Tag: infertility

I lost a part of myself that day…

I lost a part of myself that day…

I thought it was going to be easy until it was not. I thought (as a good medical student) it was just a standard medical procedure but then it was more than that. I thought the second time around would be just as the first. I wanted answers, and I wanted them fast. I wanted to know what went wrong, I wanted to fix it. I wanted to understand from a scientific point of view what caused my two precious peanut boys to stop developing. And then, after the D&C was done, and I returned home, I felt an emptiness like I never had before. I lost a part of myself that day and the days that followed.

On the surgical room, the surgeon not only removed a physical part of me but she also took the emotional and spiritual parts of me that could never be replaced.
I vaguely remember going back to school like a zombie, not feeling anything but pain and sorrow. I had to be strong enough to study, take exams, go to medical school interviews, and be a balabusta. No matter what I did, that feeling of emptiness was not going away. Every time I read or saw a video with content related to pregnancy loss, I broke into tears. During those three months of non-stop bleeding (and non-stop niddah), all I wanted was a hug and a kiss from my husband. I was furious, confused, and miserable because of that never ending niddah status. More often than not I blame myself or my overactive immune system or the medications I was on. Then I followed to blame my husband and his nonchalant attitude. Finally, it became my obsession, to the point that my hubby said it was the only thing I talked about.

But how not to be obsessed with the fact that…

I will never kiss my babies.

I will never hear them cry.

I will never change their diapers.

I will never see them crawl.

They will never have a bris, bar mitzvah, or a chasuna.

It does not matter how much time passes, I will always love them and be obsessed because I lost an essential part of who I am. But I will never forget them nor will I ever stop being thankful for allowing me to be a mother for a short couple of months.

I am now able to talk (and write) about my loss without a meltdown, without tears in my eyes. And I have started to research and read scientific journals about the causes and treatments of pregnancy loss, which has helped me find some closure and has convinced me that it was not my fault. I have finally achieved the acceptance status, no more anger, no more resentment. I feel ready to try and love again.

 

RPL: The effects of Age and Aneuploidy

RPL: The effects of Age and Aneuploidy

Just as the external physical body shows signs of aging, such as wrinkles and gray hair, the internal organs and cells also age. Thus, maternal age is one of the most determinant factors in regards to pregnancy success rates and live births. At the age of 40, it is estimated that as much as 30% of embryos are aneuploidy (a cell with an abnormal number of chromosomes), while at the age of 45, this increases to almost 100%. Thus the incidence of embryos with chromosomal abnormalities increase as maternal age increases. Most aneuploidies arise from errors in meiosis, typically due to nondisjunction (inability of a chromosome to properly separate) and account for approximately 50% of first trimester losses, 30% of second-trimester losses, and 3 % of stillborn births. Aneuploidy also accounts for unsuccessful IVF cycles when embryos are not screened.
Amongst the lethal aneuploidy category, 35% cause spontaneous abortions (such as 45X and trisomy 16, 21 and 22); while about 4% cause stillborn births (such as trisomy 13, 18 and 21). Of those aneuploidies that are somewhat compatible with life, trisomy 21, also known as Down syndrome, is the most common autosomal trisomy. Individuals with Down’s syndrome typically show signs of cognitive impairment, heart defects, and muscle weakness. The only other two autosomal trisomies that are detected in appreciable numbers are 13 and 18, however, affected individuals rarely survive the first few months of life.

trisomy21
Trisomy 21/Down’s Syndrome

On the other hand, Klinefelter’s syndrome (male 47, XXY) is an example of a sex chromosome trisomy. Affected individuals commonly show reduced sexual development and fertility, but they often have somewhat normal life spans. Monosomies are the opposite of trisomy, in that individuals affected have one chromosome less, 45 instead of 46. One uncommon monosomy is Turner syndrome (female 45, X0). Affected females have an array of symptoms, as there are a few variations of Turner’s syndrome (fully affected vs mosaicism), but typically include infertility, impaired sexual development, short stature, and heart defects.

Current Available Intervention

Couples who have conceived an embryo with an abnormal karyotype in the past, regardless of the pregnancy outcome, may be offered IVF with preimplantation genetic diagnosis (PGD) or comprehensive chromosomal screening (CCS). PGD encompasses both screening and diagnostic measures, which aims to analyze, select and transfer only embryos that have the appropriate number of chromosomes. PGD has been found to reduce the rate of miscarriage once pregnancy is achieved, but its ability to provide a better outcome for live birth compared to natural conception over time is controversial.

References:

Chromosomal Abnormalities: Aneuploidies | Learn Science at Scitable. (2017). Nature.com. Retrieved 11 August 2017, from https://www.nature.com/scitable/topicpage/chromosomal-abnormalities-aneuploidies-290

Bashiri, A., Harlev, A., & Agarwal, A. (2016). Recurrent Pregnancy Loss. Cham: Springer International Publishing.

The What, How, and Why of Recurrent Pregnancy Loss (RPL)

The What, How, and Why of Recurrent Pregnancy Loss (RPL)

Many of us, who have been in the journey of TTC for a while, might have unfortunately experienced one or several pregnancy losses. From biochemical pregnancy, early 1st trimester miscarriages, to a stillborn, each loss is emotionally tolling and frustrating. Many doctors would tell you that one loss is just an unfortunate fluke, very unlikely to happen again. But did you know that as many as 15% of all women under 35 years of age will experience an early loss (Bashiri, Harlev & Agarwal, 2016)? No woman likes hearing these statements or being a data entry in these statistics. So, like a good medical detective and curious “yenta” that I am, (and once my mourning and healing process allowed me to do so), I decided to investigate more about pregnancy loss. I hope that this information might help someone out there achieve closure, accept that you did nothing wrong to cause this, and believe that it is not your fault this happened.

But did you know that as many as 15% of all women under 35 years of age will experience an early loss (Bashiri, Harlev & Agarwal, 2016)? No woman likes hearing these statements or being a data entry in these statistics. So, like a good medical detective and curious “yenta” that I am, (and once my mourning and healing process allowed me to do so), I decided to investigate more about pregnancy loss. I hope that this information might help someone out there achieve closure, accept that you did nothing wrong to cause this and understand more about some of the causes and treatments.

What is RPL?

Recurrent pregnancy loss (RPL) is defined by ASRM as “two or more clinical pregnancies losses documented by either ultrasonography or proved in a histopathologic examination” before 20 weeks gestation. However, the “Royal College of Obstetricians and Gynaecologists (RCOG) and the European Society of Human Reproduction and Embryology (ESHRE) [defines it] as three or more consecutive losses before 24 weeks gestation”. This is a significant discrepancy, which might cause certain physicians to delay diagnosis and treatment in women with only two losses. (This is why is extremely important to understand and accept that you are your best advocate and to seek advice/treatment from an RE who is open minded and would proactively look for the patients’ input). As well, many physicians and medical societies do not count chemical pregnancies as part of the diagnosis of RPL, but after much controversy, it has been included in many studies as part of the RPL diagnosis (as implantation rate could be diminished due to poor uterine lining receptivity, uterine anomalies or blood clots).

Common causes of RPL:

RPL_Causes

  • Autoimmune disorders and other immunological anomalies
  • Parental chromosomal aberrations (genetic problems
  • Uterine anomalies
  • Endocrine/hormonal abnormalities
  • Thrombophilias/Blood clotting disorders.
  • Infections
  • Obesity/Undernutrition
  • RPL: The effects of Age and Aneuploidy

Over the next few articles, I will attempt to further examine each one of these causes and discuss potential treatments (if available).

References:

  • Bashiri, A., Harlev, A., & Agarwal, A. (2016). Recurrent Pregnancy Loss. Cham: Springer International Publishing.
  • Chromosomal Abnormalities: Aneuploidies | Learn Science at Scitable. (2017). Nature.com. Retrieved 11 August 2017, from https://www.nature.com/scitable/topicpage/chromosomal-abnormalities-aneuploidies-290
  • Schattman, G., Esteves, S., & Agarwal, A. (2015). Unexplained infertility. Pathophysiology, Evaluation and Treatment.. New York, NY: Springer.
Our infertility story and choosing a medical school

Our infertility story and choosing a medical school

The most amazing thing about applying to medical school is knowing that you gave your best in each of the 100’s of essays you wrote and the interviews you attended. Of course, it was an exhausting and money draining journey, so when I heard of my first acceptance, I was on top of the world. However, when I tell people that I was going to a DO school and not an MD school, I could see the confusion and disappointment on their faces. I don’t get me wrong; I do get that many people out there are not familiar with DO’s. Thus I take that into consideration as part of their “facial gesture assessment.”

When DH and I embarked on the journey of applying to medical school, we simultaneously started navigating the infertility road. At the time, however, we had no idea of the toll of IF treatments. A year and four months later, I was rejected from more than a dozen medical schools, put on a couple of waitlists (or what I called “death lists”) and got a couple of acceptances. On top of that, we underwent four cycles of fertility treatments, had one very early pregnancy loss (about a month or so) and an 8-week loss of our twin peanut boys, which included a D&C and three months of non-stop bleeding. The roller-coaster of hormones made me gain an awful 25 lbs, gave me mood swings, hot flashes, headaches, and what not. I went through good, bad and really tough days, plus all of the stages of grieving, while still finishing my last two semesters of school and interviewing at med schools in three different states.
After my hCG finally went down to zero, I decided that I needed a break from the fertility clinic, and doctors in general. I think at that point I was still in denial and too much pain, but it was one of the best decision I’ve ever taken. During the next six months, I took control of my health, went from a morbidly obese BMI of 32 to a healthy BMI of 25 (lost 40 lbs and still counting), graduated, and chose a great DO school instead of a great MD school.
It was not an easy decision. We weighted the cons and pros of everything, from moving to another state, the holistic vs. the conventional approach to medicines, Step 1 scores, job security for DH, and most importantly health insurance coverage.

Why was health insurance so important? Well, that’s a given, in an era where Obamacare, the insurance Marketplace, and the Trump administration are constantly scaring everyone in America about the future of healthcare coverage. However, more than that, going to the MD school meant losing our current super fantastic PPO health insurance policy ($100 deductible, 90% coverage in network and no referrals needed at all). Furthermore, the state where the MD school is located doesn’t have a state fertility mandate, which basically means that state laws specifically exclude coverage for fertility diagnosis and treatment.
This wasn’t fair! (But who said life was fair?). Once again, a curve ball is coming my way, and I have no idea how to spin it off to a home run. I certainly loved both schools and could have been happy at either, from an educational standpoint. But, what about having babies? Should we postpone having them for another four years because of lack of fertility insurance coverage? We definitely could not afford to pay for it out of pocket. So, in the end, it all came down to the possibility of having children ASAP (with the help of G-d and science). I am glad about our choice. I am a happy camper at DO medical school so far, and we are embarking in Season #2 of IF treatments, hoping for a baby (or babies) to stick with us next time around.

Infertility Support Organizations

Infertility Support Organizations

A TIME : USA

A TIME is the premier, internationally acclaimed organization that offers advocacy, education, guidance, research, and support through our many programs to Jewish men, women, and couples struggling with reproductive health and infertility.

A TIME is strongly endorsed by leading Rabbonim and physicians and is widely recognized as an organization that is sensitive to the privacy of each couple while providing a wide array of essential services in a caring and professional manner.

Services:

  • Medical referrals
  • Support groups
  • Hashgacha/Supervision
  • Insurance advocacy
  • Therapy
  • Adoption services
  • Rabbonim referrals

http://www.atime.org/

US Phone: (718)-686-8912

Puah Institute: USA & Israel

PUAH Institute, established in 1990, has helped thousands of couples suffering from infertility through the process of building a family. Staff members have an extensive breadth of knowledge enabling PUAH Institute to handle everything from complicated medical inquiries to relevant halachic questions. Couples receive the benefit of PUAH Institute’s expertise in a private and compassionate environment conducive to their needs. Professional expertise is also available to the general public through a wide variety of lectures, seminars and training courses. Participants at these sessions include rabbis, physicians, healthcare providers, and couples, all of whom share the common goal of raising awareness about reproductive health issues at both the social and medical levels.

Services:

  • Medical referrals
  • Hashgacha/ Supervison
  • Counseling
  • Events
  • Rabbonim

https://www.puahonline.org/

Bonei Olam: USA & Israel

Bonei Olam today is recognized in the worldwide medical arena for its leadership role at the forefront of reproductive medicine, research, and technology. Our myriad programs cover every step up the process including financial assistance, work up, medication, high-risk pregnancy, preimplantation, genetic diagnosis, pre-and-post cancer fertility, education, awareness, and adoption assistance.

Services:

  • Financial assistance
  • Insurance advocacy
  • Fertility preservation
  • Free loan program
  • Advanced genetic testing & research
  • Adoption services
  • High-risk pregnancy care

http://www.boneiolam.org//

Brooklyn NY Phone: (718)-252-1212

Lakewood NJ Phone: (732) 942-7773

Monroe NY Phone: (845) 751-1212

Spring Valley, NY Phone: (845) 388-1212

West Coast CA Phone: (323) 673-1212

Canada Phone: (514) 312-2977

Israel Phone: 1-800-300-307

Chana: UK

For 22 years, Chana has been giving emotional and practical support to Jewish couples who are experiencing primary or secondary infertility. Many couples in the Jewish community are affected, often dealing with their situation in silence and alone. Chana is here to help.

Services:

  • A strictly confidential helpline
  • Specialist medical support and information
  • Confidential counseling for individuals and couples
  • An expert Medical Advisory Panel
  • Information events

http://www.chana.org.uk/

Helpline: 020 8201 5774

Office London Phone: 020 8203 8455

Infertility Treatment Grants and Scholarships

Infertility Treatment Grants and Scholarships

Hope does exist for patients whose primary barrier to infertility treatment is the cost. Below is information about nonprofit organizations that provide financial assistance to select infertility patients.

For details, including application deadlines, please visit their websites. The listing of these organizations does not mean or imply an endorsement by RESOLVE.

Baby Quest Foundation

Grants are awarded two times yearly.
Provides a dollar range of $2,000-$16,000 (combination of money and medications).
Open to all, genders, singles, same sex couples, all who are permanent residents of the U.S., etc. (Click here to see more requirements on the Baby Quest website).
Baby Quest funds a range of procedures including egg and sperm donation, egg freezing, artificial insemination, in vitro fertilization, embryo donation, and gestational surrogacy.
Applications fees apply – $50 Application fee.
Contact Information:
Website: Visit http://www.babyquestfoundation.org for more information about Baby Quest’s grant
Email: bqfoundation@gmail.com
APPLY FOR A BABY QUEST GRANT – NEXT GRANT DEADLINE: November 15, 2017

The Tinina Q. Cade Foundation – Family Building Grant

This grant is offered twice per year – Once in the spring and once in the fall.
Provides up to $10,000 per funded family to help with costs medical infertility treatments and domestic adoption.
Open to all; applicants must have a diagnosis of infertility from their doctor and must be legal, permanent U.S. residents.
Applications fees apply- $50 Application fee.
Dates of Interest:

Grant is available online 7/5/16.
Grant submission deadline for SPRING consideration 2/1/17.
Grant decisions announced for SPRING funding 6/1/17.
Money available for SPRING grant applicants 8/1/17 available (grant MUST be redeemed by 8/1/18).
Grant submission deadline for FALL consideration 7/1/17.
Grant decisions announced for FALL funding 10/15/17.
2017 Cade Foundation Family Building Gala (required for all grant recipients) November 2017.
Money available for FALL grant recipients 1/1/18 (grant MUST be redeemed by 12/31/18).
Savannah Grant – Exclusively for Shady Grove Fertility Patients
All Shady Grove Fertility patients are eligible to receive the Savannah Grant, which will provide up to $10,000 in support for fertility treatment.
To apply for these grants, please submit an application for the Cade Foundation Family Building Grant. Shady Grove Patients will automatically be considered for a traditional Family Building Grant as well as the Savannah Grant.
Contact Information:
Website: Visit http://www.cadefoundation.org for more information about the Family Building Grant
Email: info@cadefoundation.org
Phone: (443) 896-6504
Fax: (410) 741-3701
APPLY FOR THE FAMILY BUILDING GRANT

The International Council on Infertility Information Dissemination- Scholarship:

The INCIID program is not a grant. INCIID does not pay a recipient’s expenses. Couples that meet certain criteria (financial and medical need) may be eligible for participation.
Provides a basic IVF cycle which is donated by a facility. This includes the treatment and physician services and monitoring at the designated clinic.
INCIID depends on donations to operate programs. Community members who pledge to an annual donation as a Bronze ($55 annually) member are eligible to receive a scholarship. The cost for a bronze annual level donation is a minimum of $55.00. Donate Here.
If you are NOT already a registered member, you can register in the community FIRST.
The selection committee selects couples based on cost-of-living, submitted paystubs, tax returns and a letter from their doctor recommending IVF as medically necessary.
Visit INCIID’s Frequently Asked Questions for more information about the program and eligibility requirements.
Dates vary in this program.
Contact Information:
Website: Visit http://www.inciid.org for more information about the, From INCIID the Heart IVF Scholarship Program.
Email: INCIIDinfo@inciid.org
Phone: (703)379-9178
Fax: (703)379-1593
APPLY FOR THE INCIID SCHOLARSHIP

The JFCS Fertility Fund: A Gift From the Heart

The JFCS Fertility Fund is a fund to help individuals and families who are confronted with infertility and the financial burden of IVF treatments that are not covered by insurance.

Applicants must be Jewish and reside in the Greater Philadelphia Region.
Application Process: Grants are provided as they are received.
Other resources through JFCS: The Hebrew Free Loan Society of Greater Philadelphia provides interest-free loans to Jews in our community for fertility treatments. For more information, visit http://www.hflphilly.org
Contact Information:
Website: http://www.jfcsphilly.org/fertilityfund
Phone: 1.866.532.7669
APPLY FOR THE JFCS FERTILITY FUND

Kevin J. Lederer Life Foundation – Life Grant

Must reside in Illinois, Indiana or Wisconsin.
Must have a diagnosis of infertility certified by a medical provider, with the exception of applicants who are single, or part of a same sex couple.
Grant requests may not exceed $10,000.
Past procedures are not eligible for Life Grants.
Visit Kevin J. Lederer Life Foundation’s Frequently Asked Questions for more information about the grant and eligibility requirements.
Contact Information:
Website: Visit http://www.lifefindsaway.org for more information on how to apply.
Email: grants@lifefindsaway.org
APPLY FOR A LIFE GRANT – Grant recipients will be announced July 2017

The Parental Hope Grant

The Parental Hope Family Grant Applicant (or Co-Applicant) must have one of the following:

A medical diagnosis of infertility by a Reproductive Endocrinologist according to the American Society for Reproductive Medicine’s definition of Infertility; or
Be a carrier of a genetic disease or chromosomal disorder that requires the use of Assisted Reproductive Technology (“ART”) services for healthy offspring; or
A Reproductive Endocrinologist has recommended ART services due to recurrent pregnancy loss.
$50 non-refundable application fee.
Contact information:
Website: http://www.parentalhope.org
Email: info@parentalhope.org
APPLY FOR THE PARENTAL HOPE FAMILY GRANTS – Parental Hope Family Grants are awarded annually. The next Application deadline is August 1, 2017.

Pay it Forward Fertility Foundation – Fertility Grant

The grant applies only to in vitro fertilization treatment (IVF), IVF with donor eggs and embryo adoption.
Grant amounts vary among the grant recipients, and partial and full grants can be awarded.
The age limit for the female partner is under 40 years old unless using donor eggs or doing embryo adoption. The application states that the female patient must be under the age of 40 when starting an IVF cycle.
Applicants must be United States (U.S.) citizens or permanent U.S. residents.
Visit Pay it Forward Fertility’s Frequently Asked Questions for more information about the grant and eligibility requirements.
$50 donation fee for processing application.
Contact Information:
Website: Visit http://www.payitforwardfertility.org for more information on how to apply.
Email: info@payitforwardfertility.org
Phone: (855) 888-PIFFF (7433)
APPLY FOR THE PAY IT FORWARD FERTILITY GRANT

In-State Assistance Only

New York State Infertility Demonstration Program
A grant from New York State for IVF treatment that is given to select IVF clinics.
On-Site Infertility Facilities Selected to Participate.
Funds are allocated to select centers meeting high standards of IVF success rates and patient volume.
To determine if you are eligible for the New York State Infertility Demonstration Program, please contact one of the providers on this list.
Contact Information:
Website: Visit Infertility Demonstration Program for more information
Email: bwh@health.state.ny.us
Phone: 1-800-522-5006 or through TTY access at 1-800-655-1789
Fax: (518) 474-6041

Cleveland Clinic – Ohio Hospital Care Assurance Program (HCAP)
You must be a resident of Ohio, Florida or Nevada and meet the geographic requirements identified in the policy.
They offer emergency and other medically necessary hospital-level services free of charge.
Eligibility:

(1) You are currently an eligible recipient of the General Assistance or the Disability Assistance Programs

(2) Your income is at or below 100% of the Federal Poverty Guidelines (the FPG).

For information regarding Cleveland Clinic Financial Assistance Policy and Financial Assistance Application Form, please refer to the contact information below for Cleveland Clinic financial counselors.

Contact Information:
Website: http://my.clevelandclinic.org – Financial Assistance
Phone: (866) 621-6385

Halachic Infertility

Halachic Infertility

Halachic Infertility refers to a case where a woman ovulates prior to immersion in the mikva. Since studies have shown that relations must occur before ovulation in order to result in conception, this “early ovulation” results in infertility.

A woman who suspects that she ovulates before she can immerse in the mikvah should first determine her date of ovulation. There are several ways to do this:

1) She can measure her temperature upon arising every morning (the “basal body temperature”). There is generally a rise of about 0.3 degrees Centigrade (0.5 degrees Fahrenheit) just prior to ovulation. This method can be cumbersome for women who wake at irregular times, and body temperature can be affected by other factors, such as illness. Therefore, other methods are more popular today.

2) She can use an “ovulation prediction test,” which measures the surge in lutenizing hormone (LH) that precedes ovulation by 12-24 hours. These kits are readily available in pharmacies or Amazon without a prescription, and may be used in the privacy of one’s home.

(Here you can find many types of ovulation test) https://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=ovulation+test

3) A physician may order blood tests to determine hormone levels on particular days of her cycle.

4) Under direction of a physician, she may undergo a series of ultrasounds which follow the development of the ovarian follicle and record ovulation directly.

A woman who discovers that she is ovulating before immersion should next verify that her menses really last as long as she thinks. Any color other than bright red on a hefsek taharah or other internal examination should be brought to a rabbi to check whether it is, in fact, problematic. The rabbi should be aware that she cannot conceive due to early ovulation, as certain leniencies may apply in this situation. Many cases of halachic infertility can be solved by avoiding unnecessary delay of mikveh immersion.

What are the causes of “early ovulation” and what can be done within halacha to treat this issue?

There are two scenarios that result in early ovulation:

  • Short Cycle
  • Long Bleeding

Normal or Average Menstrual Cycle

On average, a regular menstrual cycle occurs every 28 days and lasts from 2 to 7 days. In most cases, women ovulate 14 days prior to their upcoming menstruation, or on the 14th day of her monthly cycle.

According to halachot of niddah, women cannot immerse in the mikvah until at least 12 days (11 days according to Sephardic opinions)  from the onset of menstruation.

On average, a woman will therefore immerse (depending on the duration of bleeding) anywhere from the 12th day of her cycle to the 14th day of her cycle. Most women will ovulate after immersion, an optimum time for fertility. Women who have an average 14 day cycle and bleed for a full 7 days will ovulate on the day of immersion, a situation which is considered to be borderline and may result in infertility.

Short Cycle

Short cycle infertility is defined as a case where even a woman with the shortest duration of bleeding cannot immerse in the mikveh prior to ovulation. Women whose cycles are 25 days or less will not immerse until at least the 12th day after the onset of monthly bleeding. Since ovulation generally occurs 14 days before the onset of monthly bleeding, we can calculate that ovulation in such cycles will occur on or prior to the 11th day of the monthly cycle. Such women cannot immerse prior to ovulation, which results in infertility.

Women whose cycles are 26 days are considered to be borderline cases; some may ovulate prior to immersion while others may ovulate after immersion, depending on the duration of her bleeding period.

Long Bleeding

Long bleeding is defined as a case in which either the duration of menstrual bleeding or occurrences of irregular bleeding lead to an inability to immerse in the mikveh prior to ovulation.

Any instance where the duration of bleeding combined with the mandatory minimum 7 day waiting period after the cessation of period leads to immersion after ovulation. For instance, a woman with a 27 day cycle will ovulate on day 13 of her cycle. If her period lasts for 7 days, she will immerse no earlier than day 14.

Please note that a monthly period lasting for longer than 7 days may require medical attention. A physician should be consulted.

Solutions

The above calculations are explanatory in nature and should not be relied upon to calculate the date of ovulation. There are methods to determine the exact date of ovulation which should be used to determine if religious infertility is indeed the case. If it is determined that a woman is indeed suffering from religious infertility there are methods within halacha to address the situation.

The following solutions are not general in nature. Each case must be evaluated and treated on an individual basis in consultation with a Rabbi or Puah Rabbinic Counselor.

  • Short Cycle Solutions: Short cycles can be caused by excess stress or dietary issues. In such cases, dietary changes (eating 3 healthy well balanced meals each day), relaxation techniques and/or moderate exercise may result in the extension of the cycle to normal levels. If these solutions are not effective, there are natural remedies as well as pharmacological remedies that may be prescribed. This should only be done in consultation with a fertility professional and/or Puah Rabbinical Counselor.
  • Long Bleeding Solutions: Many cases of long bleeding are the result of unnecessary stringency in the observance of the laws of niddah. The responsibility in this area is placed on the woman herself and the natural inclination when in doubt is to err on the side of caution. As such, there are women who postpone their immersion date in error and can actually halachically immerse earlier than they think. If there is any question as to the determination of a stain or spot halachically, a Rabbi should be consulted for a definitive halachic ruling.

    Not every case, however, can be solved through halachic leniency. In particular, the seven blood-free days cannot begin before bleeding has stopped, as confirmed by a hefsek taharah. Therefore, a woman with early ovulation whose menses last at least five days may require medical intervention in order to conceive.

    There are a number of medical treatments that can delay ovulation. One common treatment is clomiphene citrate (Clomid, Serephene, or Ikaclomin). This drug is normally used in fertility treatment to induce ovulation, but it is helpful in this case, because it has the side effect of delaying ovulation. Another approach is to use estrogen at the beginning of the cycle to delay ovulation by a few days. Other hormonal manipulation can delay ovulation as well. All these medications require a prescription, and must be used under the supervision of a physician.

    If the standard medical treatments fail or are unsuitable, there are other possible ways to intervene, but these should be developed by a medical team working together with a rabbi experienced in fertility.

    There are also natural remedies that may be employed to shorten the duration of a menstrual cycle. For example, in some cases, drinking the juice of one lemon each day of menstruation has been shown to be effective in shortening the duration of a period.

Reference:

http://www.jewishfertility.org/halachic-infertility.php

http://www.yoatzot.org/womens-health-and-halacha/?id=584

 

What fertility treatments are permitted on Shabbat?

What fertility treatments are permitted on Shabbat?

Diagnosis & Treatment on Shabbat

What treatments are permitted on Shabbat? What tests can be done on Shabbat? Is there a difference between the way treatment should be performed on Shabbat as opposed to any other day?
There is some discussion among the Rabbis as to the halachic status of couples experiencing fertility issues. Some rabbis are of the opinion that such couples are considered slightly ill since they are not actually suffering from a specific medical condition. However, most Rabbis do consider them to be ill, even though their lives are not in danger.

It is essential to note that a sick person suffering from a non-life threatening condition is:

  • permitted to take medicine
  • permitted to transgress certain rabbinic prohibitions for the purpose of treatment
  • permitted on Shabat to ask a non-Jew to perform certain types of work for him for the purpose of treatment
  • In light of this most authorities will permit certain tests and treatments on the Sabbath or festivals.

Monitoring Ovulation

There are three basic methods to test ovulation

  1. Basal Body Temperature (BBT): Normally one is prohibited from measuring their temperature on Shabbat as it falls into the category of “measuring”. Measuring for the purpose of the mitzvah is permitted. In this case, measuring BBT to achieve pregnancy is part of the mitzvah of procreation. It is therefore permitted on Shabbat (only when using a non-digital thermometer).
  2. Home Ovulation Testing Kit: The urinalysis strips used in this test change color to indicate ovulation. Normally one is prohibited from coloring on Shabbat as it falls into the category of “dying”. Since the strip is immediately discarded, this type of coloring is a rabbinic prohibition. It is therefore permitted, as noted above.
  3. Blood Test and Ultrasound (BW/US): The drawing of blood on Shabbat is a Torah prohibition. US involves the use of electricity, which is also prohibited on Shabbat. Since there are permissible methods of achieving the desired information, this method is not permitted on Shabbat.
  4. Other Tests: Most other types of evaluation testing are not time specific. Whenever testing can be performed during the week it is prohibited on Shabbat.

Ovulation Induction

Clomiphene Citrate (CC): Taking medication is normally prohibited on Shabbat. As stated above one who is ill can take medication to treat their illness, in this case, fertility. As such CC or other such fertility medications can be taken on Shabbat. One should be careful not to tear the letters on the wrapping on Shabbat and it is advisable to prepare the tablets before Shabbat when possible.
Injections: There are several halachic issues involved with administering injections on Shabbat. As noted above, drawing blood on Shabbat is prohibited by the Torah. At the present, all injections for ovulation induction are intramuscular or subcutaneous and do not require the drawing of blood. Therefore this Torah prohibition does not apply.
Assembling the needle: This falls into the category of building a vessel and is prohibited on Shabbat. Therefore when possible the needle should be attached to the vial before Shabbat. One should be careful not to compromise the sterile environment that is essential for treatment. In cases where this is impossible, a non-Jew can be asked to assemble the needle or it can be done in an unusual way. Please consult your Rabbi in such a case.
Sterilizing the injection site: One may not use cotton wool dipped in alcohol to clean the site of the injection, which is included in the prohibition of “squeezing”. One should use a pre-prepared alcohol swab of synthetic material, or pour alcohol directly onto the skin and then wipe off the excess with cotton.
In light of the above, it is preferable not to administer injections unless this is absolutely necessary on Shabbat. When possible they should be administered before and after Shabbat. If this is impossible, it is preferable for a non-Jew to give the injection. In a case where no other possibility exists, the injections may be given by a Jew on Shabbat as described above.

Chorionic gonadotropin (hCG) injections need to be given at a particular time. In the case where the injection must be given on Shabbat. As above, it is preferable that this should be done by a non-Jew, but when this is impossible even a Jew may do so as described above.

Receiving an injection on Yom Kippur appears to be permitted and is not considered in the category of eating.

Intrauterine Insemination (IUI)

Sperm preparation for intrauterine insemination involves a number of actions that are forbidden on Shabbat such as the use of electricity and the separation of the sperm. It is preferable not to undergo such treatment on Shabbat. Therefore, when embarking on treatment the couple must inform their doctor that he must schedule their treatment such that it will not fall on Shabbat. However, since an IUI must be performed to coincide with ovulation this cannot always be avoided. In such a case the couple must consult their Rabbi.

All fertility treatments involving processing eggs, sperm or embryos require close rabbinic supervision. The supervisor must be available to come to the laboratory on Shabbat. In places where the clinic is not near a residential Jewish area, this may create extremely grave, and even insurmountable, difficulties.

In-Vitro Fertilization (IVF)

The halachic issues and solutions regarding IVF are similar to those of IUI. IVF involves days that the couple needs to be in the clinic and days when the medical staff work on the embryos but the couple need not be in attendance. While all efforts should be made to avoid a retrieval or implantation on Shabbat, it is permissible for a non-Jew to check embryos on Shabbat.

The couple must inform the doctor of these limitations and urge him not to schedule a Thursday, Friday or Shabbat retrieval. When retrieval does fall on Shabbat the couple must consult their Rabbi.

When egg transfers fall on Shabbat it can often be pushed off until after Shabbat, or brought forward to a Friday.

Supervision is required for an IVF and this may present problems if the procedure falls on the weekend, since the supervisor must be in attendance throughout the procedure.

Traveling to the Hospital or Clinic on the Sabbath

In the rare cases, such as in a case of ovarian hyperstimulation, where delaying treatment is potentially life-threatening, a woman may travel to the hospital by car on the Sabbath. However, with regard to all other types of fertility treatment that may be permitted on the Sabbath, many authorities do not permit traveling by car. In such cases, the couple should stay within walking distance of the hospital or clinic over the Shabbat.
Some rabbis hold that it is permitted for a non-Jew to drive a woman to the hospital on the Sabbath in order to undergo fertility treatment. It is preferable to make this arrangement with the non-Jew before the Sabbath and the non-Jew should open and close the door of the car if this causes the light to turn on and off.

Yom Tovim/Festivals

The laws of Shabbat are applicable to all the festivals. One should bear this in mind when scheduling treatment and avoid the times in the year when the festivals occur wherever possible.

Summary
Couples facing fertility issues are considered by the Halachah as ill
They are permitted to undergo testing and treatment on Shabbat if it is necessary and does not contradict a Torah prohibition

References: http://www.jewishfertility.org/diagnosis-treatment-shabbat.php

Hormone levels & fertility blood work

When TTC, it is important to closely track your cycle, ideally through the use of urine-based ovulation testing (ovulation tracking), basal temperature tracking, or blood work. As a Frum woman, if you believe that hormonal imbalance or halachic infertility may be contributing to your difficulty in achieving pregnancy, it is crucial to determine whether or not ovulation is occurring within 24-36 hours of going to the mikvah (more on this topic in a later post).

Please note that all labs have their own normal values, and those presented in these charts are just an average. These charts are provided as a tool to help Frum patients have a better dialog with their doctors, not for self-diagnosis or as a substitute for good medical care.

Female Hormone Levels
Hormone to Test
Time
to Test
Normal
Values
What Value Means
Follicle Stimulating Hormone (FSH) Day 3 3-20 mIU/ml FSH is often used as a gauge of ovarian reserve. In general, under 6 is excellent, 6-9 is good, 9-10 fair, 10-13 diminished reserve, 13+ very hard to stimulate. In PCOS testing, the LH:FSH ratio may be used in the diagnosis. The ratio is usually close to 1:1, but if the LH is higher, it is one possible indication of PCOS.
Estradiol (E2) Day 3 25-75 pg/ml Levels on the lower end tend to be better for stimulating. Abnormally high levels on day 3 may indicate existence of a functional cyst or diminished ovarian reserve.
Estradiol (E2) Day 4-5 of meds 100+ pg/ml or 2x Day 3 There are no charts showing E2 levels during stimulation since there is a wide variation depending on how many follicles are being produced and their size. Most doctors will consider any increase in E2 a positive sign, but others use a formula of either 100 pg/ml after 4 days of stims, or a doubling in E2 from the level taken on cycle day 3.
Estradiol (E2) Surge/hCG day 200 + pg/ml The levels should be 200-600 per mature (18 mm) follicle. These levels are sometimes lower in overweight women.
Luteinizing Hormone (LH) Day 3 < 7 mIU/ml A normal LH level is similar to FSH. An LH that is higher than FSH is one indication of PCOS.
Luteinizing Hormone (LH) Surge Day > 20 mIU/ml The LH surge leads to ovulation within 48 hours.
Prolactin Day 3 < 24 ng/ml Increased prolactin levels can interfere with ovulation. They may also indicate further testing (MRI) should be done to check for a pituitary tumor. Some women with PCOS also have hyperprolactinemia.
Progesterone (P4) Day 3 < 1.5 ng/ml Often called the follicular phase level. An elevated level may indicate a lower pregnancy rate. If low progesterone levels are an issue for you, consider taking a natural fertility supplement like FertilAid for Women.
Progesterone (P4) 7 dpo > 15 ng/ml A progesterone test is done to confirm ovulation. When a follicle releases its egg, it becomes what is called a corpus luteum and produces progesterone. A level over 5 probably indicates some form of ovulation, but most doctors want to see a level over 10 on a natural cycle, and a level over 15 on a medicated cycle. There is no mid-luteal level that predicts pregnancy. Some say the test may be more accurate if done first thing in the morning after fasting.
Thyroid Stimulating Hormone (TSH) Day 3 .4-4 uIU/ml Mid-range normal in most labs is about 1.7. A high level of TSH combined with a low or normal T4 level generally indicates hypothyroidism, which can have an effect on fertility.
Free Triiodothyronine (T3) Day 3 1.4-4.4 pg/ml Sometimes the diseased thyroid gland will start producing very high levels of T3 but still produce normal levels of T4. Therefore measurement of both hormones provides an even more accurate evaluation of thyroid function.
Free Thyroxine (T4) Day 3 .8-2 ng/dl A low level may indicate a diseased thyroid gland or may indicate a non- functioning pituitary gland which is not stimulating the thyroid to produce T4. If the T4 is low and the TSH is normal, that is more likely to indicate a problem with the pituitary.
Total Testosterone Day 3 6-86 ng/dl Testosterone is secreted from the adrenal gland and the ovaries. Most would consider a level above 50 to be somewhat elevated.
Free Testosterone Day 3 .7-3.6 pg/ml
Dehydroepiandrosterone Sulfate (DHEAS) Day 3 35-430 ug/dl An elevated DHEAS level may be improved through use of dexamethasone, prednisone, or insulin-sensiting medications.
Androstenedione Day 3 .7-3.1 ng/ml
Sex Hormone Binding Globulin (SHBG) Day 3 18-114 nmol/l Increased androgen production often leads to lower SHBG
17 Hydroxyprogesterone Day 3 20-100 ng/dl Mid-cycle peak would be 100-250 ng/dl, luteal phase 100-500 ng/dl
Fasting Insulin 8-16 hours fasting < 30 mIU/ml The normal range here doesn’t give all the information. A fasting insulin of 10-13 generally indicates some insulin resistance, and levels above 13 indicate greater insulin resistance.

 

Blood Glucose Levels
Type of Test Time to
Test
Normal
Values
What value means
Fasting Glucose 8-16 hours fasting 70-110 mg/dl A healthy fasting glucose level is between 70-90, but up to 110 is within normal limits. A level of 111-125 indicates impaired glucose tolerance/insulin resistance. A fasting level of 126+ indicates type II diabetes.
Glycohemoglobin / Glycosylated Hemoglobin (HbA1c) anytime < 6 % An HbA1c measures glucose levels over the past 3 months. It should be under 6% to show good diabetic control (postprandial glucose levels rarely going above 120). Good control reduces the risk of miscarriage and birth defects.

 

Glucose Tolerance Test with Insulin (GTT / IGTT)
Time Normal Glucose Values Normal Insulin Values What the Results Mean
Fasting < 126 mg/dl < 10 mIU/ml Normal glucose results are 70-90, 111 or over is impaired, 126 or over is diabetic. Insulin levels above 10 show insulin resistance.
? hour < 200 mg/dl 40-70 mIU/ml A truly normal glucose response will not exceed 150.
1 hour < 200 mg/dl 50-90 mIU/ml Some want to lower the threshold on glucose to < 180 to identify early stages of diabetes. Insulin > 80 shows insulin resistance, or a level 5 times that of the fasting level (i.e., a fasting of 11 followed by a 1 hour > 55)
2 hours < 140 mg/dl 6-50 mIU/ml A truly normal glucose response is 110 or lower.
Insulin > 60 is IR.
3 hours < 120 mg/dl
4 hours < 120 mg/dl

 

Cholesterol, Triglycerides and C-Peptide
What to Test Time to Test Normal
Values
What value means
Triglycerides (TG) 8-16 hours fasting < 200 mg/dl Borderline high is 200-400, high is 400-1000, and very high is >1000. Elevated levels are a risk factor for coronary artery disease.
Cholesterol Total 8-16 hours fasting < 200 mg/dl A level of 200-239 is borderline high, and a level 240+ is high. Increased levels are associated with increased risk of heart disease.
low-density lipoprotein cholesterol (LDL) 8-16 hours fasting < 160 mg/dl This is the “bad” cholesterol. In someone with one risk factor for heart disease, < 160 is recommended, with 2 risk factors < 130, and those with documented coronary heart disease the target is < 100
high-density lipoprotein cholesterol (HDL) 8-16 hours fasting > 34 mg/dl This is the “good” cholesterol which may be increased through a healthy diet and exercise. The HDL level is usually estimated by taking total cholesterol and subtracting LDL, rather than by direct measure.
C-peptide 8-16 hours fasting 0.5 to 4.0 ng/ml Levels increase with insulin production.
Creatinine < 1.4 mg/dl Levels 1.4 mg/dl and higher may indicate renal (kidney) disease or renal dysfunction.

 

Male Hormone Levels
Hormone to Test Normal Values What value means
Testosterone 270-1100 ng/dl Testosterone production is stimulated by Leydig cells in the testicles. Low levels of testosterone combined with low FSH and LH are diagnostic of hypogonadotropic hypogonadism.
Free Testosterone .95-4.3 ng/dl  
% Free Testosterone .3% – 5% A normal male has about 2% free, unbound testosterone
Follicle Stimulating Hormone (FSH) 1-18 mIU/ml Basic hormone testing for males often only includes FSH and testosterone.
Prolactin < 20 ng/ml A level two or three times that of normal may indicate a pituitary tumor, such as a prolactinoma, which may lead to decreased sperm production. Elevations can be treated with bromocriptine.
Luteinizing Hormone (LH) 2-18 mIU/ml LH stimulates Leydig cells and production of testosterone. A problem with LH levels alone is rarely seen, so testing is only needed if testosterone level is abnormal.
Estradiol (E2) 10-60 pg/ml  
Progesterone (P4) .3-1.2 ng/ml  

 

Progesterone in Pregnancy
When Normal Values What Level Means
Mid-Luteal Phase 5+ ng/ml As mentioned above, a level of 5 indicates some kind of ovulatory activity, though most doctors want to see a level over 10 on unmedicated cycles, and over 15 with medications. There is no mid-luteal level that predicts pregnancy.
First Trimester 10-90 ng/ml Average is about 20 at 4 weeks LMP, and 40 at 14 weeks LMP. It is important to note that while a higher progesterone level corresponds with higher pregnancy success rates, one cannot fully predict outcome based on progesterone levels. Progesterone supplementation is unlikely to help if started after a positive pregnancy test.
Second Trimester 25-90 ng/ml Average is 40 at beginning, 90 at end.
Third Trimester 49-423 ng/ml Usually peaks at about 175.

 

hCG Levels in Early Pregnancy
Days Post Ovulation/Retrieval Weeks/Days LMP Average Singleton Level Average Twin Level
10 3w3d 25  
12 3w5d 50  
14 4w0d 100  
16 4w2d 200  
Early-detection pregnancy tests (detecting 20 miu/ml hcg) can assist you in detecting pregnancy before your missed period.

 

Oral Glucose Tolerance Test for Gestational Diabetes
Time Normal Values Gestational diabetes is diagnosed if 2 or more levels are above the normal range. It is treated through diet, insulin injections, and sometimes with metformin. You may want to check All About Gestational Diabetes.
Fasting < 105 mg/dl
1 hour < 190 mg/dl
2 hours < 165 mg/dl
3 hours < 145 mg/dl

 

Reference: http://www.fertilityplus.com/faq/hormonelevels.html#female

 

Fertility Meds

Fertility Meds

Most people dread taking medications because they don’t understand how the medication works, or because they are expensive and time-consuming. Therefore, many will try to swing their doctor to avoid giving them meds or give them a “generic” to reduce costs. However, when it comes to the fertility meds, many are only available in the Brand name (meaning no generic exist) and are extremely expensive. If until now you have been TTC without fertility meds and have now been introduced to the overwhelming world of fertility drugs, don’t despair! In this article, I will try to demystify the many fertility drugs and will give you hints on how to save money on them.

Oral Fertility Meds  (aka the first line of treatment)

The fertility pills such as Clomid (Clomiphene) and Femara (Letrozole) help the pituitary gland improve the stimulation of developing follicles (eggs) in the ovaries. They work by blocking estrogen receptors in the hypothalamus, which in turns releases higher amounts of GnRH into the anterior pituitary, telling it to release higher levels of FSH and LH. Thus the ovaries are “forced” to increase follicle development and estrogen. The increasing levels of circulating estrogen as sensed by the hypothalamus, which then sends an LH surge producing ovulation. The side effects can range from headaches, mood swings, ovarian cysts to weight gain. They also increase your chances of twins. Clomid has been known for causing thinning of the uterine lining, which can potentially impact implantation rates or causes miscarriages.

Injectables

Injectable medications are the second line of fertility treatment, usually used after several cycles with CC failed. Injectable medications can be subdivided into several categories.

  • GnRH Agonist (Lupron, Buserelin, Nafarelin, Synarel):

This medication mimics the structure of GnRH molecule in the hypothalamus, thus is able to bind to the GnRH receptor and elicit the response of the anterior pituitary to release FSH and LH during the first 4-6 days. Thus, the blood levels of LH and FSH which are initially raised with the initiation of GnRHa therapy are sustained well above normal for 4-6 days, producing a “flare effect” (a 10x increase in LH).  However, it sorts of gets stuck and ultimately blocks the receptor from further activity and inhibits the action of this hormone in the brain. This is referred to as “pituitary down-regulation”. At this point, the pituitary gland becomes depleted of FSH and LH. However, after taking it for 10-20 days, it produces a hypogonadal effect, thus drastically reducing FSH and LH. The administration of subcutaneous GnRHa is rarely associated with significant side effects. Some women experience temporary fluctuations in mood, hot flashes, nausea. It is given subcutaneously.

lupron

  • GnRH Antagonist (Ganirelix, Cetrotide, Cetrorelix, Orgalutron):

Also known as antagon, GnRH antagonists are competitive inhibitors of GnRH. They work by blocking GnRH from binding to its receptor in the hypothalamus and rapidly depleting FSH and LH, preventing premature luteinization (ovulation). Unlike the agonist long course of treatment (10-20 days), the antagonist is effective within 2-3 days of treatment. They are usually recommended in women with PCOS, as they reduced the risk of OHSS. As well, they reduced the possibility of having a cycle cancellationganirelix.

  • Gonadotropins (Menoupur, Follitism, Gonal-F):

There are two gonadotropins, FSH and LH. These gonadotropins are excreted in the urine. Two varieties are commercially available. The 1st is menotropins or urinary-derived Human Menopausal Gonadotropins (hMG). The 2nd is genetically-engineered Recombinant DNA-gonadotropins, (FSHr and LhR). If administered to women at a sufficient dosage beginning early enough in the menstrual cycle, commercially available gonadotropins will prompt the development of multiple follicles each of which houses one egg. LH (and hCG) directly stimulates the tissue surrounding the ovarian follicles ) which in response produces male hormones (predominantly testosterone). The testosterone is then carried to the surrounding follicles where FSH converts it to estrogen. Risks and Side Effects of Gonadotropin Therapy: some women taking gonadotropins report breast tenderness, backaches, headaches, insomnia, bloating, and increased vaginal discharge, which are directly due to increased mucus production by the cervix.

  •  Human Menopausal Gonadotropins (hMG)– Menopur, Merional 75IU: hMG contains both FSH and LH. Menopur also contains a small amount of added hCG.menopur
  • Urinary-Derived FSH (Bravelle) this is essentially hMG that has been processed further to extract most of the LH. It is less expensive than FSHr.Bravelle
  • Recombinant FSH FSHr (Folistim, Gonal-F and Puregon): derived by way of genetic engineering. FSHr appears to be more bioactive than urinary-derived FSH products such as Bravelle and hMG and response to FSHr, more consistent and predictable.

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gonalf

Recombinat LH (Luveris): Since some LH is essential to provoke the ovarian stroma to produce some testosterone for delivery to the follicles for conversion into estrogen, a small amount must be given with FSHr to achieve egg development.

  • HCG (aka trigger shots Pregnyl, Novarel, Ovidrel):

The effect of the “trigger shot” is to send eggs into a reproductive division known as meiosis where the objective end point is a decrease in the number of chromosomes in the egg from 46 to 23 (half) prior to ovulation or egg retrieval. In the process, approximately half of the chromosomes are expelled from the egg nucleus in a membranous envelopment. This so called first polar body comes to lie immediately under the envelopment of the egg (the zona pellucida) in a region known as the perivitelline space. Ovulation will occur 36 after the HCG trigger is given. This trigger shot comprises one of three medications: a) urinary-derived hCG (hCGu), e.g., Novarel, Pregnyl and Profasi, b) Recombinant hCG (hCGr), e.g., Ovidrel, or c) an agonist such as Lupron, which upon being injected provokes a surge in the release of pituitary gland-derived, LH) is initiated.