Dr. Silverberg has been chosen by the American Society for Reproductive Medicine Board of Directors to receive the 2011 ASRM Service Award. Members who have met a 10 year milestone for serving on ASRM boards and/or committees are granted this award. Dr. Silverberg will be recognized at the upcoming 67th ASRM Annual Meeting in Orlando, FL for this accomplishment.
You’re ready to devote your time, emotional reserves, and discretionary income to getting pregnant. Up until now, your physical discomfort has been at the hands of skilled and ultra-competent healthcare professionals. You’ve endured blood draws, vaginal ultrasounds, and possibly even laparoscopic day surgeries. But that was different. Now it’s you or a significant other who will literally stick it to you.
Assisted reproductive technology can seem overwhelming. But for the courageous couple that really wants to have a child of their own, the end justifies the means. You and your fertility doctor have a plan that may include injections in conjunction with intrauterine insemination (IUI) or with the process of in-vitro fertilization (IVF).
There’s that word again. Injections. Shots. Needles. Sharps. Take a deep breath and face your fears. This is the tool that delivers hope. Under a doctor’s care, fertility medication can work wonders. This medication can help develop eggs, tell your body when to release those eggs, and nourish a growing baby after conception. Why is it delivered in an injection form? (rather than a pill ?) The medication works best when delivered this way into your body. It’s simply the most effective way to achieve results.
Texas Fertility Center will provide extensive and compassionate injection training with practice sessions until you feel comfortable and confident. We understand the stress you endure and want to make injections as painless and stress free as possible. In the end, it is very common for us to hear that the injections are much easier than patients have initially expected.
After you’ve completed a TFC injection class, prepare a place at home where you’ll administer your shots. This could be the kitchen, bathroom, bedroom, or anyplace with a clean surface. Here, you will assemble all the supplies you’ll need so they are within reach: medicine, syringes, alcohol swabs, and a sharps container for discarded needles. For cycles that enlist multiple medications, consider labeling clear plastic containers for each prescription.
Always begin by washing your hands with antibacterial soap and water. The needle should never come in contact with anything. When in doubt, throw it out. Next, rub the cap of the medication container with an alcohol swab and follow the instructions provided to you. You might need to mix or dilute a medicine before drawing it into the syringe, or the doctor may order prefilled syringes.
It’s important that you expel any air that remains in the liquid medication. To do this, you’ll point the needle toward the sky, draw slightly back on the plunger and lightly flick the syringe. (You’ve seen this move on all the doctor shows.) Let the air bubbles that appear rise to the surface – and then depress the plunger slightly until they escape out of the tip. A tiny bit of liquid may overflow, too.
Your injection will fall into one of two categories: subcutaneous (under the skin) or intramuscular (in the muscle). Subcutaneous injections, given with a shorter needle, enter either in the abdomen or upper thigh and tend to be relatively painless. The longer needle of intramuscular injections requires an injection site with more muscle tissue—the thigh or
Hip -and will hurt more than a sub-Q shot but less than a blood draw. Although most of the injections are given subcutaneously, occasionally intramuscular injections are required. Texas Fertility Center provides an in-depth guide for each type of injection, in-office training, and phone support. Plus, you will practice on a rubber ball or practice pad until you feel ready for human patient.
Listen to your fertility nurses. They will winnow down years of experience into a digestible tutorial on injections. Talk to other couples going through infertility. Texas Fertility Center hosts seminars and classes where you’ll gain both practical knowledge and emotional support. The Internet even has some useful videos and blog tips. We’ve compiled some of the best injection tips we’ve heard over the years:
1. Whoever is giving the injection should exude confidence (even if he/she has to fake it), prepare the syringe out of the patient’s line of sight, and deliver the shot in a quick, purposeful motion.
2. Some patients find that applying a warm compress before and after the injections and massaging the area with a tennis ball helps the medication absorb more quickly and eases discomfort. Some patients find that ice cubes or numbing patches from a pharmacy before the shot alleviate their discomfort. Alternating the injection site also helps lessen the discomfort.
3. Offer generous words of encouragement and compassion.
4. Pinch the skin when giving a subcutaneous injection and spread the skin taut when giving intramuscular injections.
5. Play soothing music or a funny TV show in the background as a distraction.
6. Reward yourself after each shot.
7. Involve your spouse. If giving yourself a shot scares you, this is a good way to have your partner share the burden and become actively involved in the process.
8. Remember why you are taking these shots. It will be worth every stick!
Dr. Kaylen Silverberg was asked by Teva Pharmaceuticals to present the results of their nationwide multicenter trial evaluating the efficacy of a new progesterone vaginal ring in patients undergoing IVF at the recent annual meeting of the American College of Obstetricians and Gynecologists, May. Dr. Silverberg was one of the principal investigators of this trial. The study suggests that the ring, if approved by the FDA, may offer patients another alternative to the painful intramuscular injections of progesterone that used to be standard IVF treatment.
Recently the study abstract was released in the American College of Obstetrics and Gynecology Abstract book. The paper is now available in the Texas Fertility Center Research Library papers section.
The study poster is also available on online at http://www.txfertility.com/Research/Posters
Efficacy of a progesterone vaginal ring versus progesterone gel for luteal phase supplementation – Kaylen M. Silverberg, MDa & Brandon K. Howard, PhDb
40% of Infertility is Caused by the Male PartnerWhen evaluating couples who are having difficulty conceiving, it is not uncommon to find that the male partner may have an abnormal semen analysis. In fact, 40% of the causes of infertility are due to the male.
It is very important to take a medical history from the man in the intial appointment.
Steroids, Illict Drugs and Smoking
Some men use anabolic steroids for body building and/or recreational drugs, such as marijuana. Steroids suppress the hypothalamic pituitary area lowering the stimulation of the testicle. As a consequence, sperm production can drop dramatically. This is similar to a woman using an oral contraceptive agent (birth control pill).
Marijuana lowers the production of testosterone and increases the production of estrogen, a compounding negative effect on sperm production.
Likewise, smoking has a detrimental effect on sperm function.
If the man is overweight, his excess fat increases the conversion of the male’s testosterone to estrogen, again changing that ratio to an unfavorable situation. Fortunately, these adverse effects are usually reversible. Therefore, changing these social habits and improving the man’s general health can lead to an improvement in sperm production.
When the evaluation of the semen is abnormal, it is appropriate for the man to be referred to an urologist for an evaluation. Usually the urologist will perform a “pelvic exam” which consists of examination of the testicles (which are responsible for the production of sperm) and a rectal exam to evaluate the prostate gland.
The Prostate Gland
The prostate produces approximately 1/3 of the semen (the liquid portion of the ejaculate). Inflammation of the prostate gland can result in the production of inflammatory white cells. These white cells can result in the development of reaction oxygen species (ROS) in the semen. ROS can interfere with sperm function, even when the numbers of sperm are adequate.
Varicoceles
One of the common findings from the examination by the urologist is a varicocele. This is a swelling of the testicular vein in the scrotum, more commonly found on the left. Occasionally, the urologist may recommend that the varicocele be repaired. Results of the procedure have been mixed with some men showing an improvement of the sperm motility and morphology. However, some men show no change and some may experience a decline in the sperm numbers.
Hormone Evaluation and Low-T
Also, it is important for the evaluation of the male to include a hormonal evaluation. A serum FSH and a serum testosterone are critical to ensure that the testicles are functioning properly.
If a man is found to have a low serum testosterone with either a low or normal serum FSH, he is a candidate for clomiphene therapy. Most couples have assumed that clomiphene is a fertility drug for women only. However, in certain clinical situations, men can use clomiphene.
Clomiphene acts on the hypothalamic-pituitary area of the brain to stimulate the release of FSH and LH. These hormones stimulate the ovary in women and the testicle in men. Therefore, in the appropriate clinical setting, this medication can be helpful for men.
A few years ago, our group evaluated men who were candidates for clomiphene therapy and found that the medication caused a significant increase in their serum FSH, LH, and testosterone levels. More importantly, there was a significant increase in the numbers and motility of their sperm. However, there was no increase in the number of normal sperm (morphology).
The starting dose of clomiphene for men is 25 mg on a daily basis. The medication is manufactured as a 50 mg pill. Therefore, it is necessary for the pill to be cut in half so that the man can take 25 mg. In six weeks, a serum testosterone and FSH are drawn to determine if the testicle is responding. If the hormonal response is inadequate, the medication is increased to 50 mg on a daily basis.
On the other hand, if there is a response at either level, the medication is continued until conception is obtained. The sperm cycle is 70 to 90 days for men. An improvement in spermatogenesis may not be seen for at least three to four months. After six months, usually no further improvement is noted. If there is no response to the higher dose of clomiphene, it may be that this therapy is not going to be beneficial.
An elevated serum FSH suggests that the man has testicular failure as the cause of his poor sperm production. Usually the cause of a low sperm count with an elevated serum FSH is genetic. In this situation, it is uncommon that any surgical procedure or hormonal therapy will improve sperm production.
Therefore, these guys are not very good candidates for Clomid.
If the quantity of sperm is not too low, these couples may benefit from intrauterine insemination (IUI). However, there needs to be at least 10 million moving sperm following the preparation of sperm for IUI. If the numbers are below that level, then it is best for the couple to undergo in vitro fertilization (IVF).
IVF is very successful even with very low numbers of sperm. When the numbers of sperm are very low, it is common for these couples to need to utilize intracytoplasmic sperm injection (ICSI) during the IVF procedure. ICSI involves injecting sperm directly into the egg in the IVF laboratory utilizing an operating microscope.
If the abnormality is so severe that there are no sperm seen in the ejaculate (referred to as azoospermia), some men are candidates for surgical extraction of the sperm directly from the testicle. When sperm are surgically retrieved, the couple needs to undergo IVF/ICSI to achieve pregnancy because sperm obtained surgically are immature and cannot fertilize an egg on their own, even with insemination.
A complete evaluation of the male is important when working with a couple struggling to become pregnant. Occasionally, improving general health and avoiding recreational drugs may be all that is necessary to significantly increase sperm production. Also, there are many available treatment options for couples, even when the male has a very low sperm count.
Dr. Silverberg tackles this common question in his latest article added to our website. To read more go to:
http://www.txfertility.com/ivf-stimulation-protocols.php
Dr. Vaughn recently gave a lecture to the UTMB OB/GYN residents at Brackenridge Hospital on Hysteroscopy and Fluid Management. The physicians at Texas Fertility Center take an active role in the resident training program and participate in the monthly lectures.
What’s worse? A root canal or someone telling you yet again: “Relax and you’ll get pregnant.” This is one myth worth talking about with your friends and family. Tell them vacations don’t cure infertility. However, targeted fertility testing and effective treatments can lead to success.
At Texas Fertility Center, we highly recommend learning to manage stress; however, unwinding for a weekend won’t cure infertility. Trust us. These trite words of advice – relax and you’ll get pregnant – will never appear on a reproductive endocrinologist’s prescription pad.
First off, if you’ve tried unsuccessfully for 12 months (6 if you are over 35) and are still not pregnant, it’s time to see a fertility doctor. One in 8 couples experience infertility because a lot can go wrong. Eggs age. Sperm act lazy. The uterus won’t accept visitors. You wouldn’t tell a person with diabetes or cystic fibrosis to relax and wait for the symptoms to go away, right? That’s why the correct response to well wishers with relax-it-will-happen advice is this: Infertility is a disease and my doctor and I have a plan to overcome it. Thanks, anyway.
Now that we’ve established the myth, let’s examine the physiological impact of stress. Extreme, chronic, long-term stress will impact your overall health. In some women, chronic stress can cause irregular menstrual cycles and thus irregular ovulation. That’s because high levels of cortisol or epinephrine hormones, which the body produces in response to stress, can wreak havoc on the reproductive system. Also, excess stress just feels plain lousy and makes it difficult to manage other challenges in your life.
Psychologists report that infertility causes stress nearly as acute as that experienced by women undergoing treatment for cancer or heart disease. The roller-coaster life of a couple undergoing infertility treatment can undoubtedly test your mental and physical strength.
Couples with infertility have a lot of reasons to feel stress:
• It’s frustrating to feel that your body is somehow ‘broken’
• Fertility tests and treatments can take time and be expensive
• It can be difficult to be around friends and family who don’t have any idea of what it’s like to deal with infertility.
There are things that you can do to lower stress (and potentially enhance fertility) as you are considering further fertility evaluation and treatment. These things can make you feel more empowered at times when you are feeling powerless.
Top 5 Ways to Minimize Stress during Fertility Treatment
1. Exercise. Moderate physical activities such as power walking, yoga and zumba dancing release endorphins that combat stress. Intensive workouts could disrupt the reproductive cycle, so ask your physician or nurse about the ideal exercise regimen.
2. Add acupuncture. Some studies show the centuries old practice of acupuncture improves fertility rates. Like physical therapy, patients typically see results only with regular, ongoing treatment.
3. Get a massage. If the idea of spending more money on a spa visit sounds counter-productive, find a massage therapy school or rent a how-to video for your partner.
4. Meditate. Trigger the relaxation response with slow, abdominal breathing and visualization. In addition to lowering your stress level, meditation may improve sleep patterns and concentration.
5. Enlist support. Talking about infertility helps, and no one can empathize quite like your partner. Groups such as Resolve or private counseling also reinforce the consoling message that you are not alone.
No matter how many months you’ve tried to get pregnant, the last two weeks of the cycle bring the same mixed emotions. Hope surges, crests and plummets with each passing day after ovulation. It’s the Flashback rollercoaster ride that repeats itself month after month.
Whether you try to get pregnant on your own or with the help of a fertility doctor, surviving the two-week wait until confirming a pregnancy takes resolve, humor and military-caliber discipline to master the art of relaxation.
Hearing someone tell you to “not stress” is counter-productive. If you had an on-off switch, you would flick it, right? Inducing the relaxation response takes some trial and error, so begin now discovering what works best for you. Try building some feel-good activities into the last two weeks of your natural or assisted reproductive technology (ART) menstrual cycle.
What relaxes you?
Maybe it’s an evening walk with a friend, neck or foot massage, warm bath or chick flick. Researchers link yoga, meditation and acupuncture with stress relief, so you might incorporate these into your monthly regimen. Or, try tackling a new novel at the start of every cycle. Set a date to get together with friends for a book discussion after your pregnancy test to give yourself something to look forward to after the results.
Makes scents.
You may associate aromatherapy with a store in the mall, but there exists a very strong case for the benefits of finding a scent that you associate with positive memories. Your olfactory processing center sits directly next to the area of the brain associated with memory and emotion. That’s why when you smell vanilla, for example, it takes you back to baking with your mother. Test what scents elicit positive responses by smelling candles, essential oils or lotions.
Now that you’ve scheduled stress-relievers into your waiting period, it’s time for the pregnancy test. Make a plan for how you’d like to receive the news from your fertility nurse. Some patients choose to have the message delivered to a home answering machine and prefer not to have the conversation at work.
No surprises here.
Worrying won’t get you pregnant. In fact, it’s not healthy for you or a developing fetus. If you’re reading this article, you’ve already jumped on the menstrual cycle — that out-of-control vehicle that takes you on fertility’s wild ride. Take proactive steps to remain calm during the two-week wait and try to focus on the destination you’re heading toward — a healthy pregnancy and baby. If it doesn’t happen this month, it means you are not pregnant for now …however next month is another opportunity.
Knowledge is Power
Know the steps your body takes to prepare for and sustain a healthy pregnancy.
1) The Menstrual Phase (days 1-5) begins with the first day of your period and signals the start of another cycle.
2) During the Follicular Phase (days 1-13), your brain and ovaries work together to grow follicles, each containing a single egg. The ovaries signal the uterus to prepare for a pregnancy by thickening the uterine lining.
3) Next, a surge of luteinizing hormone (LH) signals the egg’s impending release during the Ovulatory Phase (days 10-18). Ovulation typically occurs on day 14, though this can vary if you have more frequent or less frequent periods than every 28 days. The egg then progresses into the fallopian tube, where it should meet sperm and fertilize before its entry into the uterus.
4) Your body should ideally produce progesterone to support a pregnancy and embryo development during the final Luteal Phase (days 15-28). If embryo attachment occurs, the pregnancy tissue will begin producing human chorionic gonadotropin (HCG), the hormone that results in a positive pregnancy test.
Pregnancy symptoms during the luteal phase include increased urination (due to hCG); fatigue and bloating (associated with progesterone); mild nausea (from increased blood volume); and a slight rise in your body temperature. Of course, many PMS symptoms mimic pregnancy signs, so try not to read too much into every twinge and change.
Dr Kaylen Silverberg, of Texas Fertility Center in Austin, TX and his co-authors just published a paper about a patient who conceived following radical cervical cancer treatment. Using IVF stimulation and freezing her embryos, Texas Fertility Center was able to protect the patient’s fertility while she underwent extensive cancer treatment. Following radical surgery to remove her cervix, where the cancerous lesion was first found, the patient also underwent extensive chemotherapy and radiation of the ovaries and uterus.
Once the patient was clear of the cancer and following the completion of her chemotherapy and radiation, Dr Silverberg and his team were able to successfully stimulate the patient’s uterus to generate a lining sufficient to support a pregnancy. They then implanted one of the frozen embryos that the patient and her husband had stored with Austin IVF prior to cancer treatment. The patient fortunately conceived and she then carried the baby until 24 weeks of pregnancy. At that time, she unfortunately lost the baby due to an unrelated obstetric complication. Because of the emotional and physical stress on the patient, a known gestational carrier was used to conceive a second baby that was delivered at term and is doing fine.
This paper, published in the recent issue of Gynecologic Oncology, gives hope to the thousands of young women who are treated for gynecologic cancers every year. Whereas previously these women had a very poor prognosis – they would either not survive their cancer or would be sterile following treatment – they now have legitimate hope for a fertile future following cancer treatment.
to read the full article:
http://www.txfertility.com/08papers.php
It is not uncommon for a woman to want to have another baby after having had a tubal ligation. There are many reasons women seek a reversal of their sterilization procedure. In some situations patients have undergone the sterilization procedure and later become divorced. When she finds another partner, she may want to have a baby with him, even if he has fathered babies in a previous relationship. Occasionally, women may simply regret having had a sterilization procedure and want to undo it.
At ovulation, an egg is released from the ovary and is picked up by the fimbriated end of the fallopian tube (the portion of the tube nearest the ovary). The egg remains in that area until it is fertilized by a sperm. If fertilization does not occur, the egg is resorbed by the fallopian tube. A tubal ligation is performed to ensure that the tube is blocked so that the sperm is prevented from traveling to the fimbriated portion of the tube. Therefore, the egg does not become fertilized.
Patients talk of “untying” their fallopian tubes. Actually, the tubes are not simply tied, but rather a portion of the fallopian tube has been surgically destroyed so that it becomes obstructed. To reverse a tubal ligation, the damaged area of the fallopian tubes needs to be surgically removed and the remaining tubal segments need to be repaired (sewn back together). This surgical procedure can be performed with a very small incision just above the pubic bone or through a laparoscope. It is a tedious procedure and usually takes a couple of hours to complete the reconstruction.
The success rate of the procedure is determined by several factors. Most importantly, the surgery should be performed by someone well trained and experienced in doing the procedure. The highest success rate of reversing a tubal ligation is when the fallopian tube has been clipped or a very small portion of the tube has been removed. If the sterilization procedure was performed by cauterizing (burning with an electrical current) or a very large portion of the tube has been removed, the success rate for reversal is much lower. In this situation, it is far better for the woman to undergo in vitro fertilization (IVF). IVF has a very high success rate for most young women desiring to have a baby after a sterilization procedure. And, IVF has a very low ectopic (tubal) pregnancy risk and does not require surgery. Also, if the new male partner has a very low sperm count, the more successful procedure for the couple is to undergo IVF.
Women desiring to become pregnant following sterilization should consult a reproductive endocrinologist who is skilled in fallopian tube reanastomosis (tubal reversal) and IVF. A thorough review of the type of sterilization procedure and a semen analysis will provide the necessary information to make the better decision as to whether the patient should have a reconstructive surgical procedure or undergo IVF.
