Understanding Fertility Testing from Reproductive Endocrinologist Dr. Mark Leondires
My patients are in their 20s, 30s or 40s; they can be healthy and fit or obese; they can be any race or religion. I am a reproductive endocrinologist, and I’m reminded daily that infertility does not have one look. Even patients who are generally healthy can struggle to get pregnant.
At my practice, we determine a woman’s level of fertility based on her medical and family histories, age, basal antral follicle count, day 3 follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH) level. Collectively these factors give us a complete picture of a woman’s reproductive health; however, AMH testing, which is relatively new, is generally considered to be very reliable.
AMH levels are measured by a simple blood test. Because AMH tests measure a protein as it secretes in to ovaries, it is not affected by estrogen and other hormones, and can therefore be tested at any point in the menstrual cycle and even in patients on birth control pills.
Options for Women with Low Ovarian Reserve
Women with low ovarian reserve have several options. If they are considering having a family, they may decide they are ready to start trying. If they are not ready to start a family, they can freeze eggs for the future. Alternatively, they can continue to monitor their egg reserve or seek further testing to get a better understanding of their reproductive health. All of these options benefit from early detection; the earlier we know if there is an issue, the more we can help.
While it is true that the likelihood of getting pregnant decreases dramatically after 35 years of age, any woman in her reproductive years can be affected by infertility. Women should be able to get pregnant within a year of trying. If they have not, then they should see a fertility specialist. If they are over 35 years old, they should see a reproductive endocrinologist after trying for six months. It is also important to know that male partners contribute up to 40 percent of infertility issues; both partners should see a fertility specialist for diagnostic testing.
Free AMH Testing Details
Reproductive Medicine Associates of Connecticut (RMA of CT) is hosting two events in October with free AMH testing. Each event will include an opening presentation about infertility, including an explanation of the AMH test. Attendees will then have a blood test taken and a nurse will call with the results within 10 business days. The events are being held:
RMA of CT Stamford Office
1290 Summer Street, suite 3200
October 11, 2012 at 6 p.m.
RMA of CT Danbury Office
67 Sand Pitt, suite 300
October 11, 2012 at 6 p.m.
Preregistration is encouraged: www.rmact.com/amh.
We hope women in the area take advantage of this event to learn more about infertility and to have a free AMH test, even if their plan is wait to start a family.
This blog post appeared originally on the Stamford Patch.
Fertility and Adoption Conference Take-Aways
A Family of My Own had its fertility and adoption conference in Rye Brook, New York this past Saturday.
Kudos to the organizers, Preya Shivdat, Elizabeth Carellas and Nina Antolino. It was a well-organized, well-thought out and well-executed conference.
I had the pleasure of listening to Dr. Mark Leondires speak that day. His topic was "Finding Hope: Working Together to Understand Your Fertility and Treatment Options in the Age of Modern ART."
His presentation was compassionate and scientific and thoughtful. He reminded all of us that no one really wants to be in fertility treatment. We all wish that conceiving happened outside of a doctors office, at home. He spoke about alternative paths to creating our families and ways in which we can adjust our vision to include paths that we had previously rejected.
The day also included one of RMACT's Finance Managers, Natesha Lane, sharing her expertise about fertility insurance coverage and the state mandates. Her audience was most appreciative to have heard her, as she was thorough, helpful and informative.
I enjoyed speaking on Fertile Yoga and the different aspects of mind/body techniques that I bring into the classes.
We recorded our sessions, so look forward to seeing them, edited, on the blog site soon.
Fertile Lessons from Yoga
Jump to the next day, when I taught yoga to a very experienced group of yogis. The focus of the class is a vigorous physical challenge, with heart and breath wide open--a pleasure to teach. My focus for the class was on the questions that come up and to allow answers to come to us as they may: To notice what the questions are, first and foremost; To recognize that the questions themselves often hold the answers; And that the answers are not always what we think they will be.
One student, during a particularly challenging pose, when told about doing handstand next, blurted out "no." We all laughed. She finished the sequence. We moved to headstand and handstand.
Loved her next comment.
She amended her initial response to this: "No, moving toward maybe."
I just love it.
Fertility Treatment Mindfulness
I remember being in fertility treatment and swearing that I would do what I was doing, but I would never do "that." You know what I mean. "That," being the next step, the next medication, the next procedure.
If you are like me, you probably have said that too, especially about fertility treatment. If you are like me, you probably have amended that "no" to a "maybe" and even changed it to a "yes" and gone on to treatment that you had previously rejected.
We all need to get there in our own time. It takes, as Dr. Leondires so eloquently put it on Saturday, self-reflection and self-care to be able to move on in fertility treatment. Whether that's moving from an IUI to IVF or from IVF to donor egg or to start speaking to adoption agencies or consider childfree living.
I do love that.
"No, moving to maybe."
Next place to go?
Dr. Mark Leondires to Speak on Male Infertility for RESOLVE
April is a busy month for Reproductive Medicine Associates of CT. We're participating in many regional and national events, including the male infertility TeleSeminar, hosted by RESOLVE, with guest speaker Dr. Mark Leondires, RMACT's very own Medical Director. Please read below for details about attending this seminar, specifically on male factor infertility issues. RSVP's are necessary, so read through to the bottom of the blog to find out how to attend. Click here for a complete calendar of events upcoming at RMACT.
Male Factor Infertility TeleSeminar
Thursday, April 19, 2012
9:00PM ET/ 8:00PM CT/ 7:00PM MT/ 6:00PM PT
Male Factor Infertility From the Man’s Perspective
Infertility is not just a woman's issue
Guest Speaker: Dr. Mark P. Leondires
Medical Director of Reproductive Medicine Associates of Connecticut (RMACT)
Topics to be covered during this session are:
Dr. Mark P. Leondires is the Medical Director and lead infertility doctor with Reproductive Medicine Associates of Connecticut (RMACT), and is board-certified in both Obstetrics and Gynecology and Reproductive Endocrinology and Infertility.
RSVP online for this male factor TeleSeminar.
RESOLVE's TeleSeminar Series occurs on the first and third Thursday of each month at 9:00PM Eastern time during 2012; all are free of charge. RESOLVE works with our corporate partners and professional members to provide you with the latest research, tips, and advice to help you resolve your infertility. Check out the TeleSeminar schedule here.
RESOLVE: The National Infertility Association
In order to continue to be able to provide free programs and support groups as well as low-cost educational programs, we encourage you to visit our web site to learn more on how you can support RESOLVE's mission.
As a volunteer non-profit consumer organization, RESOLVE is committed to providing unbiased information and support. Participation as a sponsor or presenter at this event does not imply endorsement by RESOLVE for any person or entity in any fashion. RESOLVE encourages its members to be educated consumers and to fully investigate any and all information available on the options available or presented to them.
For more information on local events, support groups, electronic bulletin boards, and other information relevant to your family building journey, please visit RESOLVE online.
Again, to attend "Male Factor Infertility From the Man's Perspective," on Thursday, April 19, 2012 at 9 p.m. RSVP online.
New Year's Eve Message from Medical Director of RMACT
Who would ever think that they would get hundreds of holiday cards with children on them every year?
Since 2002, I have looked forward to the holiday cards I receive from all over the world from patients of RMA of CT. As a staff we look forward to them. We oooh, and ahhh over each one. At times we giggle at the utter adorableness and there are times we are simply humbled by the stories which accompany these cards.
Perhaps the most amazing aspect of this holiday bounty is that these are cards from couples from all walks of life who may have never had a family, celebrating theirs with us. I recently received a card from a patient from2002. They continue to remember us and share their family with us, even 8 years later. The picture of their now family of four is so special to me as a reminder of how the work that we do creates on-going joy for families. I am constantly touched by the humanity and passion of all of our patients. I have heard from several patients that they have their children wave when they drive past the office. When I went into medicine I wanted to be a pediatrician. The path I took is more fulfilling than I imagined, helping people make their little one’s.
So I thank all of you who send cards and notes and SO look forward to more. It is amazing to think that we have helped bring over 2,500 children in to families where they were so very wanted. Truly, we have a magical responsibility, as the birth and growth of a child is a magical journey.
Please share this with those who want children; that there are many paths out there and to seek help if they are having difficulties.
Happy New Year to All....
Mark Leondires, MD
Dr. Mark Leondires, Medical Director of Reproductive Medicine Associates of Connecticut, talks about stress and infertility. Read below:
Stress and Infertility
It’s a hot topic among those who talk about fertility, as seen last month at the fertility field’s most prominent and prestigious professional group, the American Society for Reproductive Medicine (ASRM). Reproductive doctors from around the world – from Greece to Japan to several of the U.S.’s most respected institutions – made presentations about their recent studies concerning stress.
These clinical studies examined stress and infertility from nearly all angles: whether stress resulted from infertility and its complicated emotions, whether negative stress resulting from life-events impacts the success of in-vitro fertilization (IVF), even whether patients were able to accurately asses their own stress.
Fertility researchers have found both negative and positive correlation when they study stress and infertility. The real question is what marker does one use to study stress, as everyone’s stress response is unique. One study’s conclusion reads: “Logistic regression analyses revealed that [both] infertility-specific stress and non-specific stress were negatively associated with a pregnancy outcome after IVF. Psychological stress was negatively associated with IVF outcome, after controlling for biomedical variables. Fertility treatment protocols should consider including counseling interventions to potentially mitigate adverse effects of stress.” (The relation of psychological stress to pregnancy outcome among women undergoing in-vitro fertility and intracytoplasmic sperm injection; Gourounti, K. et al. ASRM Meeting 2011)
It is very clear that infertility increases stress on relationships between partners. In addition, as a couple enters treatment there are scheduling demands, anxieties about treatment options, financial stressors, and worries about potential for success. It appears to me that what my colleagues at ASRM were grappling with is what we know in our hearts versus what we can prove through science in a clinical study.
Our patients report benefits from learning to manage their life stressors. Whether patients are stressed as a result of infertility or if stress is one variable causing infertility is actually immaterial. My patients who manage their stress are more likely to get pregnant.
Since there is no downside to learning how to manage stress and improving overall health, there is no reason to resist recommending stress management options to patients. Although these interventions may or may not increase the likelihood of getting pregnant, there are two important known benefits: fertility patients have something to take control of and it improves their overall ability to manage stress in their lives.
Managing stress can be accomplished in different ways; and for most patients there are many approaches that are effective. First, I believe in having a strong network – patients need to talk to their partners, family, and friends. And when this is uncomfortable (many fertility patients hesitate to share private details with someone who has not experienced infertility), then share your thoughts and emotions with a support group or a therapist.
Second, find a release such as meditation, yoga or exercise in general. This will also help patients optimize their health, which is important for achieving a healthy pregnancy.
That leads me to the third approach: reduce the outside stressors (e.g., unhealthy foods) on a patient’s body and mind which can be mediated by working with a nutritionist or an acupuncturist.
Over the past several years, my partners and I have incorporated adjunct services such as these into our practice at Reproductive Medicine Associates of Connecticut (RMA of CT). We started with Fertile Yoga, and based on positive patient feedback we added an acupuncturist to the staff. Then patients expressed other needs and we began peer-led support groups and added a nutritionist to our staff. There are four key services – Fertile Yoga, acupuncture, nutrition counseling and therapy for individuals and couples – as well as several related workshops and seminars. Some are free of charge, some are covered by insurance and some are paid for out of pocket. Patients rave about them all.
This month we launched the RMA of CT Integrated Fertility and Wellness Center. It marks a symbolic stand, as well as a practical one. Patients will have greater ease in finding a practitioner and a time for appointments. At the core of our fertility treatment remains advanced reproductive medicine – but our method is to treat the whole patient.
Read below what the medical director of Reproductive Medicine Associates of Connecticut (RMACT) and the team of board certified reproductive endocrinologists in the program have to say about frequently asked questions.
"Infertility can be confusing, and people frequently ask questions because they want to know if they should seek help from a fertility specialist," says Dr. Mark Leondires, Medical Director. "The questions and answers below are intended to give some basic knowledge. Many couples put off seeing a fertility specialist when they are having trouble getting pregnant, but they are typically reassured after being diagnosed and starting a treatment plan."
What is infertility?
Infertility is a disease or condition of the reproductive system often diagnosed after a couple has had one year of unprotected, well-timed intercourse, or if the woman has been unable to carry a pregnancy that results in a live birth.
Is infertility a "women's problem"?
Infertility is a medical problem. Approximately 35% of infertility is due to a female factor and 35% is due to a male factor. In the balance of cases, infertility results from problems in both partners or the cause of the infertility cannot be explained.
How long should we try before we see a doctor?
In general, if you are less than 35 years old and have been trying for more than one year you should schedule an appointment with a fertility specialist. If you are greater than 35 years old we would like to see you after at least six months of timed, unprotected intercourse. However, if you have a reason to suspect you may have a problem getting pregnant such as a history of pelvic inflammatory disease, painful periods, miscarriage, irregular menstrual cycles, or if your partner has a low sperm count, you should seek help sooner. Many couples have a hard time admitting that there may be an infertility problem, but be reassured there are often many things we can do to help.
What is a Fertility Specialist?
A fertility specialist, or Reproductive Endocrinologist, is a medical doctor who has been specially trained in the complex issues that can contribute to infertility. In addition to being trained as an Obstetrician/Gynecologist which requires a four-year residency a fertility specialist must complete an additional two to three year fellowship in reproductive endocrinology. This fellowship training is highly specialized to focus on the diagnosis and treatment of infertility and female endocrinology.. A physician can become Board Certified in Reproductive Endocrinology by successfully completing the fellowship as well as written and oral examinations.
Currently in the Unites States, there are only about 1,000 Board Certified Reproductive Endocrinologists. Specifically for infertility related to males, Urologists with a sub-specialty in Andrology are the most qualified experts as they have often completed two-year fellowships and passed exams to become Board Certified in Andrology.
At what time of the month is a woman fertile?
The most fertile time of a woman's cycle is just before or the of day ovulation. Ovulation usually occurs two weeks before a period starts, so it is necessary to count backwards from the anticipated start of the next period in order to find the most fertile time. Take the number of days in the usual cycle (from the beginning of one period to the beginning of the next) and subtract 14. For example, a woman with a 32-day period would likely ovulate around day 18 (32-14=18), while a woman with a 28-day cycle would ovulate around day 14 (28-14=14). We recommend every other day intercourse around the day of ovulation. That would mean days 12, 14 and 16 for women with 28 days cycles.
It is best to have intercourse before ovulation rather than afterwards, so a woman who ovulates on day 14 would have a good chance of conceiving if she has intercourse on either day 13 or 14. For women with irregular cycles you can extend the period of having sexual relations to every other day from day 11 to 18 ( 11-13-15-17). In order to better understand what day you ovulate take your average menstrual cycle length (for example 32 days) and subtract 14 and that will give you that day you ovulate around (that would be about day 18). Therefore you would have relations days 15-17&19 to cover all your bases.
Alternatively, women with irregular cycles may want to use an ovulation predictor kit, which can be purchased over the counter at most local pharmacies. This involves testing your urine around the time of ovulation using a detector stick, which give you a visual reading. Additionally, there are electronic monitors which detect ovulation by tracking two hormones (estrogen and luteinizing hormone) starting with urine testing on day one of your menstrual cycle. The methods that utilize urine predictor sticks or urine ovulation detector machines are usually highly sensitive, accurate, and reliable.
How can a woman tell if she ovulates?
The simple, inexpensive way of finding out the approximate time of your ovulation is to take your basal temperature (that is, your body temperature at rest) every morning and record it on a chart. You can buy a Basal Body Thermometer at your local drug store. Save all your charts so you can review them with your doctor. Three or four months of charting should be adequate. If your temperature goes up after the middle of your menstrual month you likely do ovulate. In general you ovulate about two days prior to the temperature rise.
How often should we have intercourse?
It is a good idea to have intercourse every other day around the time you ovulate. Remember, every woman is different, and may not ovulate exactly on "Day 14." And, just because you ovulated on "Day 14" this month, doesn't mean you will next month. It is preferable to have intercourse every other day rather than every day so that sufficient sperm will be available. To increase your chances of the egg becoming fertilized, do not douche or use lubricants immediately before having intercourse.
What fertility testing should our fertility doctor perform?
Your doctor will likely do the following:
- Blood tests to check reproductive hormone levels in the woman; estradiol (E2), progesterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid hormone, prolactin, and possibly male hormone levels.
- Complete semen analysis on the male partner
- Hysterosalpingogram (HSG), an x-ray exam to evaluate if the woman's fallopian tubes are open
- Ultrasound to confirm the normal appearance of your uterus and ovaries in the woman
What about smoking and drinking alcohol and caffeine?
There is evidence linking reproductive impairment with exposure to alcohol, tobacco, and caffeine.
Alcohol and tobacco use have been demonstrated to affect the reproductive capacities of both men and women, and tobacco is an especially potent reproductive toxin that negatively effects female fertility by damaging eggs. In men there is a direct effect on sperm quantity, quality, and reproductive function. In general we ask that women consume less than 150 mg of caffeine per day which is equivalent to two small 8 oz cups per day. Remember sodas and tea also contain caffeine. In addition, it is wise to be in the best physical shape possible while you attempt to conceive and, of course, to ensure a healthy pregnancy and baby.
Are hot tubs really bad for a man?
Yes. High temperatures can damage sperm. That is why the scrotum is located outside the body - to act as a kind of "refrigerator" to keep the sperm cool. So, it is a good idea to avoid hot tubs, saunas, and steam rooms when men are trying to help in the pregnancy pathway.
What else can we do?
Learn as much as you can about infertility.
- Get and read good, reliable information (not just from popular magazines) from your doctor, library, or trusted friends or family.
- RESOLVE (http://www.resolve.org/) and the American Fertility Association (AFA - www.theafa.org) has over 60 fact sheets on different topics related to infertility, and support groups in many areas.
- Also visit the ASRM (http://www.asrm.com/), SART (http://www.sart.org/), ACOG (www.acog.org) and CDC (http://www.cdc.gov/) web sites for more information.
Dr. Mark Leondires, Medical Director of Reproductive Medicine Associates of CT, and I were interviewed last week, along with one of our fabulous patients, Michelle, and the segment aired earlier this week. View the entire segment as well as the written part:
It was all about Fertile Yoga and RMACT's Integrated Fertility and Wellness Program.
Thank you to Michelle for sharing your beautiful story and presence with us, both in class and for the filming of this segment!
Fertile Yoga was created three years ago when I realized that there was no program specifically for men and women in fertility treatment.
Yoga is now the hot thing for fertility. We've been offering it to the public in Fairfield County, free of charge, for close to three years.
How wonderful to have the light, literally, shone on this program that can offer so much hope and relief to women and men who are in the midst of treatment.
Having experienced infertility and fertility treatment and having spent all of my adult life working with and for patients struggling with infertility, I am tremendously grateful to be able to share Fertile Yoga and have it seen in a bigger way.
I don't quite know how to talk about Fertile Yoga without sounding like I'm bragging. It's probably the piece of my week that allows me to speak most sincerely from my heart. While I'm proud of having created it and nurtured it (HUGE thank you to Reproductive Medicine Associates of CT for having the vision to financially support it!), I am also most humble to the patients that become my students.
Fertile Yoga was created for them and for you. It is my honor and privilage to share it with you.
Yesterday I was interviewed, along with a beautiful pregnant woman and Dr. Mark Leondires, by Channel 3.
The interview was about Fertile Yoga. One of the points that I wanted to make was that Fertile Yoga is part of a bigger plan at RMACT.
Three and a half years ago, we had several components of a integrated fertility wellness program. Acupuncture was well established as well as a thriving mental health program within the practice.
The belief that our patients need to be treated as people, not infertility diagnoses is strongly rooted with every one of our board certified reproductive endocrinologists. This is a philosophy that everyone in our practice supports.
And so we went farther at RMACT. For the last three years, Fertile Yoga has been financially supported by RMACT. I created the program after having been a patient for six and a half years, a patient advocate and educator for almost twenty years and a certified yoga teacher of three years.
Fertile Yoga is free of charge to all students, open to everyone.
RMACT believes strongly that the relaxation and stress reduction that Fertile Yoga brings is both helpful to the patient's quality of life as they go through treatment as well as enhancing the possibility of conception.
Almost two years ago, a nutritionist was brought to our program, part time. This past January, Carolyn Gundell, MS, joined us full time. Her experience with PCOS patients in the last decade (Polycystic Ovarian Syndrome) had, over the past two years brought dramatic changes for many of our patients. This little understood and often misunderstood endocrine disorder can severely hamper one's ability to become pregnant. Carolyn's expertise, as well as her consulting with our physicians, have helped our patients immeasurably.
Several years ago, there was a large scale study done with RMANJ (Reproductive Medicine Associates of NJ) on the advantages and effects of Laser Acupuncture. Today, our acupuncturists, Amy Matton and Jing Zhang have an onsite space where acupuncture can be done, either traditionally or with laser, right before retreivals and transfers.
Our mental health professionals include Dr. Lisa Tuttle and Jane Elisofon, MSW, LCSW. They both see patients individually, as well as couples, counseling donors, run support groups and more! Lisa and Jane are resopnsive and sympathetic to patients emotional needs in ways that only therapists so immersed in infertility and treatment can be. Our patients, and our practice, are lucky to have them.
So while I was being interviewed about Fertile Yoga, these other wonderful professionals kept me company in my brain and heart.
Our Integrated Fertility and Wellness Program is one that we have created thoughtfully. That we have built, one piece at a time. A program that our patients benefit from, that we all benefit from.
Who knows what's next?
I’m going to steal a new word that Dr. Mark Leondires from Reproductive Medicine Associates of CT used recently. I spoke with him and asked him how he was.
Here was his response, “Iggitable”. He probably won’t like how I spelled it, but this is what it combines: irritable and agitated (or maybe it was aggravated?). He liked his new creation because it reflected how he was truly feeling. He even seemed to like how the word sounded out loud. Who knows, maybe he even liked the way that the word rolled off his tongue.
Sometimes existing words don’t exist to describe how we feel. Or they are woefully inadequate.
How about upset to describe not having your baby yet? Or frustrated? Disappointed do it for you? What do you think about concerned to describe the months that move by with no pregnancy?
Let’s just go with inadequate. Insufficient. Don’t quite cover it. Not nearly.
How about devastated? Heart broken? Unable to function normally?
It’s not as easy as it looks or sounds to create new words. Dr. Leondires did an admirable job. I’m not finding it easy to do at all.
What I can explain to the world of the fertile is this. You may not understand it. You may not get why we, your friends and family, are so emotionally overwrought or unavailable because of infertility.
But do you understand pain? Do you know what it feels like to have your heart broken?
Then do the details really matter?
Do the words really matter?
CCS: Top Fertility Specialist Dr. Leondires Discusses New Fertility Technology
Dr. Mark Leondires
, Medical Director of Reproductive Medicine Associates of CT, recently spoke with reporters from WTNH about the breakthrough and award winning new fertility technique called "Comprehensive Chromosomal Screening". CCS
, as it is also referred to, is an embryo screening technique available in only five fertility centers in the United States.
How CCS Improves Pregnancy Rates
CCS can verify that all 23 pairs of chromosomes are healthy and normal. Techniques used in the past, including PGD
(Preimplatation Genetic Diagnosis) could screen up to 9 chromosomes and focused mainly on single gene disorders.This reduces the miscarriage rate tremendously as the majority of first trimester miscarriages are due to chromosomal abnormalities. This technique also reduces the occurance of multiple births
as one can be more confidant about the viability of the embryos that are replaced into the uterus.
Dr. Leondires takes you step by step through this process in the interview, as well as showing you how CCS looks in the lab itself.