Couples attempting to achieve pregnancy may want to consider genetic counseling and genetic screening. Couples may be at increased risk for carrying genes that could cause genetic disease in their child if they have had a child with a genetic disease or if either member of the couple has a history of a genetic disease, has a family history of particular diseases, or is of a particular ethnic background. For example, people of northern European descent have a 1/25 chance of carrying one copy of the gene for cystic fibrosis. If both parents are carriers, they have a 25% chance of having a child with cystic fibrosis, a serious disease that primarily affects the lungs and pancreas. Similarly, individuals of Jewish ancestry are at increased risk of carrying a gene for Tay –Sachs disease. This fatal disease affects a child when two genes are inherited, one from the father and one from the mother.
The following is a questionnaire designed to assess whether or not genetic counseling and screening may be appropriate for you. If you do not understand a question, please note this on the form. The physician will review your questions at your initial visit. If desired, genetic counseling and/or screening can then be arranged.
Thank you,
The Saint Barnabas Institute for Reproductive Medicine
Family History
Do you or any family members have (check all that apply and indicate relationship to you):
_____ Northern European (English, Irish, German, Polish, French, Norwegian, etc.)
_____ Southern European (Greek, Italian, Spanish)
_____ Hispanic
_____ African-American/African/Black
_____ Asian or Pacific Islander
_____ Native American (American Indian including Aleut and Eskimo)
_____ French Canadian
_____ Jewish
_____ Other (please explain)
CMV: What you Need to Know
Cytomegalovirus: Information for Patients
Cytomegalovirus (CMV) is a virus in the herpes group of viruses. It may cause no symptoms at all, a very bad cold, or more serious illnesses such as hepatitis or a mononucleosis-like syndrome (low grade fever, extreme fatigue, head cold symptoms). In the general population, the prevalence of CMV antibodies is about 60%. People who have antibodies have been exposed to the virus and mounted a defense (antibodies) against the virus. In most adults and children, getting CMV is not a problem. However, getting or having a current infection when you are pregnant is a very serious thing.
CMV can be transmitted from the mother to the child across the placenta, or during birth. Infection with CMV during pregnancy can cause low-birth-weight infants, jaundice, liver enlargement, deafness, eye infections, neurological damage, and death.
WHY WE TEST FOR CMV
CMV is the most common infectious cause of congenital defects. Obviously it is very important to test for current CMV infection. It is often difficult to know if you’ve come in contact with the virus since the symptoms can be very mild or non-existent. The test we use is based on two different types of antibodies that your body will make in response to a CMV infection. If you had a previous CMV infection, only the IgG type of antibodies will be positive. This means that some time in the past, you were exposed to the CMV virus, and your body created antibodies to fight the virus. If you have a current or recent infection, and may still be shedding virus, the IgM type of antibody will be present in your blood. This type of antibody is the first response your body makes to the infection. A positive result on the IgM antibody test means that you are currently fighting the virus. Because infection during pregnancy is so dangerous, we request patients to wait 3 months before they start any assisted reproduction cycle. After 3 months, you can resume treatment. If you are negative for all the CMV antibodies, you should be retested yearly if you continue to attempt conception.
HOW TO AVOID CMV
If you do not have CMV protective antibodies, you are susceptible to CMV infection. CMV is passed via respiratory droplets, urine and other bodily secretions. Good hygiene, hand washing and avoidance of close contact with people with symptoms of a viral infection will significantly decrease the risk of transmission.
Cmv/ckm/2001
Becoming an Egg Donor
Egg Donation:
A Step By Step Guide for the Donor
Most couples never think they will have trouble starting a family; yet one in five couples of childbearing age will experience the pain of infertility. This can be a devastating experience.
The Institute for Reproductive Medicine and Science of Saint Barnabas
Now, with the assistance of today’s revolutionary fertility treatments, couples have a better chance than ever of becoming pregnant. The Institute for Reproductive Medicine reports pregnancy rates that are among the highest in the nation. Our medical staff includes internationally renowned specialists in infertility treatment, as well as distinguished embryologists and biologists who pioneered many of the assisted reproductive techniques in use today.
Initial Consultation and Screening
All donors undergo a screening to determine whether or not egg donation is appropriate for them. This includes laboratory work to study the individual’s level of day 3 FSH level, an indicator of whether or not she would be a suitable candidate. Other laboratory testing, such as HIV, blood type and other bloodwork, is performed. This is followed by a two-part psychological screening that includes a Personality Index Test and interviews with a nurse and mental health professional. Finally, a physician performs a medical examination.
There are two types of egg donors, known and anonymous. The known donor is usually a relative or friend of the recipient. The anonymous donor does not meet the recipient. Anonymous donors provide recipients with a medical history, educational background and psychological profile, all arranged through The Institute. After retrieval, the anonymous donor is not told whether or not the donation of her eggs resulted in a pregnancy.
Although currently anonymous, these donors should be aware that in the future the legal system could reverse their anonymity. The Institute takes multiple precautions to protect the privacy of the donors.
Egg Donation at The Institute: Step One: Matching Donor and Recipients
Each egg donor is notified when a match has been made with a potential recipient. At this time, the nurse and the egg donor reserve a period of time for the procedure, and The Institute orders injectable medications. The egg donor now begins a class and receives detailed instructions on how to properly administer the injectables. The dose of the medication, the time it is administered and the duration of treatment vary from person to person.
Step Two: Creating the Optimum Cycle
The egg donor calls the nurse as soon as her menstruation occurs. Then, with the help of birth control pills, both the donor and recipient cycles are synchronized. In order to maximize egg donation, the egg donor undergoes stimulation of her ovaries so that multiple eggs may be harvested. More than one egg is needed because not every egg will be healthy and not every healthy egg will produce a pregnancy.
Lupron, an injectable medication, is then taken by the donor. It prevents the eggs from releasing too early. Gonadotropins, which stimulate multiple egg production are injected by the egg donor at home and require daily administration. They are injected for an average of ten days per cycle.
During the critical two-week period close to ovulation, the egg donor begins to take her injectable fertility medication. Lupron is usually taken for two and a half weeks and is usually well tolerated, but may cause side effects. Any questions or concerns about symptoms you are experiencing should be reviewed with your nurse.
Of Note:
· During the stimulation cycle, the Institute recommends abstinence from intercourse, as the donor is especially fertile while on these medications. If intercourse takes place, the use of condoms and spermicide is strongly recommended to prevent pregnancy and sexually transmitted diseases.
· It is important to inform the Ovum Donation Team about any medications (prescription and over-the-counter), diets, nutritional supplements and herbal remedies you are taking. In general, during the donation cycle, any non-essential medications should be stopped. Please review this with the nurse prior to making any changes on your own.
· Tattooing and piercing should not be done within 1 year of egg donation to prevent the risk of transmission of hepatitis and HIV.
Step Three: Monitoring the Cycle
Once the stimulation cycle has started, the egg donor comes to either The Institute in Livingston or the designated satellite, in the morning every 1-3 days to be evaluated for follicle maturation. This is determined by daily blood levels and ultrasound, which are performed between 6:30 and 7:30 a.m. Monitoring is performed in the morning so that the results are available by the afternoon for review by the physician. The nurse will call you at that time to make any necessary medication adjustments and to let you know when to return for more testing.
Sometimes donors have other commitments that may interfere with the cycle, and it is important to inform the team fully about this. Not everyone responds the same way to the medications and the cycle schedule does not always go as planned. Once the stimulation starts, the donor must be available for monitoring every day if necessary until the retrieval takes place. It is usually two weeks from the beginning to the retrieval, but may take several days longer.
Step Four: The hCG Injection
At an exact time determined by the physician, an injection of human Chorionic Gonadotropin (hCG) is given to bring the eggs to final maturity. This injection is performed at home and the donor needs someone else to administer the medication because it is an intramuscular injection.
The timing of the hCG injection is critical to the success of the cycle. If it is given too early or too late, it could significantly lower the chances for obtaining healthy eggs. If you experience any problems with the injection, please notify the nurse immediately. A nurse or physician is on call 24 hours a day, 7 days a week and 365 days a year through our main number.
Retrieving The Eggs: The Final Step
The night before the egg retrieval, the donor should neither eat nor drink because the procedure involves the use of intravenous anesthesia. On the day of the event, each patient must be accompanied by a person who can drive her home and stay with her for 24 hours after the procedure. At 36 hours after the administration of hCG, eggs are harvested from the donor. This procedure is performed at The Institute’s operating facility at the Atkins Kent Building, across the street from the Medical Center.
Retrieval involves aspirating the fluid in the ovarian follicles with a special needle to obtain the eggs. The pain-free procedure, performed with the patient under intravenous anesthesia, is done in the Same Day Surgery Center by a physician using ultrasound visualization and does not require an incision.
Egg donors can return home a few hours after the egg retrieval. Safety regulations restrict the patient from operating machinery after sedation. The donor should rest that day and avoid intercourse or aerobic activity. It is important that the donor have a companion for the first 24 hours after the retrieval. Although complications are unlikely, the most common time for serious complications to occur is during the 24 hours after retrieval.
Of Note:
Intercourse should be avoided to prevent unwanted pregnancy in the donor and infection in the donor after retrieval.
Aftercare for the Egg Donor
To make sure that she recovers completely from the egg retrieval, each donor should follow a few simple guidelines.
1. Check in with The Institute within 24 to 48 hours after egg donation.
2. Take an antibiotic the day of the retrieval and finish the entire four-day dose. Antibiotics protect against any infection.
3. Get plenty of rest the day of the egg retrieval.
4. Resume your regular diet, but supplement it with plenty of extra fluids.
5. Be aware that you will be extremely fertile in the time before your next menstruation and unprotected intercourse could result in a pregnancy.
6. Avoid aerobic or high impact activity.
7. Avoid intercourse as the ovaries are fragile at this point and excessive movement of the ovaries could increase the risk for bleeding and twisting of the ovaries.
8. Weigh yourself every day and call the Institute if you notice more than a 2-pound weight gain in one day.
9. Monitor your urine output. If it is significantly less than the amount you are drinking or the urine becomes dark, please contact the Institute and speak with a nurse.
10. Please call a nurse at the Institute should any pain, fever, nausea, vomiting or bleeding occur.
11. Make sure that you have a companion stay with you for the first 24 hours after retrieval. This is a requirement for your safety.
12. Call The Institute immediately should any complications occur.
Follow Up/Compensation
Donors can expect to begin menstruation approximately 14 days after the egg retrieval. At this time, the donor should call the nurse to schedule a Day Three Ultrasound appointment at The Institute. This final step ensures that the ovaries have returned to normal size.
At this last appointment, all donors who have completed the retrieval process receive a compensation check.
Donating Again
After the retrieval process, some egg donors wish to donate more eggs. Many donors can donate more than one time. These issues should be discussed with a nurse at The Institute.
Frequently Asked Questions About Egg Donation
Q. Will it hurt?
A. You may experience some mild lower abdominal discomfort while on the medications. During the retrieval you will be completely asleep. After the retrieval you will have mild to moderate pelvic discomfort for 24-72 hours. During this time you may take over the counter pain medications. If these are not effective, you should contact a nurse at the Institute.
Q. How will this affect my ability to have children of my own?
A. Theoretically, serious complications of egg donation could diminish your future fertility. To our knowledge, no such case has ever been reported. To the best of our knowledge, an uncomplicated donor cycle should not affect your ability to have children in the future. However, egg donation is less than 20 years old and longer-term effects are not known.
Q. Will ovum donation cause cancer?
A. There have been some studies linking fertility medications to an increased risk of ovarian cancer. Many other studies show no increased risk, so this is an area of controversy. It there is an increased risk, that risk is low and can be decreased by the use of oral contraceptive pills (the birth control pill).
Q. What will the psychologist ask me?
A. Questions that will be asked by the mental health professional relate to your reasons for wanting to be a donor and how you feel about sharing your genetics with another individual (offspring of the recipient) that you may never know. In addition, the psychological interview is designed to help you determine if egg donation is right for you.
Q. What does the medical exam entail?
A. This is a routine physical exam of the heart, lungs, abdomen and pelvis. Tests performed at the time of the exam include a Pap smear and cervical cultures. A transvaginal ultrasound is done to view your uterus and ovaries and help the physician determine the proper dose of fertility medications to give you during the cycle. A probe is placed in the vagina to give the optimal view of the pelvis. The ultrasound study is brief and causes less discomfort than a standard speculum exam.
Q. How will I feel on the medications?
A. Most donors have no side effects. When side effects do occur, they are usually very mild. The most common symptoms are fatigue and mild pelvic cramping. Rarely, donors may have significant pelvic discomfort, moodiness, headaches and bloating.
Q. What are the risks of being an egg donor?
A. Donors may risk psychological distress if they are rejected from the program or if the screening process uncovers a previously unknown medical problem. Donors rarely experience Ovarian Hyperstimulation Syndrome (OHSS), a condition where the ovaries become overly enlarged. This may require bedrest and extra testing to monitor. In extremely rare cases, a donor may require hospitalization. Careful monitoring can reduce this risk. Very rarely, torsion (twisting of the ovary), bleeding or infection of the pelvis may occur. Whether or not the risk of ovarian cancer may be slightly increased is unknown at this time (see above).
Q. What does it mean if I am rejected?
A. The most common reason for rejection is a donor profile that does not match the needs of the recipient population. If the reason for rejection has implications for the donor's health, the Institute team will notify the candidate so that she may receive the medical follow up she needs.
With the help of egg donors, The Institute has helped to make dreams come true for many families. For more information on becoming an egg donor, please call The Institute at 1 (800) 824-3123 or email claudiap@sbivf.com.
Your
doctor has ordered pre-operative bowel prep for you. This procedure
will decrease the contents in the bowel, making your surgery easier.
Materials
1 bottle of magnesium citrate 2 Fleet’s Enema’s
These may be bought over the counter at any pharmacy.
The day before your surgery:
Umbilicus
(navel or belly button): The incision for laparoscopy will be in or
near the umbilicus. Please gently clean the area with soap, water and
cotton swabs before surgery to reduce the risk of infection.
Clear liquid diet all day. (i.e. clear soups, juice, water, tea and coffee)
· Please limit caffeine consumption. · No milk or solid foods are allowed. · Drink plenty of fluids so you will not get dehydrated.
Take
one half of the bottle of magnesium citrate in the morning and half in
the afternoon. This preparation will stimulate the bowels to empty. Do
not take it just before bed.
Fleet’s Enema: In the afternoon and
then again in the early evening. This will also stimulate the bowels to
empty. Allow time for the enema to work before going to bed.
Nothing
by mouth after midnight. You must have an empty stomach before surgery
otherwise your surgery will be cancelled. Do not even sip water when
brushing your teeth in the morning. You may be instructed to take
medications, if so, you may take them with a small sip of water.
DO
NOT FORGET TO inform the anesthesiologist when you meet with him or her
before the surgery that you have had a bowel preparation. The
anesthesiologist may want to increase your intravenous fluids.
Polycystic Ovarian Syndrome
By Serena H. Chen, MD
Polycystic
Ovarian Syndrome or PCOS affects 6% of women of reproductive age. Many
women with chronically irregular periods may have PCOS without
realizing it. It is important to know about PCOS because it can affect
not only your ability to conceive but your general health as well.
While the cause for PCOS is unknown and there is no “cure” for this
condition, you can lower your health risks by knowing about PCOS and
taking advantage of the management options available.
Irving
Stein and Michael Leventhal first recognized PCOS in the 1920’s when
they noted an association between no menstrual periods or infrequent
periods, bilateral polycystic ovaries, obesity and excessive male
pattern hair growth or hirsutism. As a result, PCOS was formerly known
as Stein-Leventhal syndrome. However, other names given to this
condition include: Hyperandrogenic Chronic Anovulation and PCOD or
Polycystic Ovarian Disease. Today PCOS is preferred because researchers
do not know the cause of this syndrome and not all women with PCOS have
all the symptoms described by Stein and Leventhal.
DIAGNOSIS
How
do you know if you have PCOS? Unfortunately, there is no single test
that will tell you that you have PCOS. Women with this syndrome usually
have irregular menses from the time they start having periods.
Therefore, this is the most common and reliable symptom of PCOS.
Irregular menses are classified as cycles that are longer than 35 days
from the first day of bleeding to the day before the next bleed, or
less than 8 cycles per year.
In response to this common
symptom, many women with PCOS are given oral contraceptive pills to
regulate their menses, but are not formally diagnosed with PCOS. To
obtain a diagnosis, the physician must rule out other possible causes
for irregular menses. Usually this involves checking a pregnancy test,
checking your thyroid function with a TSH (thyroid stimulating hormone)
level, and checking a prolactin level as well. These are all simple
blood tests. If your physician suspects PCOS, you may be given
medroxyprogesterone acetate (brand name Provera) to see if it will
induce a period. This can help differentiate PCOS from other causes of
no menses such as ovarian failure and hypothalamic amenorrhea. Women
with these conditions have low estrogen levels and usually will not
bleed in response to Provera. Women with PCOS will have normal to
slightly elevated estrogen levels and will usually have a full period
after this medication.
Many women with PCOS will have problems
with acne and hirsutism – excessive hair growth on the face, chest and
abdomen. These are signs of elevated levels of male hormones or
androgens and are seen in up to 80% of women with PCOS. If you have
these symptoms your doctor may order testosterone, DHEAS and 17 hydroxy
progesterone blood levels. If your symptoms are mild, these are not
necessary. If they are moderate to severe, these tests will rule out
hormone producing tumors and adrenal disorders that can look like PCOS.
Other characteristics of PCOS include excess weight, multiple
small follicles on ovarian ultrasound and an elevated LH:FSH ratio in
the blood. About 50% of women with PCOS are overweight, making this
characteristic consistent with PCOS, but not conclusive from a
diagnostic standpoint. About 80% of women with PCOS have polycystic
ovaries on ultrasound, but 20% of women with PCOS will have normal
appearing ovaries on ultrasound and 20% of normal women will have
polycystic ovaries on ultrasound. Therefore, like excess weight,
ultrasound can support a diagnosis of PCOS but not make it.
Another
supporting test is the LH:FSH ratio. LH is luteinizing hormone and FSH
is follicle-stimulating hormone, both of which are made by the brain.
Dysfunctional signaling between the ovary and the brain in women with
PCOS leads to elevated LH:FSH ratios (greater than 3). These are
indicative of PCOS because elevated LH levels cause elevations in male
hormones and irregular ovulation, which leads to irregular periods. In
ovarian failure, FSH levels are elevated. In hypothalamic amenorrhea,
FSH and LH levels are normal or low.
IMPACT OF PCOS UPON YOUR HEALTH
Why
is it important to know whether you have PCOS? PCOS not only causes
irregular menstrual cycles, it puts you at increased risk for other
health problems. However, these risks can be decreased or minimized if
managed correctly. Irregular menses are a result of chronic
anovulation. The ovary produces estrogen, but it does not release eggs
and does not produce progesterone. Not only is progesterone necessary
for pregnancy, but it also prevents overgrowth of the lining of the
uterus. Overgrowth of the lining of the uterus can lead to heavy
bleeding, and after years of irregular periods, to cancer of the lining
of the uterus. Irregular and infrequent ovulation leads to problems
conceiving for most women with PCOS.
Recently researchers have
found that many women with PCOS have elevated insulin levels or
hyperinsulinemia and are resistant to insulin action. Insulin
resistance can lead to a variety of health problems including obesity.
Obesity in turn worsens insulin resistance, but even thin women with
PCOS have higher than normal insulin levels. Because of this resistance
to insulin, PCOS patients have an increased risk of developing
diabetes, high blood pressure, high cholesterol and heart disease. In
the past, physicians have considered PCOS to be a gynecologic disorder,
but we now know that PCOS can have a negative impact on a woman’s
overall health.
TREATMENT
How is PCOS treated?
Because PCOS can affect many different aspects of a woman’s health, a
multi-pronged treatment plan is often necessary. The treatment for
irregular menses depends upon whether or not a woman with PCOS is
trying to conceive. For women not trying to conceive, the oral
contraceptive pill is a safe and effective treatment for most women.
The birth control pill can regulate your period, provide very effective
protection against endometrial cancer and can improve symptoms of
hyperandrogenism such as hirsutism and acne. An alternative is periodic
treatment with progesterone to induce menses.
For women
attempting to conceive, the first line of therapy is often clomiphene
citrate, a pill that can induce ovulation in 80% of patients with PCOS.
For women who do not repond to clomiphene citrate, more advanced
treatment with insulin sensitizing agents and/or injectable
gonadotropins may be recommended. These more advanced treatments should
be monitored by a specialist with experience in using these drugs in
women with PCOS. PCOS patients are very sensitive to stimulation with
gonadotropins and at high risk for ovarian hyperstimulation syndrome if
not properly monitored.
For treatment of hirsutism and acne, a
combination of medication to lower androgen levels and local treatment
such as electrolysis may be necessary. The oral contraceptive pill is a
very effective treatment for lowering androgen levels in the skin. It
is even more effective when combined with spironolactone, a mild
diuretic that also acts as an antiandrogen in the skin and hair
follicle. Spironolactone must be used with an effective contraceptive
since it can feminize a male fetus if used in early pregnancy. There
also are many other agents that are effective in treating hirsutism and
acne in PCOS. These include flutamide, cyproterone acetate (not
available in the USA), ketoconazole and finasteride. However, none of
these agents has been shown to be more effective than the birth control
pill and/or spironolactone. All are more expensive and many have a
higher rate of significant side effects. So the oral contraceptive pill
and/or spironolactone remain the first choice for treatment of
hirsutism and acne.
What about the effects of PCOS on
metabolism? Is there a way to lower the risk of diabetes, high blood
pressure, high cholesterol and heart disease? The high insulin levels
seen in PCOS increase the risks for these serious health problems and
make weight loss more difficult for overweight PCOS patients. However,
weight control is critical for your health if you have PCOS and as few
as 5 to 10 pounds can make measurable improvements in insulin levels,
glucose tolerance, blood pressure and cholesterol levels. All patients
with PCOS should make a balanced diet and regular exercise a top
priority. Although it may be difficult reaching an ideal weight, you
should be encouraged knowing that even small improvements can make
significant differences in your health.
What about the new drugs
for PCOS? Researchers have demonstrated very promising results with
insulin-lowering agents that improve hormonal and metabolic parameters
in patients with PCOS, induce ovulation and improve pregnancy rates.
The most studied of these agents, which can be used alone or in
combination with fertility drugs, is metformin (brand name Glucophage).
Metformin, used for the last 20 years to treat diabetics, lowers
insulin levels without causing hypoglycemia, so non-diabetic women with
PCOS can tolerate the drug. This drug may help a patient lower her
insulin levels so her body will be more responsive to diet and
exercise, and it has been used successfully to induce ovulation in PCOS
patients who were very resistant to fertility drugs. However, it
remains to be seen whether long-term use will be beneficial and, while
the drug is unlikely to cause serious side effects, many people
experience nausea and diarrhea. This requires that the drug be started
in low doses and gradually increased and that the patient be monitored
carefully. Troglitazone (brand name Rezulin), which is more effective
than metformin in lowering insulin levels, has been used effectively in
PCOS. However, the FDA has withdrawn it, due to concern about side
effects. Other agents related to troglitizone may be safer and
available in the future. Another promising agent that seems to be well
tolerated is currently in clinical trials: D-chiro-inositol, which also
lowers insulin levels.
SUMMARY
PCOS, a common cause
for irregular menses, can have serious consequences for a women’s
reproductive and general health. If you think you may have PCOS it is
important to have a thorough evaluation. Weight control through a
sensible diet and exercise plan is crucial for women with PCOS and may
improve symptoms and response to treatment. While there is no cure for
PCOS, there are effective treatments available to manage the symptoms.
Speak with your doctor about the options that are best for you.
Copyright Serena H. Chen, 2000, all rights reserved.
