In the March issue of Obstetrics & Gynecology there are two committe opinions that recommend expanded carrier screening for recessive genetic disorders. This is due to the lower costs of expanded testing in our current age of “Genomic Medicine.” Pre-conception genetic screening gives future parents valuable information as there are currently commonly employed technologies that can prevent the birth of an affected child. Couples have the very viable option of Pre-implantation Genetic Disease (PGD) screening of embryos through “in vitro” fertilization procedures. The committe opinions are well written and I plan to use them as part of my informed consent process.
“I Want Twins” …#IVFTwins… IVF and Twin Complications
Attention all patients looking for IVF Doctor that will help them have twins
“We want IVF Twins” is not an uncommon request. Here are two recent email enquiries that prompted this commentary:
“My fiance’ and I would like to have two kids, but we would like to have them all at once. Is this something that you can facilitate at your facility? We’d like to know if this is a procedure you can assist with prior to us paying the $300.00 consultation. If so, please send me the necessary documents for us to complete so we can schedule a visit sooner rather than later. Possibly Friday, May 22, 2015 if you have available time slots.”
Another recent enquiry is as follows:
“Hi, my name is _____, I am 40 years old. I have __ daughters, I didn’t have any problems with any of my pregnancies. And me and my husband want twin boys. I want information on exactly how long and what I should do, and how much this Operation costs. Thank you.”
And my reply is:
Multiple pregnancies such as twins are the principal complication of assisted reproductive techniques such as IVF. Twin pregnancies have a much higher risk of complications. Most are due to the much higher risk of pre-term birth. Twins deliver pre-term 58% of the time and 56% of twins have low birth weight (CDC 2012). Twins have up to a 6 times higher risk or cerebral palsy and up to a 6 times risk of severe cardiovascular anomalies. Twins are 4 times more likely to die in pregnancy and 7 times more likely to die shortly after birth.
Over the 21 year span of my career, our specialty has strived to improve the success of our treatments. Unfortunately, this usually required the implantation of more than one embryo. The most common reason for failure of a fertility treatment is that the embryos are not genetically normal. The most common reason for the implantation of more than one embryo is lack of good information about the genetics of the embryos.
It is still common practice to transfer 2 embryos when patients are treated with standard IVF procedures. If that is done, then the risk of a twin pregnancy is 25-30%. The transfer of two instead of one embryo may increase the chance of a successful treatment from 35% to as high as 50% depending on the age of the patient. This all applies for embryo transfers based on IVF without genetic testing of the embryos. The transfer of 2 embryos that have been shown to be “genetically normal” by the embryo biopsy tests can result in a twin pregnancy in more than 80% of cases. This is an unacceptable high rate of a “complication.”
The newest technologies allow us to test the chromosomal makeup of the embryos on the 5th or 6th day of embryo lab culture. with this information we have been able to establish a preimplantation genetic screening single euploid embryo transfer program. A euploid embryo is one where the chromosomal makeup of the embryo is known to be 23 pairs of normal chromosomes.
This technology requires the use of a microscopic laser to remove 8-10 cells from the trophectoderm of the blastocyst. It is a leap in accuracy from the biopsies that we have been performing since 1999 at the six to eight cell stage (third day of embryo growth). Initial scientific evaluation of the newer technology of blastocyst biopsies in 2012 gave outstanding results with the transfer of single embryos resulting in pregnancy rates in the 60% range regardless of maternal age.
Right away we knew that this method of assessing embryos was good since we were able to transfer single embryos with confidence. The older technology had limitations as reflected by the fact that we were unable to maintain similar pregnancy rates despite transferring 2-3 embryos routinely during the past decade. With the newer technology, we have enjoyed pregnancy rates in excess of 70% since 2013 in our pre-implantation genetic screening program where more than 95% of the transfers are of a single euploid embryo. Results continue to be exceptional. In the first quarter of 2016 (at the time of this post) 21 of 23 patients have had a positive pregnancy test (91%) in our frozen thaw genetically tested embryo program (PGS) and 19 of the 23 have an ongoing pregnancy (82%). In one case a patient with a single embryo did not have a transfer as the embryo was not recovered after thaw. Remarkably, only one of the 23 patients received two embryos while all others received one.
Our Single Euploid Embryo Transfer Program began in 2013. in 2013 and 2014 the technology for assessing the chromosomes was microarray based that gave as much information as sequencing approximately 3% of the genome of the embryos. This was enough to tell us that there were 23 pairs of chromosomes.
Since January of 2015, the technology for assessing the chromosomes has improved to what is called “next generation sequencing.” The information obtained is considered to be about 3 times more and with higher resolution. Next generation sequencing is like reading about 10% of the genome of the embryo.
Current technology that sequences about 10% of the genome is sufficient because more testing would yield information of uncertain relevance at this time.
Multiple pregnancies are a known “complication of Assisted Reproductive Techniques.” IVF procedures where the embryos are not tested genetically may lead clinics and patients to accept the transfer of more than one embryo more often. These are accepted risks based on clinical guidelines. Transferring or implanting more than one healthy looking and “genetically normal” embryo is not advisable because it leads to an unacceptable high risk of resulting in a complicated pregnancy that endangers the babies. The complications and potential morbidities can be life changing and permanent.
Please refer to another good resourse for much more information on this subject: www.oneatatime.uk.org
Fertility Center and Applied Genetics of Florida
Sarasota and Bonita Springs, Florida
The United States Supreme Court ruled today in a 5 to 4 vote that same sex marriages are legal and constitutional. This is a momentous step in extending liberty and rights to all Americans.
Many of our patients will benefit from the ruling by having rights that the relationship of marriage grants them. This has implications to medical decisions, wills, insurance, and many other areas. Our gay and lesbian parents will surely gain better parenting rights and in the short term our same sex male married parents will soon have the ability to have their names appear on the birth certificate of their baby immediately at birth.
In our society, marriage is both a legal state and in most cases, a religious union. It is impressive how our country is so free and well founded that our Supreme Court ruled in favor of same sex marriage despite expected resistance from some organized religious leaders.
Protecting the rights and liberties of the few, protects us all.
Julio E. Pabon, M.D.
Headline: Fertility Doctor Breaks from Protocol and succeeds with Divine Intervention!
Fertility Doctor Breaks from Protocol and succeeds with Divine Intervention!
Yes, it’s true. Sometimes one has to be flexible.
A few weeks ago I was about to do an embryo transfer of a single genetically tested (euploid) thawed blastocyst for an extremely sweet couple. They had struggled with fertility problems for quite some time. Unfortunately, we were well aware of a reduced chance of implantation given a very thin peak endometrial lining despite high dose estrogen for more than six weeks. We finally called the date for her progesterone start so we committed to the thaw and transfer. We had only one remaining frozen embryo for thawing and transfer.
As I approached her in the procedure room, she asked me to come near the right side of the procedure table. She surprised me when she pulled out a little white spray bottle and sprayed my hands. My Jewish patient told me that her Jewish neighbor had given her some holy water from her trip to the Vatican.
We all said a little prayer and then I faced a dilemma. At this time I will usually wash my hands, but my hands had just been sprayed with holy water from the Vatican!!!
I decided to not wash the holy water off and just put on my procedure gloves. The embryo transfer went like a dream. NONE OF US HAD HIGH EXPECTATIONS…..including our patient who was not the most compliant with her supplements before her blood pregnancy test. To all of our astonishment, her pregnancy test was positive and continued to rise. I recently referred her to her Obstetrician, our dear Dr. M. Finazzo. She is was more than 9 weeks along.
I thought I should share this cute story.
My Sincere Best Wishes to all the families we try to help.
Julio E. Pabon, M.D., F.A.C.O.G.
I have a high bmi can the tubal reversal still be done?
This is a question that we received in an email this weekend.
The answer is yes. Unfortunately, just because I can do something, it does not mean that it should be done.
The question should not be not only about whether a tubal reversal is a difficult or risky procedure for a patient with a high BMI, but should address the subsequent high risk pregnancy that may result.
Please “Google” “Obesity and Pregnancy Risk” “Obesity and Surgical Risk”
I spend a significant amount of my time counseling patients about the importance of good health before elective procedures, IVF, and pregnancy. This is only because there is a large amount of scientific data supporting this. It is difficult to tell a lady that her BMI is too high. I try to be sensitive and bring up my own struggles with weight. Nonetheless, some patients don’t listen and some are sometimes offended.
Regarding elective surgery like a microsurgical tubal reversal, it is in the best interest of the patient to help to make the procedure as safe as possible. Obese patients have a higher risk of many surgical complications. It makes sense to try to become more fit for the surgery and the subsequent pregnancy.
Regarding IVF, many studies have shown a lower chance of pregnancy in obese patients and a higher risk of many subsequent complications in the pregnancies that are achieved.
As many of you know, I am a fan of a low carbohydrate lifestyle. I often recommend it. I also inform patients about Weight Watchers programs. I am not a fan of “bariatric surgery.” In may opinion, the main problem leading to the obesity epidemic is our over-indugence in a high energy diet full of sugar, flour, and all forms of Carbs.
Julio E. Pabon, M.D.
Sarasota and Bonita Springs Florida
Please read the attached documents for detailed information about this subject:
Number 549, January 2013
(Replaces Committee Opinion Number 315, September 2005)
Committee on Obstetric Practice
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Obesity in Pregnancy
ABSTRACT: In the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese, putting them at a greater risk of pregnancy complications. Therefore, preconception assessment and counseling are strongly encouraged for obese women and should include the provision of specific information concerning the maternal and fetal risks of obesity in pregnancy, as well as encouragement to undertake a weight-reduction program. At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of body mass index (calculated as weight in kilograms divided by height in meters squared), and recommendations for appropriate weight gain should be reviewed at the initial visit and periodically throughout pregnancy. Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated. Obese patients undergoing cesarean delivery may require thromboprophylaxis with pneumatic compression devices and unfractionated heparin or low molecular weight heparin. For all obese patients, anesthesiology consultation early in labor should be considered, and consultation with weight-reduction specialists before attempting another pregnancy should be encouraged.
The prevalence of obesity in the United States has increased dramatically over the past 25 years. The recent National Health and Nutrition Examination Survey found that in the United States, more than one third of women are obese, more than one half of pregnant women are overweight or obese, and 8% of reproductive-aged women are extremely obese (1). The obesity problem is greatest among non-Hispanic black women (50%) compared with Mexican American women (45%) and non-Hispanic white women (33%) (1).
In 2009, the Institute of Medicine (IOM) published revised pregnancy weight gain guidelines that are based on prepregnancy body mass index (BMI) ranges recommended by the World Health Organization. These ranges are independent of age, parity, smoking history, race, and ethnic background (2, 3). The revised IOM recommendations define normal weight as a BMI of 18.5–24.9, overweight as a BMI of 25–29.9, and obesity as a BMI of 30 or greater. The IOM guidelines do not differentiate between Class I obesity (BMI=30–34.9), Class II obesity (BMI=35–39.9), and Class III obesity (BMI≥40) (2).
Overweight and obese women are at increased risk of several pregnancy complications, including gestational diabetes mellitus, hypertension, preeclampsia, cesarean delivery, and postpartum weight retention (4–8). Similarly, fetuses of pregnant women who are overweight or obese are at increased risk of prematurity, stillbirth, congenital anomalies, macrosomia with possible birth injury, and childhood obesity (9, 10). Additional concerns include potential intrapartum, operative, and postoperative complications and difficulties related to anesthesia management. Obese women are also less likely to initiate and sustain breastfeeding (11).
In a prospective multicenter study of more than 16,000 patients, a BMI of 30–39.9 was associated with an increased risk of gestational diabetes mellitus (odds ratio [OR], 2.6 and 4.0), gestational hypertension (OR, 2.5 and 3.2), preeclampsia (OR, 1.6 and 3.3), and fetal macrosomia (OR, 1.7 and 1.9), when compared with a BMI of less than 30 (7). In this same study, the cesarean delivery rate was 20.7% for women with a BMI of 29.9 or less, 33.8% for women with a BMI of 30–34.9, and 47.4% for women with a BMI of 35–39.9. Other studies have consistently reported higher rates of preeclampsia, gestational diabetes mellitus, and cesarean delivery (particularly for arrest of labor) in obese women than in nonobese women (4–6).
At least three cohort studies suggest that obesity is an independent risk factor for spontaneous abortion among women who undergo infertility treatment (12–14). In recognition of this association, it is recommended that health care providers encourage obese women to lose weight before beginning infertility therapy. Data also link obesity with spontaneous abortion among women who conceive naturally (15).
When counseling obese women about potential pregnancy complications, it is important to inform them of the associated fetal risks, including prematurity, stillbirth, congenital abnormalities (eg, neural tube defects), macrosomia, and childhood and adolescent obesity. Some studies have reported a higher rate of premature delivery for obese women than for women of normal weight (4, 16). However, in a study of more than 2,900 obese women, prepregnancy obesity was associated with a lower rate of spontaneous preterm birth (17). A large Swedish cohort study reported a greater risk of antepartum stillbirth among obese patients than among women who had a BMI of less than 20 (16).
Obese pregnant women are more likely to give birth to an infant with congenital anomalies (9), and obesity also lowers detection rates of fetal anomalies during prenatal ultrasonography (18). Data establish that the risk of neural tube defects among obese pregnant women is double that of pregnant women of normal weight after correcting for diabetes as a potential confounding factor (19–21). The benefit of the administration of folic acid doses higher than 400 micrograms per day has not been studied in obese pregnant women without diabetes.
Multiple studies have shown that maternal obesity and excessive weight gain during pregnancy are associated with large-for-gestational-age infants (5, 22–24). Furthermore, these large-for-gestational-age infants are at increased risk of childhood and adolescent obesity (6, 25, 26). Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 g in women without diabetes and greater than 4,500 g in women with diabetes (27).
It is important to discuss potential intrapartum complications with obese women, such as the challenges associated with anesthesia management and the increased risk of complicated and emergent cesarean delivery. Other potential problems include difficulty estimating fetal weight (even with ultrasonography) and the inability to obtain interpretable external fetal heart rate and uterine contraction patterns.
If an anesthesiology consultation was not obtained antepartum, it should be conducted early in labor to allow adequate time for the development of an anesthetic plan. The use of epidural or spinal anesthesia is recommended in the obese pregnant patient when anesthesia is needed or elected; however it may be technically difficult or impossible to administer this type of anesthesia because of obscured landmarks, difficult positioning, and excessive layers of adipose tissue. Alternatively, the use of general anesthesia in obese pregnant women also poses several challenges, including difficult endotracheal intubation due to excessive tissue and edema (28) and intraoperative respiratory events from failed or difficult intubation (29).
Operative and postoperative complications among obese pregnant women include increased rates of excessive blood loss, operative time greater than 2 hours, wound infection, and endometritis (30–32). Sleep apnea occurring in this group of women may further complicate anesthetic management and postoperative care (33).
Obese women who require cesarean delivery have an increased incidence of wound breakdown and infections (31, 34). Antimicrobial prophylaxis is recommended for all cesarean deliveries unless the patient is already receiving appropriate antibiotics (eg, for chorioamnionitis) (35). For obese women who require cesarean delivery, consideration should be given to using a higher dose of preoperative antibiotics for surgical prophylaxis (36). Attempts to decrease the incidence of wound breakdowns and infections that have been studied include closure of the subcutaneous layers and the placement of subcutaneous drains. Investigators have demonstrated that suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption (37, 38). However, postoperative placement of subcutaneous draining systems has not consistently been shown to be of value in reducing postcesarean delivery morbidity (39, 40).
Because of an increased risk of venous thromboembolism, placement of pneumatic compression devices before cesarean delivery is recommended for all women not already receiving thromboprophylaxis (41). Obese patients, especially those who are hospitalized and immobile, may be at increased risk of thromboembolism. Individual risk assessment will lead some health care providers to plan thromboprophylaxis with pneumatic compression devices and unfractionated heparin or low molecular weight (LMW) heparin in such patients (42). However, cesarean delivery in the emergency setting should not be delayed because of the timing necessary to implement thromboprophylaxis (41). Postpartum unfractionated heparin or LMW heparin prophylaxis has been recommended for patients thought to be at high risk of venous thromboembolism (43, 44); however, data are insufficient to determine whether the benefits of unfractionated heparin or LMW heparin prophylaxis in this group of patients outweigh the risks (45, 46).
Because of the increased likelihood of complicated and emergent cesarean delivery, extremely obese women may require specific resources, such as additional blood products, a large operating table, and extra personnel in the delivery room. Particular attention to the type and placement of the surgical incision is needed (ie, placing the incision above the panniculus adiposus) (34, 47). There are additional logistical challenges to monitoring labor and performing an emergent cesarean delivery in the extremely obese patient. Therefore, these patients should be counseled about these possible complications of an emergent cesarean delivery.
Bariatric Surgery Considerations
The number of obese reproductive-aged women undergoing bariatric surgery is increasing (48). Although maternal gastrointestinal complications, including obstruction and hemorrhage, can occur as a result of this procedure, the incidence is infrequent (49, 50). Furthermore, pregnancies after bariatric surgery are less likely to be complicated by gestational diabetes mellitus, hypertension, preeclampsia, and macrosomia than are pregnancies of obese women who have not undergone such surgery (51, 52).
Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated because they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium. Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary (53). Bariatric surgery is not an independent indication for cesarean delivery (54).
Obese women are at increased risk of several pregnancy complications; therefore, preconception assessment and counseling are strongly encouraged. Obstetricians should provide education about the possible complications and should encourage obese patients to undertake a weight-reduction program, including diet, exercise, and behavior modification, before attempting pregnancy. Specific medical clearance may be indicated for some patients.
At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of BMI, and recommendations for appropriate weight gain should be reviewed both at the initial visit and periodically throughout pregnancy (3). The 2009 IOM guidelines recommend a total weight gain of 15–25 lb (6.8–11.3 kg) for overweight women (BMI=25–29.9) and 11–20 lb (5.0–9.1 kg) for all obese women (BMI ≥ 30). (For an online BMI calculator, see http://www.nhlbisupport.com/bmi). Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Nutrition and exercise counseling should continue postpartum and before attempting another pregnancy. Because these patients are at increased risk of emergent cesarean delivery and anesthetic complications, anesthesiology consultation early in labor should be considered (22).
Recommendations for obese women who are pregnant or planning a pregnancy include the following:
- Preconception assessment and counseling are strongly encouraged and should include the provision of specific information concerning the maternal and fetal risks of obesity in pregnancy and encouragement to undertake a weight-reduction program.
- At the initial prenatal visit, height and weight should be recorded for all women to allow calculation of BMI, and recommendations for appropriate weight gain, guided by IOM recommendations, should be reviewed both at the initial visit and periodically throughout pregnancy.
- Nutrition consultation should be offered to all overweight or obese women, and they should be encouraged to follow an exercise program. Nutrition and exercise counseling should continue postpartum and before attempting another pregnancy.
- Women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation, when indicated, because they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium.
- For patients undergoing cesarean delivery who have additional risk factors for thromboembolism such as obesity, individual risk assessment may require thromboprophylaxis with pneumatic compression devices and unfractionated heparin or LMW heparin.
- Consideration should be given to using a higher dose of preoperative antibiotics for cesarean delivery prophylaxis.
- The use of suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption.
- Anesthesiology consultation early in labor should be considered.
- Consultation with a weight-reduction specialist before attempting another pregnancy should be encouraged.
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- Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Washington, DC: National Academies Press; 2009. ⇦
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Copyright January 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.
Obesity in pregnancy. Committee Opinion No. 549. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:121;213–7
As seen on HealthDay News in 2011:
Obesity May Increase Risk of Surgical Complications
Inflammation, infection much more likely following elective procedures, study shows
FRIDAY, July 8 (HealthDay News) — Obese people who have elective surgery are nearly 12 times more likely to suffer from complications than those of normal weight, new research indicates.
Since data on surgical outcomes are often used by insurance companies, the Johns Hopkins researchers argued that the findings should change how doctors and hospitals are reimbursed for more complex procedures or penalized for higher complication rates.
Operations on obese patients are more demanding because they take longer and the operating fields are deeper, study leader Dr. Marty Makary, an associate professor of surgery, explained in a Hopkins news release. Obese patients who undergo surgery are also at greater risk for surgical site infection and slower healing because of reduced blood flow in fat tissue, Makary noted. Despite these added risks, Makary noted, “payments are based on the complexity of the procedure and are not adjusted for the complexity of the patient.”
The study is published online in the journal Plastic and Reconstructive Surgery.
In conducting the study, researchers examined insurance claims, identifying 2,403 obese patients and 5,597 normal weight patients who underwent elective breast procedures, such as breast lifts, reductions and augmentations, between 2002 and 2006.
Within 30 days of surgery, 18.3 percent of the obese group experienced at least one complication, compared to 2.2 percent of non-obese patients. More specifically, obese patients were 22 times more likely to have inflammation, 13 times more likely to develop infection and 11 times more likely to experience pain.
The findings are significant, given that 34 percent of adults in the United States are estimated to be obese — up from just 15 percent a decade ago. Meanwhile, the number of people having elective plastic surgery is also on the rise. Annual plastic surgery volume increased 725 percent between 1992 and 2005. Despite the trend, the study’s authors concluded the increased risk of complications could deter some surgeons from taking on these higher-risk obese patients.
“It’s more work, and it’s a more complex surgery, as opposed to operating on a thin patient. And the payment is the same,” Makary pointed out. “There are definitely incentives there for surgeons and institutions to select healthier patients. They’re getting reimbursed less per unit of work for obese patients.”
The researchers concluded that more research is needed to determine the role obesity plays in a wider range of surgeries so that new standards can be established to account for any differences, particularly increased risks.
The American Heart Association details some of the cardiac risks associated with surgery in obese patients.
FDA News Release
FDA and EPA issue draft updated advice for fish consumption for persons trying to conceive, pregnant, or breastfeeding.
For Immediate Release
June 10, 2014
The U.S. Food and Drug Administration and the U.S. Environmental Protection Agency today issued draft updated advice on fish consumption. The two agencies have concluded pregnant and breastfeeding women, those who might become pregnant, and young children should eat more fish that is lower in mercury in order to gain important developmental and health benefits. The draft updated advice is consistent with recommendations in the 2010 Dietary Guidelines for Americans.
Previously, the FDA and the EPA recommended maximum amounts of fish that these population groups should consume, but did not promote a minimum amount. Over the past decade, however, emerging science has underscored the importance of appropriate amounts of fish in the diets of pregnant and breastfeeding women, and young children.
“For years many women have limited or avoided eating fish during pregnancy or feeding fish to their young children,” said Stephen Ostroff, M.D., the FDA’s acting chief scientist. “But emerging science now tells us that limiting or avoiding fish during pregnancy and early childhood can mean missing out on important nutrients that can have a positive impact on growth and development as well as on general health.”
An FDA analysis of seafood consumption data from over 1,000 pregnant women in the United States found that 21 percent of them ate no fish in the previous month, and those who ate fish ate far less than the Dietary Guidelines for Americans recommends—with 50 percent eating fewer than 2 ounces a week, and 75 percent eating fewer than 4 ounces a week. The draft updated advice recommends pregnant women eat at least 8 ounces and up to 12 ounces (2-3 servings) per week of a variety of fish that are lower in mercury to support fetal growth and development.
“Eating fish with lower levels of mercury provides numerous health and dietary benefits,” said Nancy Stoner, the EPA’s acting assistant administrator for the Office of Water. “This updated advice will help pregnant women and mothers make informed decisions about the right amount and right kinds of fish to eat during important times in their lives and their children’s lives.”
The draft updated advice cautions pregnant or breastfeeding women to avoid four types of fish that are associated with high mercury levels: tilefish from the Gulf of Mexico; shark; swordfish; and king mackerel. In addition, the draft updated advice recommends limiting consumption of white (albacore) tuna to 6 ounces a week.
Choices lower in mercury include some of the most commonly eaten fish, such as shrimp, pollock, salmon, canned light tuna, tilapia, catfish and cod.
When eating fish caught from local streams, rivers and lakes, follow fish advisories from local authorities. If advice isn’t available, limit your total intake of such fish to 6 ounces a week and 1-3 ounces for children.
Before issuing final advice, the agencies will consider public comments, and also intend to seek the advice of the FDA’s Risk Communication Advisory Committee and conduct a series of focus groups.
From Dr. Pabon: Please keep up to date by following the final recommendations from the FDA. My most practical advice is to try to limit the consumption of fish products from fish “higher in the sea food chain” as mercury levels seem to concentrate in the top predators like shark, grouper, and swordfish.
J. Pabon, M.D.
Sarasota and Bonita Springs, Florida
My little guy, James (11), has been asking me many questions about my likes and preferences. I did not catch on that father’s day was close. My wife finally told me friday morning that he has been planning to make a gift for me. I told her that all I wanted was time and memories. Later, my eyes teared as I drove to the office when I thought about my boys and the fact that both of them prefer time and memories over material things.
Holidays have become very materialistic. Many of us are concerned about the next gift to give or receive. Instead, it is important to use the dates to center ourselves about our religions, our veterans, our presidents, our heroes, our mothers and fathers.
The time we share is the greatest gift.
Best wishes to all.
Julio E. Pabon, M.D.
Sarasota and Bonita Springs, Florida
As a Florida IVF Doctor or Reproductive Endocrinologist, I agree with the new recommendations for older infertility patients. In our Florida IVF clinics in Sarasota and Bonita Springs, I have been discussing the new recommendations for older IVF patients for quite some time. Richard Reindollar’s team has reported in both the “Fast-track” study and in the “Fort T” studies that patients should made aware of the differential chances of pregnancy associated with different treatments. He has demonstrated that older patients benefit from more aggressive treatment like IVF sooner rather than later.
As I discuss on a daily basis, older patients have a decreased chance of pregnancy because they make more genetically abnormal embryos. In the past, many good Ob/Gyns and Reproductive Endocrinologists were hesitant about moving patients quickly to IVF due to the fear of multiple pregnancies and associated severe complications like pre-term birth and a much higher risk of neonatal morbidity, mortality, and congenital anomalies associated with twin and higher order pregnancies. With current scientific advances, even older patients can be treated with single embryo transfers after pre-implantation genetic screening of blastocysts. The application of PGS for a planned single “Euploid” (and embryo with 23 pairs of chromosomes) transfer allows patients of all ages to have implantation rates with a single embryo that are higher that even implanting 3 or more embryos that have unknown genetic makeup.
Below is a recent Bulletin from the American Society of Reproductive Medicine detailing the results of these studies:
Volume 16, Number 25
May 6, 2014
Highlights from Fertility and Sterility
Older Women Should Move More Quickly to IVF
A new study demonstrates that, for couples of older reproductive age with unexplained infertility, immediate IVF is the most efficient treatment, resulting in fewer treatment cycles and a higher live birth rate.
In an NIH-funded, randomized clinical trial, 154 couples receiving infertility treatment at Boston IVF and Brigham and Women’s Hospital were randomly assigned to one of three groups to receive a specific type of treatment for their first two cycles. One group was assigned to have IVF. The other two groups were assigned to have intrauterine inseminations (IUIs) with the female partner receiving either an oral medication to induce ovulation (clomiphene citrate- CC) or injectable ovulation drugs (follicle stimulating hormone-FSH).
If patients in the two insemination groups did not achieve an on-going pregnancy after two cycles, they were switched to IVF for their subsequent cycles.
The participating couples were required to have been trying to conceive for at least six months and to not have previously tried any of the treatments being used in the study. The female partner had to be between 38 and 42 years old, with regular menstrual cycles, at least one ovary and fallopian tube, acceptable ovarian reserve, no disorders of the reproductive organs and no history of ectopic pregnancy. The male partner had to have enough motile sperm.
After two cycles of the assigned treatment, differences were observed in pregnancy rates and live births between the groups. Of patients who went straight to IVF, 49% became pregnant and 31% gave birth. Of those taking oral medications and having inseminations, 22% became pregnant and 16% gave birth. For the injectable medication/insemination group, 17% became pregnant and 14% gave birth.
All couples who had not been successful in their first two cycles of any treatment used IVF in their subsequent treatment cycles, but the couples in the immediate IVF group of the study went through 36% fewer total cycles than the couples who began their treatment in either of the ovulation drug/IUI groups.
By the end of the treatment, of all the couples in the study, 71% had conceived a clinical pregnancy and 46% delivered at least one live-born baby. 84% of all live births in the study came about as a result of IVF. For those couples having a live birth, those who started with IVF took an average of two cycles to conceive, while those who started with ovulation drugs and IUI averaged three to four cycles. Of the 154 couples enrolled, 140 started and 115 completed treatment.
While the major finding of this study is that immediately starting infertility treatment with IVF in older couples is the most effective treatment, it also showed that, if a couple chooses to try ovulation drugs with insemination first, oral fertility drugs (clomiphene citrate) are as effective as injectables (FSH).
Richard Reindollar, MD, Executive Director of the American Society for Reproductive medicine (ASRM) was the study’s principal investigator when he was at Dartmouth Hitchcock Medical Center (DHMC), prior to ASRM. He described how the study came about. “Previously, in the Fast Track and Standard Treatment (FAST-T) trial, we found that for young couples with unexplained infertility, proceeding to IVF after three cycles of clomiphene with IUI was more cost-effective than the standard approach at the time- which required them to go through several additional cycles of injectable ovulation drugs with insemination before allowing them to try IVF. We suspected that immediate IVF without any prior cycles with IUI would be more effective in an older age group but needed to demonstrate that through a rigorous trial.” Marlene Goldman, ScD, Professor at DHMC and first author of the paper stated, “While we recognize that not all patients might choose to start treatment with IVF, the results of this trial will give reproductively older patients with unexplained infertility the evidence they need to skip less effective treatments and start their families more quickly if they wish to do so.”
Goldman et al, A randomized clinical trial to determine optimal infertility treatment in older couples: the Forty and Over Treatment Trial (FORT-T), Fertility and Sterility, in press.
Dr. Julio E. Pabon,
Greetings! You have been nominated again this year as one of Sarasota’s Top Doctors. For the 14th year, Castle-Connolly Medical Ltd. (America’s trusted source for identifying Top Doctors through peer nominations and The Best in American Medicine) has selected Sarasota Magazine as its exclusive partner to publish its annual Top Doctors list because of the excellence of our editorial content and the integrity of our audited circulation.
Keith C. Magnuson
As a busy practicing IVF specialist I welcome good summaries of useful information. Endometriosis is a very common affliction. It is estimated that 15% of the female population has endometriosis while about a third of patients suffering with infertility may have it. As the years pass, more good information is emerging that has diminished the indications for surgery for the endometriosis patient that is infertile. Recently, we have learned that patients may gain little from aggressive removal of ovarian endometriosis because that may significantly reduce their ovarian reserve. More patients are being treated with IVF instead of surgery. Of course, this approach does not apply to patients that need improvement of significant symptoms like pelvic pain, incapacitating menstrual pain, or painful intercourse. Below please find and excellent article written for Medcape by Peter Kovacs, MD, PhD summarizing new guidelines from the European Society of Human Reproduction and Embryology.
ESHRE Guideline: Management of Women With Endometriosis
Dunselman GA, Vermeulen N, Becker C, et al
Hum Reprod. 2014;29:400-412
Endometriosis can be diagnosed when endometrial tissue is found in extrauterine locations. It is found in 10%-15% of the general population and in up to one third of the infertile population. There are various theories that attempt to explain its etiology. Some cases can be explained by retrograde menstruation, but metaplasia, hormonal, inflammatory processes, and abnormal cytokine function also seem to play a role.
A wide variety of symptoms may accompany endometriosis. Some women are asymptomatic, whereas others are affected by dysmenorrhea, menorrhagia, dyspareunia, chronic pelvic pain, and urinary and gastrointestinal symptoms. The symptoms typically recur in a cyclic fashion, and an exacerbation can occur around menstruation.
The diagnosis can be suspected on the basis of symptoms but is established when histologic confirmation of endometrial glands and stroma is made from a tissue biopsy sample obtained from an extrauterine location.
Treatment may involve management of the symptoms, medical therapy to suppress endometriosis, and conservative or definitive surgical therapy. The decision is typically made on the basis of the severity of the symptoms, the age of the patient, her wish for future fertility, and potential contraindications to certain therapies.
This guideline is an update of an earlier one aiming to address all important diagnostic and therapeutic issues related to endometriosis.
The authors discuss that various cyclic symptoms and physical findings may raise the possibility of endometriosis, but the gold standard to establish the diagnosis is histologic analysis of tissue samples obtained at the time of surgery. Ultrasonography, MRI, and certain biomarkers may also raise suspicion but should not be used alone to establish diagnosis.
Empirical treatment of pain (without using surgical confirmation) using analgesics or suppressive therapy with oral contraceptive pills (OCPs) may be appropriate for young patients. Hormonal treatment using OCPs, progestins, androgens, and gonadotropin-releasing hormone (GnRH) agonists are all appropriate to manage pain associated with endometriosis. OCPs, especially if use is extended, are appropriate to manage dysmenorrhea and dyspareunia. GnRH agonists with or without hormonal add-back may also be offered to manage painful symptoms.
Surgery and excision or ablation of endometrial implants is also effective to manage endometriosis-associated cyclic symptoms, and providers are encouraged to proceed with removal of endometriosis at the time of diagnosis (“see and treat”). Ovarian endometriomas should be removed by cystectomy, rather than drainage and coagulation, to avoid recurrence. Deep infiltrating endometriosis should be managed by experienced surgeons, because complication rates are high. There is no proven benefit of hormonal treatment as adjuvant therapy to surgery, but nor is there proven harm with this approach. After cystectomy, hormonal therapy may be offered to reduce the risk for recurrence in patients who do not seek immediate conception.
Dietary supplements, transcutaneous nerve stimulation, traditional Chinese medicine, and acupuncture have not shown to be effective for the management of endometriosis.
Medical therapy alone does not improve one’s chance of achieving a pregnancy and should not be offered for this reason. Surgical treatment of early-stage endometriosis improves fertility outcome. Operative laparoscopy can be considered to manage advanced-stage endometriosis (stage III-IV). Before surgical removal of endometriomas, the ovarian reserve should be assessed and the results should be considered. Hormonal treatment after surgical removal of endometriosis has not been shown to improve fertility outcome.
For the infertile patient with early-stage endometriosis (stage I-II), intrauterine insemination can be offered to improve the chance of pregnancy. Success rates of in vitro fertilization seem to be lower among women with endometriosis, but reports are conflicting. GnRH agonist down-regulation for 3-6 months immediately before IVF may improve treatment outcome. The removal of larger endometriomas (> 3 cm) has not been shown to improve IVF outcome, although surgery is recommended to those with painful symptoms. After surgical removal of endometriomas and before IVF is started, hormonal therapy may be considered to reduce the risk for recurrence.
Postmenopausal women with a history of endometriosis should be offered combined hormonal treatment instead of estrogen alone if hormone replacement is needed.
Endometriosis is a rather common, benign gynecologic disease. It is defined as the presence of endometrial tissue outside the uterine cavity. The diagnosis is established by histologic confirmation of both endometrial glands and stroma in tissue specimens obtained at the time of surgery.
Asymptomatic endometriosis does not require surgical treatment, because the natural course of the disease is not known. Patients with recurrent symptoms that are not responsive to medical treatment and significantly affect everyday quality of life may need to be managed with definitive surgery: removal of the uterus and ovaries. For those with less severe symptoms, a wide variety of therapies can be offered.
Medical therapy may involve the use of nonsteroidal anti-inflammatory drugs when the main problem is the cyclic occurrence of painful symptoms. Hormonal therapy that suppresses endometriosis and induces the regression of endometrial tissue has been shown to improve pain, dysmenorrhea, and dyspareunia. OCPs, progestins, androgens, and GnRH agonists can all be considered for this purpose. Deep infiltrating endometriosis often requires surgical management. The procedure should be done by experienced surgeons, as the risk for bladder and bowel injury is relatively high and it may require the resection of the affected bowel segment.
Endometriosis can be detected in up to one third of infertile women.[3,4] Its impact depends on the stage of the disease. Even early-stage endometriosis may lower implantation rates. Surgical treatment of early-stage disease has been shown to improve pregnancy rates. Advanced-stage endometriosis may distort the anatomy and could result in infertility. Surgical correction can be considered, but most of these patients will eventually require IVF. Suppression of endometriosis with a GnRH agonist or extended OCP use improves IVF outcome.
The management of ovarian cysts may pose a clinical dilemma. One the one hand, cysts may lower the response to stimulation, could interfere with successful oocyte collecting during IVF, and may be associated with pain. They may also increase the risk for adnexal torsion during pregnancy when left untreated. On the other hand, even the most careful surgery could negatively affect ovarian reserve when healthy tissue is removed as well. A patient with already compromised ovarian function is likely not to benefit from the surgery. For those without associated symptoms, the removal of endometriomas is not required. Patients with symptoms associated with endometriosis, however, most likely would benefit from surgery before fertility treatment.
Endometriosis is associated with a wide variety of symptoms, and treatment is needed in symptomatic patients. Treatment may involve surgery, medical therapy, or a combination of the two. The treatment has to be individualized to address the patient’s symptoms and her desire for fertility. Treatment should also be determined by assessing the risk/benefit ratios of the various hormonal surgical options.
- Somigliana E, Infantino M, Benedetti F, Arnoldi M, Calanna G, Ragni G. The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins. Fertil Steril. 2006;86:192-196. Abstract
- Macer ML, Taylor HS. Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am. 2012;39:535-549. Abstract
- Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. Fertil Steril. 2002;77:1148-1155. Abstract
- Harb HM, Gallos ID, Chu J, Harb M, Coomarasamy A. The effect of endometriosis on in vitro fertilisation outcome: a systematic review and meta-analysis. BJOG. 2013;120:1308-1320. Abstract
- Marcoux S, Maheux R, Bérubé S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med. 1997;337:217-222. Abstract
- Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod. 2009;24:496-501. Abstract