weight or weight loss has
been identified as the cause
of one's infertility, the preferred
treatment would be to stop losing
weight or even to gain weight
if needed. An alternative treatment
is the use of medications.
Being
overweight or obese can affect
the hormonal signals to the
ovaries or testes. Increased
weight can also increase insulin
levels in women, which may cause
the ovaries to overproduce male
hormones and stop releasing
eggs. Weight loss is the best
plan of action, but drugs such
as clomiphene citrate or gonadotropins
can be used in overweight patients.
Proper
exercise and diet are important
for maintaining good health
and proper weight. Extreme exercise
can, however, lead to reduced
sperm production in men and
the cessation of ovulation in
women by decreasing the brain
message to the ovaries and testes.
Egg
Donation-Reversing the biological
clock
Egg quality has remained one
of the major determinants of
successful IVF. Egg quality
diminishes over age 35 and
significantly declines over the
age of 39, yielding a low chance
of successful pregnancy in an
otherwise healthy woman capable
of carrying a pregnancy. Egg
donation allows a couple to
experience a significant
increase in their rate of
pregnancy with ability to
experience a pregnancy and
delivery. In egg donation IVF,
the donor of eggs may be
anonymous or she may be a
sister, close friend, or
relative or the infertile woman.
HISTORY
OF EGG DONATION
Donor
egg IVF was initially developed
to treat women with premature
ovarian failure, women who didn't
have any eggs and couldn't become
pregnant. The applications of
this new technology have greatly
expanded. Donor egg IVF is now
used for women who are carriers
of genetic diseases, women who
have had multiple failed cycles
of IVF, women with impaired
ovarian function, or for older
healthy women. This treatment
also heightens the chance of
pregnancy for women whose attempts
at IVF have revealed a poor
response to fertility medications,
or eggs that did not fertilize
well or form viable embryos.
More on egg donation
Side
Effects of Gonadotropins
There
are many types of gonadotropins
used alone or in combination
for ovulation induction. They
include hMG (human menopausal
gonadotropin Humegon®),
FSH (follicle stimulating hormone
Gonal-F®) and hCG (human
chorionic gonadotropin, Profasi®
with the use of these drugs,
careful monitoring is required
to minimize the side effects,
discussed below.
1.
Ovarian Hyperstimulation (OHSS)
Occurring in 1 to 5 percent
of patients the chance of OHSS
is increased in women with polycystic
ovarian syndrome and in conception
cycles. When severe, it can
result in blood clots, kidney
damage, ovarian twisting (torsion),
and chest and abdominal fluid
collections. In severe cases,
hospitalization is required
for monitoring, but the condition
is transient, lasting only a
week or so. Occasionally, drawing
fluid out of the chest or abdominal
final cavity helps. The best
prevention is to not give hCG
to induce ovulation at the end
of an overly vigorous stimulation
cycle.
2.
Multiple Gestations
Up to 20 percent of pregnancies
resulting from gonadotropins
are multiple, in contrast to
a rate of 1 to 2 percent in
the general population. Although
most of these pregnancies are
twins, a significant percentage
are triplets or higher. High-order
multiple gestation pregnancy
is associated with increased
risk of pregnancy loss, premature
delivery, infant abnormalities,
handicap due to the consequences
of very premature delivery,
pregnancy induced hypertension,
hemorrhage, and other significant
maternal complications.
3.
Ectopic (Tubal) Pregnancies
While ectopic pregnancies occur
1 to 2 percent of the time,
in gonadotropin cycles the rate
is slightly increased at 1 to
3 percent. These can be treaded
with medicine or surgery. Combined
tubal and intrauterine pregnancies
(heterotopic pregnancies) occasionally
occur with gonadotropins and
need to be treated with surgery.
4.
Birth Defects
The rate of birth defects after
gonadotropin cycles is not higher
than in the general population,
at 2 to 3 percent. Furthermore,
these children are developmentally
no different than their peers.
5.
Adnexal Torsion (Ovarian Twisting)
Less than 1 percent of the time,
the stimulated ovary can twist
on itself cutting off its own
blood supply. Surgery is required
to untwist or even remove the
ovary.
6.
Gonadotropins and Ovarian Cancer
The risk of ovarian cancer seems
in part related to the number
of times a woman ovulates. Infertility
increases this risk; birth control
pill use decreases it. Controversial
data exists that associates
ovulation stimulation drugs
like gonadotropins with the
risk of future ovarian cancer.
While research is underway to
help clarify this issue, the
careful use of gonadotropins
is still reasonable, especially
considering that pregnancy and
breast feeding reduce cancer
risk.
Intracycloplasmic
Sperm Injection (ICSI)
Intracytoplasmic
sperm injection (ICSI) is a
laboratory procedure developed
to help infertile couples undergoing
in vitro fertilization (IVF)
due to severe male factor infertility.
ICSI involves, the insertion
of a single sperm directly into
the cytoplasm of a mature egg
(oocyte) using a microinjection
pipette (glass needle). ICSI
has largely replaced the two
previously developed micromanipulation
techniques because it achieves
higher overall fertilization
rates.
A
variety of sperm problems can
account for male infertility.
Sperm can be completely absent
in the ejaculate (azoospemia)
or present in low concentrations
(oligozoospermia). They may
have poor motility (asthenospermia)
or an increased percentage of
abnormal shapes and forms (teratospermia).
There may also be abnormalities
in the series of steps required
for fertilization, such as sperm
binding to and penetrating the
egg. Deficiencies in any of
these aspects of sperm function
will generally lead to lack
of fertilization.
ICSI
can facilitate fertilization
by sperm that will not bind
to or penetrate an egg. It can
also be used to treat men with
extremely low numbers of sperm.
However, ICSI is generally unsuccessful
when used to treat fertilization
failures that are primarily
due to poor egg quality.
INDICATIONS
FOR INTRACYTOPLASMIC SPERM INJECTION
-
Very
low numbers of motile sperm
with normal appearance.
-
Problems
with sperm binding to and
penetrating the egg.
-
Antisperm
antibodies (immune or protective
proteins which attach and
destroy sperm) of sufficient
quality to prevent fertilization.
-
Prior
or repeated fertilization
failure with standard IVF
culture and fertilization
methods.
-
Frozen
sperm collected prior to cancer
treatment that may be limited
in number and quality.
-
Absence
of sperm secondary to blockage
or abnormality of the ejaculatory
ducts that allow sperm to
move from the testes. In this
situation, sperm are obtained
from the epididymis by a procedure
called microsurgical epididymal
sperm aspiration (MESA) or
from the testes by testicular
sperm aspiration (TESA).
ICSI is not a perfect technique.
Some eggs will be damaged
by the ICSI process. Some
eggs have plasma membranes
that are difficult to pierce.
In other instances, the fertilized
egg may fail to divide, or
the embryo may arrest at an
early stage of development.
Egg fertilization rates of
50 percent and cleavage rates
of 80 percent or more are
expected, but only 15 to 20
percent of egg retrievals
produce a baby in well-selected
couples.
Multiple
Gestation and Pregnancy Reduction
Multiple
gestation refers to a pregnancy
in which two or more fetuses
are present in the womb. In
the general population, this
occurs in approximately 1 to
2 percent of pregnancies. However,
with the use of fertility drugs
such as clomiphene citrate or
gonadotropins and high-tech,
procedures such as in vitro
fertilization (IVF), multiple
gestations are much more common.
The vast majority of these pregnancies
are twins, but triplets, quadruplets,
and higher numbers can occur.
Fetal
risks of multiple gestation
include an increased chance
of miscarriage, birth defects,
premature birth and the mental
and/or physical problems that
can result from a premature
delivery. The average length
of pregnancy is 39 weeks for
a single gestation; 35 weeks
for twins; 33 weeks for triplets;
and 29 weeks for quadruplets.
Recurrent
Pregnancy Loss
Pregnancy
loss, more commonly referred
to as "miscarriage",
is the most common complication
of pregnancy. Approximately
10-15% of all first-time pregnancies
result in miscarriage. In most
instances, you can expect a
similar miscarriage rate in
subsequent pregnancies. Recurrent
pregnancy loss is commonly defined
as 3 or more miscarriages. Approximately
5% of couples attempting pregnancy
have recurrent pregnancy loss.
Diagnosis
The
most important part of treating
couples with recurrent pregnancy
loss is determining the cause
or diagnosis. Causes of recurrent
miscarriage include chromosomal
defects, uterine defects, hormone
deficiencies, and immunological
factors. At Rotunda, we conduct
a thorough evaluation of each
couple to determine the cause
of miscarriage. After diagnosis
has determined a cause, the
correct treatment plan can be
discussed and decided upon.
Chromosomal
Abnormalities
Chromosomal
abnormalities can be caused
by abnormalities that exist
in the genetic structure of
one or both parents. These abnormalities
are not life threatening to
the parents, but when passed
to the embryo, they can cause
miscarriage. Chromosomal analysis
of both partners can be done
to determine if abnormalities
exist by actually looking at
the chromosomes of blood cells
from both partners. Other abnormalities
can result during conception
and will only exist in the growing
embryo. If miscarriage occurs,
the cells from the embryo can
be tested to determine the existence
of abnormalities.
Uterine
Defects
Defects
of the uterus can be caused
by several factors. Some women
are born with defects in the
structure of the uterus caused
by genetics or exposure in utero
to certain chemicals. The most
well known defect caused by
a chemical is that of DES. DES
is an estrogen like compound
used from the 40's through the
70's to treat complications
of pregnancy. Children born
with this treatment experienced
fetal anomalies, including defects
in the uterus.
Other
defects can be caused by polyps
(small growths in the uterine
lining) or fibroids, which can
cause problems with implantation
of the embryo or retard the
growth of the fetus, eventually
leading to miscarriage.
Uterine
defects can be diagnosed using
hysterosalpingography, a procedure
in which dye is injected into
the uterus and then photographed
using an X-ray (see Testing
and Diagnosis). Treatment may
include surgery to go in and
reshape the uterus or remove
polyps or fibroids.
Hormone
Deficiencies
This
is an uncommon deficiency associated
with very early abortion. The
cause is an inadequate corpus
luteum (yellow body)
functioning on the ovary at the
place of ovulation (the old
follicle), which is the gland
that produces progesterone
during early pregnancy.
Progesterone is the hormone that
is necessary to maintain the
pregnancy. If this hormone is
not present in sufficient
quantities, the pregnancy will
abort, sometimes even before it
is detected.
Women
experiencing a luteal phase
defect often have this problem.
Luteal phase defects are also
caused by a lack of progesterone
produced by the corpus luteum
during the cycle. Luteal phase
defects can be detected by endometrial
biopsies and serum progesterone
levels during the luteal phase.
This
type of hormone deficiency can
be treated with supplemental
progesterone given during the
luteal phase or the first trimester
of pregnancy when an inadequate
corpus luteum is suspected.
Supplemental progesterone is
also given during superovulation
cycles such as IVF or GIFT to
counteract the increased levels
of estrogen produced by multiple
follicles. Progesterone supplementation
is often maintained through
the first trimester of these
pregnancies to ensure adequate
levels.
We
have also seen situations where
endometrial thickness is poor,
although the composition is
normal. Optimal endometrial
thickness is 8-13mm at the time
of the LH surge. We have come
to suspect that certain patients
may be deficient in estrogen
or response to estrogen. This
estrogen is required to build
up the lining in the first half
of the cycle. Thin endometrial
linings have been associated
with recurrent miscarriage and
estrogen inadequacy may be the
cause. This may be treated with
superovulation with or without
supplementation with Viagra.
Immunologic
Factors
This
is one of the newest and sometimes
most controversial problems
associated with recurrent pregnancy
loss. Autoimmune problems where
the body produces antibodies
against other body proteins
has been linked to miscarriage.
These problems are diagnosed
by tests such as Anti-Nuclear
Antibodies (ANA) and Anti-Phospholipid
Antibodies (APA), which detect
the presence of these antibodies
in the woman's blood. These
antibodies may cause an abnormal
clotting event to occur during
pregnancy, which causes interruption
of the blood flow to the placenta.
As this interruption becomes
more and more severe, the fetus
begins to starve for oxygen
and nutrients and eventually
dies. This eventually leads
to miscarriage.
Other
problems with blood coagulation
have recently come to light
as being associated with both
infertility and recurrent miscarriage.
These all have the same basic
outcome by clotting off the
placenta and causing miscarriage
at various stages in the pregnancy.
The
most notable treatment for immunologic
factors of miscarriage is the
administration of low dose aspirin,
heparin, and steroids. These
reagents cause a masking effect
that can help prevent clotting
off the placenta. While the
benefits from this treatment
remain controversial in the
medical community, our experience
with patients has led us to
believe that many patients receive
a benefit from this treatment.
This benefit has been realized
in a dramatic increase in the
number of pregnancies achieved
and delivered after we initiated
a more general use of this treatment.
In
a large group of patients, who
were previously diagnosed as
unexplained infertile or unexplained
miscarriage, our work with hematologists
has shown an association between
pregnancy loss, infertility,
and certain coagulation disorders.
Empirical treatment for the
diagnosis of these coagulation
disorders by the use of aspirin
and heparin has been offered
to our patients. While patient
caution is indicated, we feel
there are great benefits associated
with this treatment.
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