A prophylactic salpingectomy or tubal ligation may be performed laparoscopically, using a tubular scope placed through the abdominal cavity to look inside the pelvis. Other instruments are placed through the lower abdominal wall and are used to remove the tube or close off the tube entrance to the uterus. Laparoscopy is performed under general anesthesia in the hospital.

Recently, the use of a contraceptive device, Essure, has been used to obstruct flow of the inflammatory fluid from the hydrosalpinx into the uterus. The Essure is a small coil that is inserted hysteroscopically through a woman’s vagina without cutting into the fallopian tube. It takes 3 months to induce adequate scar closure of the tube and is as effective as a tubal ligation. A hysterosalpingogram is performed after the 3 month period to prove adequate damming of the flow of inflammatory fluid. This procedure may be performed in an office based surgical unit and is sometimes performed without anesthesia.

Dr. Kreiner with Drs. Howard and Georgeanna Jones

In 1987, I completed my Reproductive Endocrinology and Infertility fellowship under  Drs. Howard W. Jones Jr. and his wife Georgeanna Seegar Jones, the two pioneers of in-vitro fertilization in the USA and the entire western hemisphere.

This picture was taken at their house on the Elizabeth River in Norfolk during one of the bimonthly journal clubs.  It was routine for the Joneses to host the journal clubs twice a month during which the entire Reproductive Endocrinology team would discuss interesting cutting edge research in the field.

Learn more about the History of IVF at the Jones Institute here.

Dr. David Kreiner of East Coast Fertility is using his conscience and his expertise to provide solutions in the fertility industry. He is the first in the country to offer an In-Vitro Fertilization (IVF) package using Single Embryo Transfers (SET) at one set price to patients, while still providing high quality care. It can save the healthcare industry $1 Billion.

Plainview, NY, September 23, 2009 –(PR.com)– With all of the negative publicity surrounding the fertility industry in the wake of “octomom” and other sensational news stories, it is no wonder public opinion has turned sour towards the doctors and clinics that perform the services. Society now questions the safety, practicality and costs of aggressive treatments that often result in multiple births. So how do infertile couples pursue a more conservative route to parenthood – one that’s safer for them and their baby, still offers high success rates, yet is affordable? Dr. David Kreiner of East Coast Fertility is using his conscience and his expertise to provide a solution. He is the first in the country to offer an In-Vitro Fertilization (IVF) package using Single Embryo Transfers (SET) at one set price to patients.

In a typical IVF cycle, a doctor will transfer two, three and sometimes more embryos back into the uterus, depending on many factors, in order to achieve the highest chance of success. However, this protocol lends itself to a high risk of multiples, making risky pregnancies, long NICU stays, babies with developmental problems and handicaps, and thus extremely high healthcare costs.

With a Single Embryo Transfer, just one embryo is placed back into the woman’s uterus, nearly eliminating the chance of achieving multiples. The remaining embryos are frozen and can be transferred to the woman in future cycles.

While SET is the optimal choice for many women, the current cost structure favors transferring multiple embryos over this method. Because transferring a single embryo has a lower success rate than transferring multiple embryos, a patient may have to undergo several SET cycles before achieving a successful pregnancy. Clinics charge for each additional procedure. The patients are expected to absorb what could add up to $100 million per year in extra costs. Thus, patients and programs are pressured to transfer dangerously high numbers of embryos. The real irony lies in the fact that research has shown that universal adoption of single embryo transfers could save the healthcare system a total of $1 billion in healthcare costs. Yet, the patients who choose SET are expected to foot the bill.

That’s all changing at East Coast Fertility. Their Single Embryo Transfer Program attempts to take the financial incentive out of this push to put “all your eggs in one basket.” Dr. Kreiner and his staff are making it cost neutral to transfer only one embryo at a time by offering free cryopreservation, free embryo storage and free embryo transfers until a patient achieves a live birth, all for the cost of a single IVF cycle. ECF absorbs the extra costs in cases where successive transfers are needed. So, the patient can choose the more conservative route without having to worry about the financial implications. Dr. Kreiner believes the benefits to the patient and society are obvious, and he doesn’t feel he is sacrificing the success of his practice. “It is with confidence in our highly successful embryo cryopreservation program that we are able to limit the number of embryos transferred without decreasing the number of births that result from IVF cycles at ECF. We are willing to sacrifice some margin in those cases where patients need successive transfers.”

It remains to be seen if other clinics will follow ECF’s lead. Perhaps society should demand that fertility doctors start doing what is best for the patient even if it means having to cut into their profits on occasion. “Hopefully talking about these issues will highlight some of the negative incentives that exist in the world of Reproductive Endocrinology, and bring about change in the industry,” says Pamela Madsen, fertility blogger (www.thefertilityadvocate.com) and founder of The American Fertility Association. She continues, “It is refreshing to see Dr. Kreiner as an ethical standout in the fertility world – a patient activist who is not letting greed get in the way of practicing good medicine.”

The sobering truth: multiple pregnancies — even with ‘just’ twins — are sometimes dangerous to the health and well-being of both mother and babies.

I was on the cutting edge of IVF development in the 1980’s, a time when assisted reproductive technology was so new and inefficient, transferring six embryos in one IVF cycle was the norm.

Since then, thanks to dedicated research to fine-tune IVF, much has been learned about both clinical practice and laboratory technique. IVF is no longer experimental.

One of the most important recent developments — single embryo transfer, or SET — is being consistently backed up by study after study as the optimal IVF method for patients with a good prognosis.

The SET Program

The safest pregnancy with the greatest chances for an optimal outcome — a healthy baby — is a singleton pregnancy. In 2007, East Coast Fertility started leading the field of reproductive medicine by establishing our own SET Program.

Confidence in our high quality embryology laboratory and immensely successful embryo cryopreservation program has afforded ECF the ability to limit the number of embryos transferred, essentially eliminating the risk of triplets or more.

We understand that you’re anxious for fertility treatment to work. Besides your compelling desire to have a baby, you’re coping with worries about the costs — in time, money, and discomfort — of IVF.

So to encourage patients with good prognosis to utilize SET, we offer the following incentive:

For the cost of an IVF cycle, SET Program patients will receive free cryopreservation of their embryos, free storage and free frozen embryo transfers until you have your baby. This represents a savings of up to over $12,000. It also ensures a much better chance of a healthy baby.

Plus, some patients can take advantage of MicroIVF and save even more money and physical discomfort.

Is SET for you?

Each patient’s case is considered individually. Each factor impacting conception and pregnancy is taken into account, such as:
patient’s age
embryo quality
number of prior failed IVF cycles
use of frozen-thawed embryos

Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high. This may include:
women younger than 35 years
women who conceived with first IVF cycle
women with concerns about multiple gestation
donor egg recipients

Single Embryo Transfer is revolutionizing the practice of reproductive medicine, and the team at East Coast Fertility is committed to their collective pledge to lead the way in creating safe, healthy pregnancies.

This is one husband’s story about living with a woman on hormones. It is not always this dramatic but the stress can be very difficult for a couple and many relationships benefit from professional support when going through fertility treatments. Imagine dealing with the stress, frustrations and cyclic disappointment couples feel when trying unsuccessfully to start a family. Add to this that your wife is being pumped up with hormones that have the potential to lower her threshold of rationality and sanity. Outbursts of anger directed at especially those closest to them are very common. Under normal circumstances most of us can control our reactions without letting our emotions get in the way. Hormones can greatly diminish our ability to control our behavior when circumstances become tense and stressful. Hormones have even been used as a defense in murder cases. My recommendation is to get rid of any guns in the house and not respond to apparent emotional outbursts. This should pass when the cycle is completed and the hormones have faded from the system. If not…?

These encounters I have with patients are more frequent than they should be. Unfortunately, many women delay seeking help in their efforts to conceive until their age has become significant both because they have fewer healthy genetically normal eggs and because their ability to respond to fertility drugs with numerous mature eggs is depressed. Women often do not realize that fertility drops as they age starting in their 20s but at an increasing rate in their 30s and to a point that may often be barely treatable in their 40s.

A common reason women delay seeking help is the trend in society to have children at an older age. In the 1960’s it was much less common that women would go to college and seek a career as is typical of women today. The delayed childbearing increases the exposure of women to more sexual partners and a consequent increased risk of developing pelvic inflammatory disease with resulting fallopian tube adhesions. When patients have endometriosis, delaying pregnancy allows the endometriosis to develop further and cause damage to a woman’s ovaries and fallopian tubes. They are more likely to develop diminished ovarian reserve at a younger age due to the destruction of normal ovarian tissue by the endometriosis. Even more important is that aging results in natural depletion of the number of follicles and eggs with an increase in the percentage of these residual eggs that are unhealthy and/or genetically abnormal.

Diminished ovarian reserve is associated with decreased inhibin levels which decreases the negative feedback on the pituitary gland. FSH produced by the pituitary is elevated in response to the diminished ovarian reserve and inhibin levels unless a woman has a cyst producing high estradiol levels which also lowers FSH. This is why we assess estradiol levels at the same time as FSH. Anti-Mullerian Hormone (AMH) can be tested throughout a woman’s menstrual cycle and levels correlate with ovarian reserve. Early follicular ultrasound can be performed to evaluate a woman’s antral follicle count. The antral follicle count also correlates with ovarian reserve.

By screening women annually with hormone tests and ultrasounds a physician may assess whether a woman is at high risk of developing diminished ovarian reserve in the subsequent year. Alerting a woman to her individual fertility status would allow women to adjust their family planning to fit their individual needs.

Aggressive fertility therapy may be the best option when it appears that one is running out of time. Ovulation induction with intrauterine insemination, MicroIVF and IVF are all considerations that speed up the process and allow a patient to take advantage of her residual fertility.

With fertility screening of day 3 estradiol and FSH, AMH and early follicular ultrasound antral follicle counts, the biological clock may still be ticking but at least one may keep an eye on it and know what time it is and act accordingly.

• Injections of the natural hormones FSH and/or LH (gonadotropins) that are normally involved in ovulation every month are used for this purpose

• Additional medications are used to prevent premature ovulation

• An overly vigorous ovarian response can occur, or conversely an inadequate response

Medications may include the following (not a complete list):

- Gonadotropins, or injectable “fertility drugs” (Follistim®, Gonal-F®, Bravelle®, Menopur®): These natural hormones stimulate the ovary in hopes of inducing the simultaneous growth of several oocytes (eggs) over the span of 8 or more days. All injectable fertility drugs have FSH (follicle stimulating hormone), a hormone that will stimulate the growth of your ovarian follicles (which contain the eggs). Some of them also contain LH (luteinizing hormone) or LH like activity. LH is a hormone that may work with FSH to increase the production of estrogen and growth of the follicles. Luveris®, recombinant LH, can also be given as a separate injection in addition to FSH or alternatively, low-dose hCG can be used. These medications are given by subcutaneous or intramuscular injection. Proper dosage of these drugs and the timing of egg recovery require monitoring of the ovarian response, usually by way of blood tests and ultrasound examinations during the ovarian stimulation.

As with all injectable medications, bruising, redness, swelling, or discomfort can occur at the injection site. Rarely, there can be there an allergic reaction to these drugs. The intent of giving these medications is to mature multiple follicles, and many women experience some bloating and minor discomfort as the follicles grow and the ovaries become temporarily enlarged. Up to 2.0 % of women will develop Ovarian Hyperstimulation Syndrome (OHSS) [see full discussion of OHSS in the Risks to Women section which follows]. Other risks and side effects of gonadotropins include, but are not limited to, fatigue, headaches, weight gain, mood swings, nausea, and clots in blood vessels.

Even with pre-treatment attempts to assess response, and even more so with abnormal pre-treatment evaluations of ovarian reserve, the stimulation may result in very few follicles developing, the end result may be few or no eggs obtained at egg retrieval or even cancellation of the treatment cycle prior to egg retrieval. Some research suggested that the risk of ovarian tumors may increase in women who take any fertility drugs over a long period of time. These studies had significant flaws which limited the strength of the conclusions. More recent studies have not confirmed this risk. A major risk factor for ovarian cancer is infertility per se, suggesting that early reports may have falsely attributed the risk resulting from infertility to the use of medications to overcome it. In these studies, conception lowered the risk of ovarian tumors to that of fertile women.

- GnRH-agonists (Leuprolide acetate) (Lupron®): This medication is taken by injection. There are two forms of the medication: A short acting medication requiring daily injections and a long-acting preparation lasting for 1-3 months. The primary role of this medication is to prevent a premature LH surge, which could result in the release of eggs before they are ready to be retrieved. Since GnRH-agonists initially cause a release of FSH and LH from the pituitary, they can also be used to start the growth of the follicles or initiate the final stages of egg maturation. Though leuprolide acetate is an FDA (Federal Drug Administration) approved medication, it has not been approved for use in IVF, although it has routinely been used in this way for more than 20 years. Potential side effects usually experienced with long-term use include but are not limited to hot flashes, vaginal dryness, bone loss, nausea, vomiting, skin reactions at the injection site, fluid retention, muscle aches, headaches, and depression. No long term or serious side effects are known. Since GnRH-a are oftentimes administered after ovulation, it is possible that they will be taken early in pregnancy. The safest course of action is to use a barrier method of contraception (condoms) the month you will be starting the GnRH-a. GnRH-a have not been associated with any fetal malformations however you should discontinue use of the GnRH-a as soon as pregnancy is confirmed.

- GnRH-antagonists (Ganirelix Acetate or Cetrorelix Acetate) (Antagon®, Cetrotide®):

These are another class of medications used to prevent premature ovulation. They tend to be used for short periods of time in the late stages of ovarian stimulation. The potential side effects include, but are not limited to, abdominal pain, headaches, skin reaction at the injection site, and nausea.

- Human chorionic gonadotropin (hCG) (Profasi®, Novarel®, Pregnyl®, Ovidrel®): hCG is a natural hormone used in IVF to induce the eggs to become mature and fertilizable. The timing of this medication is critical to retrieve mature eggs. Potential side effects include, but are not limited to breast tenderness, bloating, and pelvic discomfort.

- Progesterone, and in some cases, estradiol: Progesterone and estradiol are hormones normally produced by the ovaries after ovulation. After egg retrieval in some women, the ovaries will not produce adequate amounts of these hormones for long enough to fully support a pregnancy. Accordingly, supplemental progesterone, and in some cases estradiol, are given to ensure adequate hormonal support of the uterine lining. Progesterone is usually given by injection or by the vaginal route (Endometrin®, Crinone®, Prochieve®, Prometrium®, or pharmacist-compounded suppositories) after egg retrieval. Progesterone is often continued for some weeks after a pregnancy has been confirmed. Progesterone has not been associated with an increase in fetal abnormalities.

Side effects of progesterone include depression, sleepiness, allergic reaction and if given by intra-muscular injection includes the additional risk of infection or pain at the application site. Estradiol, if given, can be by oral, trans-dermal, intramuscular, or vaginal administration. Side effects of estradiol include nausea, irritation at the injection site if given by the trans-dermal route and the risk of blood clots or stroke.

- Oral contraceptive pills: Many treatment protocols include oral contraceptive pills to be taken for 2 to 4 weeks before gonadotropin injections are started in order to suppresshormone production or to schedule a cycle. Side effects include unscheduled bleeding, headache, breast tenderness, nausea, swelling and the risk of blood clots or stroke.

- Other medications: Antibiotics may be given for a short time during the treatment cycle to reduce the risk of infection associated with egg retrieval or embryo transfer. Antibiotic use may be associated with causing a yeast infection, nausea, vomiting, diarrhea, rashes, sensitivity to the sun, and allergic reactions. Anti-anxiety medications or muscle relaxants may be recommended prior to the embryo transfer; the most common side effect is drowsiness. Other medications such as steroids, heparin, low molecular weight heparin or aspirin may also be included in the treatment protocol.