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It is anticipated that the recent overturning of Roe v. Wade may have trickle down effects that can impact patients seeking fertility treatment. As begin to observe the actual impact that this legislative change is having, we decided it would be an excellent time to meet with a couple of experts to review the current status in the state of Colorado—where we are in practice. Here is a link to our Clinical / Legal Conversation and a listening guide (below) to highlight key points in our dialogue.   

Panel Discussion with two prominent Assisted Reproductive Law attorneys (48:57):  https://youtu.be/WvtA0hxbTRk

 2:00 Introduction of today’s participants

                                Judith Hoechst—Colorado Reproductive Law Center

                                Ellen Trachman—Trachman Law Center

3:20 Clinical Summary of current status

6:00 Reassurance of safety of embryos currently stored in Colorado

7:00 Reproductive Health Equity Act (RHEA—passed April 2022)

• Codifies rights of pregnant women to make their own decision regarding their reproductive care
• No independent rights granted for embryos

9:00 Donor Conceived Persons Law (DCP—passed May 2022)

• grants certain rights to individuals conceived through use of donor eggs / sperm access to the health history / information from their donors upon reaching legal age of adulthood

11:00 Explained potential role of preconception genetic screening of embryos to help reduce the need for pregnancy termination.

14:00 Brief discussion of medications used in pregnancy termination and treatment across state lines

15:30 Considered challenges with relocating embryos from other states to Colorado

17:30 Colorado Surrogacy Act (passed May 2021)

• law to codify gestational carriers and to
• create protections for intended parents

21:50 Colorado Building Family Act (passed May 2022)

• mandate expanding fertility coverage through private health insurance

 25:00 Marlo’s Law (Parental Rights for LGBTQ parents—August 2021)

• stream-line formalization of parentage
• Birth certificates alone may not be recognized across state lines without a court order therefore this law was enacted to provide such an order

30:00 Unresolved concerns moving forward—recent example of a separating couple in which one partner sought to use embryos created during the marriage against the wishes of the other

33:00 Disposal of embryos

34:00 Embryo donation

37:00 Concerns in transferring embryos from one fertility center to another

39:00 Options for those willing to volunteer or provide donations to organizations seeking to protect reproductive rights

43:00 What to consider moving forward

47:00 Sign off and contact points for additional information

With informed optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

In the field of reproductive medicine, we are always seeking new and improved ways to create successful pregnancies. One technique that has gained a lot of attention recently is Natural Cycle FET. This protocol involves basing the timing of an embryo transfer off or a woman’s natural cycle with minimal medical interventions. As we gather more data on success rates using this technique we will be able to better decide which patients are most likely to become pregnant on this protocol.  Here is a link to an episode of our Clinical Conversation series where we are trying to create a balanced discussion of the potential pros and cons of Natural Cycle FET.  Most noteworthy, we are currently finding about 20% of cycles have to be cancelled as the parameters developing do not seem ideal for the support of implantation.

Natural Cycle FET: clinical conversations with Dr. Greene and fertility coach Lisa White

(~14 minutes):  https://youtu.be/kWwXFw71wLg

0:35 Definition: what is Natural Cycle FET?  

3:00 Comparing fertility and implantation

3:40 Current recommendations of patients best suited for Natural FET

4:45 Possible advantages of Natural Cycle FET

5:10 Possible disadvantages of Natural Cycle FET

6:00 Submitted question: How does the Endometrial Receptivity Analysis fit in with Natural Cycle FET?   

6:40 Convention or “Programmed Cycle”  

7:30 Optimizing timing and potential differences from one fertility center to another

11:00 Individualizing treatment plans. It’s good to have options.

12:30 Supporting informed decision-making as we gather more data

As we gather more data and experience with Natural Cycle FET we will become better qualified to guide patients more actively. Until then, my goal is to partner with each patient/couple to make these decisions together.

With stubborn optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Much of modern healthcare is about identifying and treating disease. However, in the field of reproductive medicine we also have an obligation to assist single people and same-sex couples to also achieve their goals of having children safely and efficiently. In this podcast we explore the options for those that are presumed to be fertile—but simply lack the biological partner to conceive naturally.  I hope you enjoy this Clinical Conversation:

NON-MEDICAL FERTILITY CHALLENGES (~15:00 minutes):  https://youtu.be/7A23qJEKiS4

0:30 Definition

2:00 Everyone deserves the opportunity become a parent

3:00 Some of the potential risks of “home inseminations”

4:30 Customizing a family building plan to your goal

6:30 Understanding your options

9:30 Freezing eggs for later use (prolonging your reproductive potential)

11:00 Navigating the legal issues

12:00 Some tips to consider

In closing, we have a special treat. Here is a link to a podcast where a same-sex male couple have shared their journey to build their family together: It takes a village, Our Pathway to Leo:

• https://podcasts.apple.com/us/podcast/it-takes-a-village-our-path-to-leo/id1604433218
• https://open.spotify.com/show/2HBEjtRcYqHabD16WSj9Zc?si=0236727fcf4f4007

With informed optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

One of the hottest on-going debates in reproductive medicine is whether or not to perform genetic testing on embryos as part of the IVF process. This debate is fueled by the fact that not every fertility center has the equipment, the personnel and the training to perform these high tech biopsies.  This Clinical Conversation  is a review of the latest study on performing genetic testing of embryos in patients with a good prognosis for pregnancy and serves as an example of study attempting to demonstrate that there is no benefit—but their design and conclusions fall short of further analysis.

Review of New England Journal of Medicine study on Genetic Testing vs Transfer of Untested Embryos (19:46):  https://youtu.be/6w6P3tm-fas

KEY POINTS

• The study only included patients that were pre-screened to have the highest chance of pregnancy prior to starting the IVF process…defined as “good prognosis patients.” The average age of these patients was 29, on average they started out with at least 20 eggs and had around 7 embryos available.   
• The study was designed as a “non-inferiority study” which means that they were trying to show that there was no difference instead of designing which treatment was associated with a better outcome.
• The patients that were in the genetic testing arm of the study were only allowed to have three embryos undergo testing. This is not the standard way that genetic testing is actually used in clinical practice and was designed to limit the benefit of PGT-A (genetic screening for aneuploidy).
• There was a higher risk of twins in the arm of the study that did not have genetic testing because more patients insisted on putting in more than one embryo.
• The miscarriage rate was significantly lower in the patients that had genetic testing—something that was not highlighted by the study authors but was obvious in the data that they presented.
• There were fewer birth defects among the patients that were in the genetic testing group.

In summary, the choice of whether or not to screen embryos prior to Frozen Embryo Transfer (FET) should be the choice of the patient and it should also be based upon the outcome data of their treatment center. One should also consider whether they are (potentially) willing to go through more than one FET to find the embryo most likely to result in a healthy pregnancy.

With informed optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Arguably the least understood aspect of modern reproductive medicine is the complex interaction between a woman’s immune system and a newly arrived embryo into her uterus. The immune cells are the means that your body is protected from anything that is genetically different. Typically, these cells are preventing invasion of viruses, bacteria or parasites. But in order to become pregnant and not experience a miscarriage—the immune system has to not only allow an embryo to “implant” but it has to actually help it establish a health blood supply to grow. Failure to do so, results in a negative pregnancy test, miscarriage or pregnancy complications like preeclampsia, preterm labor or fetal growth restriction.  

Most fertility treatment is focused on helping women initiate a pregnancy. As we’ve gotten better at initiating pregnancy, we need to place greater attention on fostering the changes to help that pregnancy continue to a healthy delivery. That’s the focus of reproductive immunology. Recently I listened to an evidence-based podcast that explains the emerging science that makes this complicated subject very accessible: https://www.wnycstudios.org/podcasts/radiolab/articles/everybodys-got-one .**

**This podcast is created by a non-profit so if you found it useful please consider making a donation

One of the most fascinating studies on the maternal-fetal immune response compared the outcomes from women that conceived with their own eggs vs women that used the eggs from an egg donor. Not surprisingly—it was found that women that became pregnant with an egg donor were at greater risk of adverse outcome due to non compatible immune reactions. They also found that using more than one embryo at a time during a Frozen Embryo Transfer was associated with an increased risk—even when women were conceiving with their own eggs. Both of these observations support the hypothesis that a successful pregnancy is dependent upon cooperation between the maternal immune cells and the placenta.

Here are some key points to assist with this reproductive challenge:

• Transferring ONE embryo instead of two or more reduces the risk of adverse outcome
• Suppressing the maternal immune reaction with steroids is not helpful and may actually add to risk of pregnancy failure by reducing the ability of maternal cells to support blood flow
• The need to increase the availability of nutrients to support the growing fetus may explain some of the reason that metformin is associated with a reduction in the risk of miscarriage and of pregnancy complications
• There are other techniques to optimize the maternal immune response to the placenta. Talk to your provider to determine if any of these treatments would be appropriate for you.

Stay informed,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Polycystic Ovarian Syndrome (PCOS) has been described as the most common hormone imbalance of reproductive age women. Yet it is estimated that only half of the women whose lives are affected by PCOS actually know that they have this condition. Despite their lack of awareness, PCOS may be contributing to their infertility, elevated risk of miscarriage, pregnancy complications as well as impacting their overall health and wellness. 

Recently we recorded one of our Clinical Conversations to help better explain the nuance of the diagnosis and management of PCOS with goal of empowering women to help actively manage their condition: https://youtu.be/hLctooFIKgY  (21min, 48 sec)

(0:30)—Reason for PCOS Awareness Month

(2:15)—Definition of PCOS

(3:30)—PCOS goes beyond the challenge of becoming a pregnancy

(5:15)—Emerging Categories/Types of PCOS

(6:00)—Rotterdam Criteria for PCOS diagnosis

(9:15)—Actively managing PCOS

(11:00)—Potential problems associated with PCOS in absence of management

(11:30)—Dynamic nature of PCOS

(14:00)—Creating short term and long term management goals

(16:30)—A few helpful tips to manage PCOS

        —Some dietary tips

        —Ironic benefits of eating soy

        —More evidence-based nutritional advice

(20:00)—Active management means directing your care

Stay aware,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

As we continue to experience fourth spike in new infections—we felt it was time to post an update on if/how we feel that the pandemic will effect the care of fertility patients. We have previously posted on the mRNA vaccines—which are now fully recommended to all women that pregnant, breastfeeding or attempting to conceive.  Here is a link to our original post on the vaccines. This Clinical Conversation  is an update on where we’re at in late summer 2021.

COVID19 (SARS-CoV-2) Late Summer 2021: UPDATE (16 minutes):  https://lnkd.in/egiX_RFs

0:30 Perspective on where we’re at

2:40 Timing of vaccinations & organizations supporting use in reproductive seeking women

3:30 Passive Immunization—how a mom can protect her baby

4:20 Safety Data supporting vaccination

7:30 Facts vs Fears

8:30 Unvaccinated at greater risk of being required to delay fertility treatment

9:45 Some tips to optimize your immunity

11:00 Forest Bathing: bringing some of the immune-boosting benefits of nature indoors

With informed optimism,

~Robert

Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

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.     

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

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

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