“Unexplained infertility” explained: insights into one of the common diagnoses for couples trying to conceive

When couples are trying unsuccessfully to conceive and then present for evaluation—a variety of standardized tests are performed. If these tests all return with reassuring results, they are left with a diagnosis of “Unexplained Infertility” (ICD-10 Code 97.9). This is the treatment code used for about a third of patients diagnosed/treated in the USA. For many couples, this is very unsettling. In this episode of our Clinical Conversation series we try to provide details on what this means. Our hope is that this information is reassuring and helps more people move on from the diagnostic phase to the treatment phase with greater confidence.     

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Unexplained Infertility (17:20):  https://youtu.be/oTFw-3QV_hc

0:55 Unexplained Infertility—brief definition and use in coding

2:00 How if “infertility” defined

3:50 Creating a new definition: “Infertility, unspecified”

6:46 Sometimes greater clarification of diagnosis is revealed during treatment

                —(9:00) Example: Implantation Problems

9:45 When to stop testing—balancing risk vs benefit vs cost

11:30 Moving from Testing to Treatment

                –(12:15) Example: Male Factor—mild vs moderate

14:00 Each patient / couple has unique circumstanced making diagnosis more challenging

With kindness and optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

ENDOMETRIOSIS UPDATE; latest information on how it impacts fertility

We have been talking about endometriosis since I began my career as a fertility specialist in 1995. Yet it is really over the last several years that I feel we are finally beginning to understand the various ways it can impact fertility. Like most disorders, it is a condition on a spectrum that can manifest in various ways with varying implications.  Here is a link to an episode of our Clinical Conversation series where I am sharing some of the latest science.  This episode includes some questions submitted by some of our regular listeners. I hope you find it to be helpful.

Endometriosis: clinical conversations with Dr. Greene and fertility coach Lisa White

(~27 minutes):  https://youtu.be/znrz0IoRGv4

0:35 Definition: what is endometriosis?  

2:50 How common is endometriosis?

4:30 How can you rule out endometriosis as a contributing factor?

4:50 Submitted question: Do you approach IVF differently in women with endometriosis?

–Endometrioma

–Implications on egg quality

9:15 Submitted question: Is it safe to have endometriosis during a pregnancy?

                —some rare forms of endometriosis described

11:00 Submitted question: Are we seeing an increase in women with endometriosis?   

12:30 Some Diet/lifestyle tips to reduce the risk od developing endometriosis?

—BONUS: link to recent article from EndometriosisNews

14:30 What supplements do you recommend for endometriosis

                —Pycnogenol: link to previous blog post

                —BONUS: new research suggests curcumin may also be of benefit

19:40 Submitted question: Is it a good idea to treat endometriosis prior to IVF?

21:30 Endometriosis and Egg Quality

—BONUS:  One topic that I overlooked in this review is emerging data on how

                Endometriosis can cause hardening of the surface of the egg which can be overcome

                by using ICSI to fertilize the eggs. Here is a link to supporting research.

24:00 What about adenomyosis (endometriosis in the muscle of the uterus)?

—BONUS: There is a test for inflammation due to endometriosis as a factor in implantation failure. It is called a Receptiva-BCL6 test. Here is a link to additional information. 

As you can note, this is such a large topic with so much information we are still learning. Use this information to assist in guiding your treatment decisions.

With informed optimism,

~Robert

Robert Greene, MD, FACOG Conceptions Reproductive Associates of Colorado

DIET, LIFESTYLE AND FERTILITY: emerging science on steps to improve outcome

There is a growing body of research that explains how we can actively improve our own health, wellness and fertility. It involves paying attention to our food choices, our activities and the chemicals that we allow ourselves to be exposed to through our choices as consumers. Here is a link to Clinical Conversation episode where I am sharing some of the latest science. 

Fertile 2021: nutrition and lifestyle (29:53):  https://youtu.be/kkC1R4Orn8c

1:00 Moving beyond theories and popular recommendations

2:00 Creating evidence-based diet-lifestyle tips to boost health, wellness and fertility

2:50 Food—let’s define what we need it to do

5.25 Moving from surviving to thriving

6:10 Eating Mindfully

                —Seeking foods in their most natural state

                —9:00 Food preparation methods (i.e., microwave oven, air fryers, etc)

                —11:30 Organic—why it matters

                —12:15 Plant-based eating

                —13:00 Timing healthy changes to fertility treatment

                —15:50 SIRT foods

                —16:40 Intermittent Fasting; what it is and why it may help

                —19:30 Concerns of ketogenic diets during fertility treatment/pregnancy

                —20:15 Alcohol—total abstinence may not be needed

22:15 Emotional Stress and is management

                —Meditation and slow deep breathing

                —Studies on fertility and egg quality

24:50 Some Additional Tips to consider

—Sleep and the potential role of melatonin

—Exposure to cold temperatures may have health promoting benefits

—Forest-bathing; emerging science how trees can influence immune resonse

27:45 Follow the evidence and make your decisions consciously

With informed optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

COVID Vaccination Guideline for Fertility Patients and Pregnant Women: Phase 1

As we proceed with the first efforts to vaccinate against SARS-CoV-2; many patients are scrambling to decide how they feel about receiving a vaccination. The current efforts are complicated by opinions that are often driven by politics. The goal of this clinical conversation is provide you with the science—so that you can make your own evidence based decision.  It is also worth nothing that organizations that guide healthcare professions are supporting the use of the vaccine for women that are pregnant or breastfeeding. These organizations include The American College of OB/GYN (ACOG), The American Society for Reproductive Medicine (ASRM), The American Society for Maternal-Fetal Medicine (SMFM) as well as the US Center for Disease Prevention and Control (CDC). In case you don’t want to listen to the entire conversation, here’s the listening guide.

Fertility Treatment+COVID+Vaccine (26:09): https://youtu.be/WpQ0M_IreLQ

1:10  Become informed so you can make your own choice

1:45  Perspective on status (mid December 2020)

4:20 What makes these first vaccines unique ?

6:15 Why are these new vaccines considered so safe?

                ***Listener’s note; this recorded live and I correct myself a couple of times for

                                Mistakenly using the word “virus” instead of  “vaccine”

10:30 [UPDATE] This vaccine has now been approved and is in use

11:45 Why does these vaccines use two injections?  

14:00 Recommendations for women currently going through fertility treatment

17:00 What about women that are currently pregnant or breastfeeding?

20:00 What about vaccines for other preventable diseases like measles?

21:45 Importance of being informed so that you can make an educated decision

23:00 Experience of other democratic countries and how they’re dealing with this pandemic

25:00 Note of gratitude

Stay informed,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

UPDATE:

ACOG Statement on the Johnson & Johnson COVID-19 Vaccine

On April 13, 2021, ACOG released a statement following the CDC and FDA decision to put the Johnson & Johnson COVID-19 vaccination program on hold.

“At this time, there is no clear phenotype of women who are more or less likely to experience this rare complication. However, until there is a better understanding of the frequency and impact of this finding, it will be important to encourage pregnant and postpartum women who wish to be vaccinated to receive the mRNA vaccines: Pfizer or Moderna.

“Individuals who have been vaccinated with the Johnson & Johnson vaccine within the last 21 days who experience severe headache, abdominal pain, leg pain, or shortness of breath should seek immediate evaluation. They should be certain to communicate that they have received the Johnson & Johnson vaccine to prompt appropriate evaluation. Given the elevated risk for thrombosis experienced by women during pregnancy or the postpartum period and while using birth control pills, evaluation of acute thrombosis is commonly performed in our specialty. Rapid treatment with anticoagulation is the standard; however, this is not the same event and anticoagulation for treatment of CVST is dangerous.” Read the full statement.

Introduction to Egg Quality: optimizing pregnancy rates and minimizing miscarriage risk

Too many people rely upon their fertility center to create results. In reality, one of the most important aspects of fertility treatment in determining success is egg quality. I’ve been doing a deep dive on the latest research to try to determine what can be done to optimize egg quality. Attached is a link to a Clinical Conversation created to begin analyzing this topic. The goal is to provide women with data-driven practical tips. I hope that you find this helpful as well as motivating to help you begin making some healthy choices to insure your success:

Egg Quality Part 1 (23:10): https://youtu.be/QTr8M-Pij30

  • 1:20 natural pregnancy rate
  • 3:00 Comparison of Sperm Quality vs Egg Quality and how they impact natural rates
  • 5:00 Components for estimating Egg Quality
  • 7:00 Aspects of egg quality
  •                 —DNA
  •                 —Mitochondria
  •                 —Other physical components of the egg
  •                 —Metabolism of the egg
  • 9:00 A new perspective on fertility treatment
  • 10:45 Age and egg quality / egg number
  • 13:00 Emerging view of egg development
  •                 —wave theory vs. continuous recruitment
  •                 —DNA markers vs age (~15:00)
  •                 —Hottest topics—>new data on genetics of eggs
  •                 —Individual variation offers hope for intervention
  • 19:30 Egg quality if often a key component of “Unexplained Infertility”

With kindness and optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

TWINdemic: fall 2020 update on COVID+Flu season for fertility patients

Unfortunately, the number of cases of SARS-CoV-2 is increasing—not just here in Colorado but in most of the country and other parts of the world as well. Additionally, we’re heading into flu season which further complicates our ability to keep our patients, our staff and our families healthy. Ironically-from the perspective of a fertility center-this combination is often being referred to as a Twin-demic.

Below is a link to our latest videoblog updating you on the current public health status. In the meantime, please take precautions:

Here’s a link:  https://youtu.be/nRtX6NVIQ_s  (about 20 minutes)

Stay informed,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Embryo Grading Explained—this is what those numbers and letters mean

Previously, we discussed what the current means of embryo testing is and what insights it provides about the DNA. In this clinical conversation, we review the way embryos are described based upon their development and their description.

If you’ve completed an IVF cycle and are now getting ready to prepare for an embryo transfer, your embryologist will tell which embryo(s) they recommend for transfer. Although there is a lot that goes into this recommend, there is a shorthand description that they use to summarize each embryo. That is the “embryo grade.”

  • 0:45        How important is embryo grading?
  • 4:15        Summary of the current (most popular) grading system
  • 8:35        Correlation between embryo grade and implantation rate
  • 12:30     Lisa’s experience—a real life example shared
  • 14:00     Genetic testing vs grading
  • 15:30     Transferring more than one embryo of different grades

This video is about 20 minutes long. Here are a few key points if you don’t want to listen to the entire post:

Here’s a link:  https://youtu.be/xQFXCe-BVak  (about 20 minutes)

Stay informed,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Genetic Screening of Embryos as Part of IVF Treatment

Modern IVF—when practiced with the most current technology—is not only more effective than ever before but can also be diagnostic. One of the tools that really provides some of the greatest insight is the use of genetic testing. Not all centers use these tools and there are several different ways to perform genetic testing. There are many opinions on what is best. Here is a recent conversation that I had with Fertility Coach and previous patient, Lisa White:  https://youtu.be/xs97X9_4gdM

In case you don’t have 30 minutes to spare—here are some key points in the conversation:

  • 00:47—Clarification of Acronyms
  • 02:00—What do I recommend and why
  • 05:00—Description of the process
  • 07:50—Who should consider genetic testing?
  • 11:40—Alternatives to transferring abnormal embryos
  • 13:50—How often do patients choose not to have testing (at our center)?
  • 14:30—False-Positive and False-Negative vs. “embryos repairing themselves”
  • 16:00—What are costs or potential savings:
  • 18:00—Lisa’s personal experience (an example)
  • 19:00—Some of the additional diagnostic information that can possibly be attained
  • 21:00—What about people using an egg donor?
  • 26:00—How is this different than “embryo grading”?

We hope that this conversation answers some of your questions so that you can guide your treatment choices.

Stay informed,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Common Questions Regarding Male Fertility—a conversation

Most fertility treatment targets the female partner. In fact, many of the male partners feel helpless during treatment. Often viewing themselves as “problem solvers,” it is common for men to as if they are bystanders during fertility treatment. As a result, many questions aren’t asked and potentially useful advice is often withheld.

In order to overcome this information gap, we’ve recorded a video conversation where we try to address the most common questions that have come up regarding male fertility testing and treatment. Topics that we cover in this video include:

  • Testing including explanation of semen analysis
  • Diet/lifestyle tips as well as supplements
  • Potential role of sperm freezing (you may not have considered)
  • Dispelling popular myths
    • Boxers vs briefs
    • Caffeine
  • Role of ICSI (sperm injection into the egg) in modern IVF
  • Emotional support for men

Here’s a link: https://youtu.be/PvzqQorMB1g (about 40 minutes)

Stay informed,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Basic Fertility Treatment (Ovulation Induction with Insemination): latest information and recommendations reviewed

One aspect of fertility treatment that exacerbates the frustration of many couples is the uncertainty. They often don’t have a specific reason for their problem—even after their testing is completed. They also don’t understand the typical challenges that everyone faces on a monthly basis. Without this information, it can be difficult to create realistic expectations. I believe it also makes the most logical and simple recommendations seem very appealing.

Basic Fertility care is often introduced as ovulation induction (OI)—using medication to regulate the menstrual cycle and optimize the timing of the “fertile window.” This procedure is often combined with “sperm wash” where the partner’s specimen is processed to optimize its potential and then placing that into the woman’s uterus—known as intrauterine insemination (IUI). This treatment has been available for decades. There have been few changes in how this is done over the last 10 years.

I reviewed the subject of OI/IUI back in 2015 and those studies are still very relevant. So please check that out as well. More recently, we have had a couple of publications that provide even more data for us to guide patients through these important decisions. Please consider the watching the following video blog for a quick (less than 10 minute) summary ( https://youtu.be/GwmbkIpw3ek ) .  In case you can’t access the link, here is a brief summary of findings;

  • Ovulation Induction with intercourse wasn’t much better than trying to conceive naturally
  • Insemination without ovulation induction had success rates comparable to natural conception
  • In considering OI/IUI
    • Success rates drop dramatically after three or four attempts
    • Having more than two follicles is not recommended due to increased risk of multiple pregnancy
    • The timing of the insemination is more flexible than most anticipate
    • There is no greater benefit in having more than one insemination per cycle
    • For women over 40, success rates were modest and associated with a lower risk of multiple pregnancy—even when three or more follicles were available            

I hope that you find this information helpful and empowering as you consider your treatment options and plan your family.

With kindness and optimism

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

References: