45 YMG physicians among New York Magazine’s “Best Doctors”

New York Magazine’s 2009 list of the region’s best doctors includes 45 Yale Medical Group physicians. Identified by their peers, the YMG doctors named in the 12th annual “Best Doctors” issue were selected from more than 6,000 physicians in the greater New York region and are listed among the top 10 percent of metro-area physicians.

“The strong representation of our faculty on the New York Magazine “Best Doctors” list highlights the broad geographic reach of our physicians’ referral network,” said David J. Leffell, MD, CEO of YMG.

John Aruny, MD Diagnostic Radiology, Vascular & Interventional Radiology Masoud, Azodi, MD Obstetrics & Gynecology, Gynecologic Oncology Robert Baltimore, MD Pediatrics, Pediatric Infectious Diseases William Batsford, MD Internal Medicine, Cardiology Henry Cabin, MD Internal Medicine, Cardiology Edward Chu, MD Medical Oncology Joshua Copel, MD Obstetrics & Gynecology, Maternal-Fetal Medicine Richard Edelson, MD Dermatology, General Dermatology Richard Ehrenkranz, MD Pediatrics, Pediatric Neonatal-Perinatal Medicine John Elefteriades, MD Surgery, Cardiac Surgery Sukru Emre, MD Surgery, Transplant & Immunology Richard Gusberg, MD Surgery, Vascular Surgery Silvio Inzucchi, MD Internal Medicine, Endocrinology & Metabolism William Kelly, DO Medical Oncology Walter Kernan, MD Internal Medicine, General Medicine Robert King, MD Child Study Center Gary Kopf, MD Surgery, Cardiac Surgery David Leffell, MD Dermatology, Dermatologic & Laser Surgery Walter Longo, MD Surgery, Colorectal Surgery Paul McCarthy, MD Pediatrics, Pediatric Primary Care R. Lawrence Moss, MD Surgery, Pediatric Surgery Edward Novotny, MD Pediatrics, Pediatric Neurology Michael Paidas, MD Obstetrics & Gynecology, Maternal-Fetal Medicine

Pasquale Patrizio, MD Obstetrics & Gynecology, Reproductive Endocrinology & Infertility John Persing, MD Surgery, Plastic Surgery Richard Peschel, MD Therapeutic Radiology Joseph Piepmeier, MD Neurosurgery, Neuro-Oncology Vincent Quagliarello, MD Internal Medicine, Infectious Diseases Kenneth Roberts, MD Therapeutic Radiology Clarence Sasaki, MD Surgery, Otolaryngology Margretta Seashore, MD Genetics Dennis Spencer, MD Neurosurgery, Epilepsy Surgery Susan Spencer, MD (1943 - 2009) Neurology Bauer Sumpio, MD Surgery, Vascular Surgery William Tamborlane, MD Pediatrics, Pediatric Endocrinology & Metabolism Lynn Tanoue, MD Internal Medicine, Pulmonary & Critical Care Medicine Hugh Taylor, MD Obstetrics & Gynecology, Reproductive Endocrinology & Infertility J. Grant Thomson, MD Surgery, Plastic Surgery Mary Tinetti, MD Internal Medicine, Geriatrics James Tsai, MD Ophthalmology, Glaucoma Service Robert Udelsman, MD Surgery, General Surgery - Endocrine Christopher van Dyck, MD Psychiatry, Adult Psychiatry Jeffrey Weinreb, MD Diagnostic Radiology, Body Imaging Robert White, MD Diagnostic Radiology, Vascular & Interventional Radiology Lynn Wilson, MD Therapeutic Radiology

Can You Be Too Old to Get Pregnant?

Elizabeth Adeney, a 66-year old woman, is now 8-months pregnant after undergoing infertility treatment in Ukraine. She is expected to be one of the oldest new mothers in the world, joining the growing list of women conceiving at an advanced age using assisted reproductive technologies.

Prior to Elizabeth Adeney, Rajo Devi, who claimed to be about 70 years old, gave birth in November 2008 to her first child, again following infertility treatment in India. In 2006, Carmela Bousada of Spain became what was believed to be the oldest new mother when she delivered twin boys at age 66. Before that, Romanian citizen Adriana Iliescu gave birth to a baby girl in January 2005, also at 66. Bousada was 130 days older than Iliescu when she gave birth.

These births, achieved through the use of donor eggs and in vitro fertilization raised concerns about the ethical implications of infertility treatment in women at advanced age, particularly with regard to maternal complications and the social issues related to the care of the children as they grow up. It is well established that advanced maternal age is associated with gestational diabetes and pregnancy induced hypertension, which, in turn, may result in preterm birth and associated adverse outcomes. Social implications of pregnancies that occur at such an advanced age are yet to be studied.

Currently, many programs in the United States use an age limit of 50 for infertility treatment based on the median age of menopause. However, these arbitrary age limits also bring additional discussions on patients’ autonomy. Therefore, the need remains for a multi-disciplinary discussion of regulatory strategies for assisted reproduction taking into account the medical, social, financial, and ethical aspects.

PCOS and Cardiovascular Risks

Women with Polycystic Ovarian Syndrome (PCOS) have an increased risk for heart disease and possibly heart attacks compared to other women of the same age and weight, studies show. Specifically, the indications of cardiovascular disease include sub-clinical hardening of the arteries and signs of significant vascular impairment, including irregularities of the cells lining the arteries and blood vessels and increased thickness and decreased compliance of arterial walls. While the main focus of PCOS specialists is treating infertility, menstrual irregularities and unwanted hair, it’s important for women and their physicians to pay attention to the increased cardiovascular risk that accompanies PCOS as well, said Dr. Pinar Kodaman, a reproductive endocrine specialist who focuses on reducing cardiovascular risks for PCOS patients through lifestyle modification and medication. Dr. Kodaman is part of the multidisciplinary team at the Yale Polycystic Ovarian Syndrome Program that treats all aspects of PCOS.

Cardiovascular disease remains the most common cause of death among women, and risk of death from a heart attack increases with age, especially in the United States where there is a high incidence of obesity, a key contributor to heart disease.

At least 50% of women with PCOS in the U.S. are obese, 40% are insulin resistant, and 10% have type II diabetes. Insulin resistance, coupled with the body’s tendency to compensate by producing even more insulin, is one of the major factors in the development of Metabolic Syndrome, and this condition exacerbates elevated lipids in the blood, obesity, glucose intolerance and unwanted facial and body hair among women with PCOS.

PCOS is also associated with increased oxidative stress, high blood pressure, elevated levels of homocysteine, an amino acid in the blood that is an indicator of higher risk of heart disease, and dyslipidemia (an imbalance of lipids in the blood), all of which also contribute to cardiovascular risk. Interestingly, even young and lean women with PCOS tend to have unfavorable cardiovascular risk profiles, Dr. Kodaman said.

The studies on cardiovascular illness and death among PCOS patients are limited; however, the cardiovascular risks associated with the syndrome are clear.

The medical management of PCOS includes therapy for failure to ovulate or irregular ovulation, unwanted body and facial hair, as well as treatment of endometrial hyperplasia, a condition in which the lining of the uterus grows too much. In addition, obesity, dyslipidemia, hypertension, and insulin resistance should also be addressed if present. Lifestyle modification with diet and exercise are first line treatments, followed by insulin sensitizers, such as metformin, for insulin resistance and statin drugs, like Lipitor, for dyslipidemia. Statins may have additional beneficial roles in decreasing oxidative stress and improving hyperandrogenemia and other biochemical disorders of PCOS.

PCOS is the most common endocrine disease affecting women of reproductive age. Up to 10 million women in the United States have PCOS, a condition characterized by hyperandrogenism (excessive secretion of male sex hormones that results in unwanted facial and body hair) and oligomenorrhea (irregular menstrual periods). Frequently, the ovaries also have a polycystic appearance on ultrasound, which appears as multiple small follicles around the perimeter of the ovary. The cause of PCOS is unknown and researchers are actively investigating it.

PCOS occurs shortly after puberty and consists of altered gonadotropin secretion favoring luteinizing hormone production, which stimulates the ovaries to produce increased levels of androgens (male sex hormones). In addition, at the level of the ovary, the follicles make less estrogen and luteinize prematurely, thereby failing to ovulate.

While PCOS is an endocrine disorder affecting women during their reproductive years, its consequences continue to have detrimental effects in the postmenopausal years. A recent a study found that postmenopausal women with clinical features of PCOS had a greater incidence of cardiovascular events. Therefore, it is imperative that PCOS be diagnosed in a timely fashion and treated effectively across the lifespan.

PCOS and Nutrition

While the causes of PCOS remain unclear, most experts believe insulin plays a major role in its development. The majority of PCOS patients have decreased insulin insensitivity, causing high levels of insulin or what is commonly known as insulin resistance. Approximately 50% of women affected by PCOS are overweight.

Risk Factors
Insulin resistance places an individual at increased risk for:
• Abnormal carbohydrate metabolism – raising the likelihood of developing type II diabetes
• Heart disease due to:
– Increased levels of LDL or “bad” cholesterol
– Decreased levels of HDL or “good” cholesterol
– Increased levels of triglycerides
– Increased blood pressure
• Significant weight gain and difficulty losing weight
• Low self-esteem

Lifestyle Modifications

Diet
Diet and exercise have been established as the first line of defense against PCOS. Studies show that a 5%-10% weight loss may substantially improve the metabolic and reproductive abnormalities associated with PCOS while lowering the risk of heart disease and type II diabetes. A registered dietitian (RD) can help customize a balanced diet, low in fat and moderate in carbohydrates, to help you achieve and maintain your weight loss goals. The RD will evaluate your current diet, lifestyle and risk factors and
establish a nutrition plan specific to your individual needs.
The following factors will be considered:
• Current height and weight
• Ideal body weight (IBW)
• Age, overall health and medical history
• Current medications or supplements taken
• Current eating patterns, food preferences and dietary customs

Exercise
Evidence clearly supports the importance of physical activity for women affected by PCOS; exercise may be just as important as diet in treating the disorder. Both aerobic exercise and strength conditioning can be effective in:
• Improving lipid levels
• Improving insulin insensitivity
• Lowering blood pressure
• Improving self-esteem
• Managing weight
• Aiding in prevention and treatment of chronic disease

An RD can help develop a customized exercise plan based on your preferences and lifestyle pattern.

Pregnant with PCOS

Pregnant women with PCOS face a number of challenges before, during and after their pregnancies. To address these concerns, Yale’s infertility specialists and Maternal-Fetal Medicine specialists at the Yale PCOS Program provide on-site consultations prior to conception and throughout pregnancy for women likely at high risk for pregnancy-related complications.

Pregnancy Risks
• Infertility – Due to ovulation disturbances, women with PCOS may find it difficult to get pregnant. YFC boasts one of the highest success rates in the region for managing PCOS-related infertility, offering individualized management strategies to minimize the risks of ovarian hyperstimulation and multiple pregnancy while maximizing success of fertility treatments. Fertility therapies include ovulation induction strategies, injectable hormones, aromatase inhibitors and in vitro fertilization.

We also recommend lifestyle interventions that may help with spontaneous ovulation.
• Miscarriage – Women with PCOS may be at increased risk for spontaneous miscarriage. Contributing factors include elevated insulin levels (insulin resistance) and high levels of luteinizing hormone (LH) or androgens (male hormones). Miscarriage risk can be reduced by lowering insulin levels through weight loss or with insulin-lowering medicines such as Metformin. Women with elevated homocysteine levels may also require increased folic acid.
• Pregnancy Complications – Women with PCOS are particularly at risk for gestational diabetes, which may increase the risk of birth defects, miscarriage, preeclampsia, preterm delivery, macrosomia (excessive birth weight) and birth injury. Weight reduction and lowering insulin levels before pregnancy are beneficial to ensuring a healthy pregnancy.
• Multiple Pregnancy – Pregnancy with more than one fetus increases the overall risk for pregnancy-related complications in women with PCOS. Because they are at high risk for multiple pregnancy following fertility treatment compared to women with other causes for infertility, our goal is to minimize this risk by utilizing gentler treatment protocols that reduce the likelihood of multiple gestation.
In addition to working with high-risk pregnant women with PCOS, YFC monitors all PCOS pregnancy outcomes to help the medical community understand the fetal and perinatal implications of PCOS.

Risks to Children of Women with PCOS
Studies suggest that PCOS diagnosis may have implications for the children of women with PCOS.
• Daughters of women with PCOS may grow up to exhibit the characteristic features of PCOS.
• Weight problems, insulin resistance and high cholesterol are consistently seen in children of women with PCOS.

Healthy lifestyle and healthy weight goals are therefore important not just for women with PCOS, but also for their children.

Infertility and PCOS

Ovulation disturbance is the most likely cause of infertility in women with PCOS who do not ovulate regularly, although other factors may contribute to fertility problems in some couples. The Yale PCOS Program provides state-of-the-art management of PCOS-related infertility. With one of the highest success rates in the region, our experts offer individualized management strategies to maximize success while minimizing the risks of ovarian hyperstimulation and multiple pregnancy in patients with PCOS.

Treatment begins with a basic infertility workup:
• Pelvic ultrasound
• Prenatal lab tests
• HSG (hysterosalpingogram) – X-ray of the uterus and fallopian tubes
• SHG (sonohysterogram) – saline ultrasound to determine uterine abnormalities
• Semen analysis
• Complete health assessment, including a risk profile for diabetes, heart disease and other diseases associated with PCOS
After reviewing these test results, we meet with
you to determine the best course of action.

Options include:
• Ovulation induction – A number of medications are available to induce ovulation in women with PCOS; dose and treatment duration are individualized:
– Clomid – orally administered fertility medication
– Gonadotropins – injectable fertility medications for those who do not respond to simpler treatments; more expensive with greater chance of multiple pregnancy
– Aromatase inhibitors – trigger ovulation in women; safer and less expensive than some alternatives
• Insulin sensitizing agents – Metformin has been shown to restore normal ovulation in some women with PCOS, may improve response to other fertility drugs, and has little or no risk of multiple pregnancies.
• In vitro fertilization (IVF) – removing eggs from your body, fertilizing them with your partner’s sperm, and implanting a fertilized egg into your womb. We utilize minimal stimulation and blastocyst culture and transfer strategies to reduce risks for such problems as ovarian hyperstimulation syndrome and multiple pregnancy.
• Lifestyle modifications – Because being overweight or obese may reduce a woman’s fertility, weight loss is highly recommended to improve fertility and pregnancy outcome. We provide a comprehensive lifestyle management program that includes weight management counseling.
• Optimizing Vitamin D status – Our ongoing research indicates lower pregnancy rates following IVF in women with low blood levels of Vitamin D. Vitamin D levels are assessed for all women attending the Yale PCOS Program and treatment provided to achieve normal levels.

Health Risks of PCOS

Women with PCOS are at increased risk fordeveloping a number of long-term health problems. At the Yale PCOS Program, we seek to address these risks before they become serious medical issues, with a combination of lifestyle modifications and medical interventions.
• Endometrial Hyperplasia – A thickening of the endometrium (uterine lining) can cause heavy or irregular bleeding, and may lead to pre-cancerous changes in the endometrium that could develop into endometrial cancer.
• Cardiovascular Disease Risk – Women with PCOS have a greater chance of developing Metabolic Syndrome – a cluster of risk factors that raise the likelihood of a heart attack or stroke later in life.
These factors include:
• Obesity – approximately 50% of women with PCOS in the US are obese
• Dyslipidemia – increased total cholesterol, triglycerides or both and decreased HDL (good cholesterol)
• Elevated blood pressure (hypertension)
• Insulin resistance – 40% of women with PCOS are insulin resistant
• Type II diabetes – affects 10% of women with PCOS
• Sleep apnea – can present as disturbed sleep, frequent sleep interruptions, restlessness, snoring, and daytime fatigue and sleepiness

Given these risk factors, women with PCOS have a seven-fold increased risk for heart attack and are four times more likely to have a stroke compared to women without PCOS.
• Breast Cancer – Some studies indicate that there is a correlation between PCOS and breast cancer, but the evidence so far is inconclusive.

Women with PCOS are encouraged to visit the Yale PCOS Program for a complete metabolic assessment and risk profile. Your initial examination will include a complete medical history, physical exam with BMI measurement, pelvic ultrasound and all appropriate lab tests. Once we have assessed your risk, we will tailor an individualized plan to meet your specific needs.

Cosmetic Concerns and Symptoms of PCOS

Cosmetic concerns are common in women with PCOS. While not hazardous to health, they may be a source of significant psychological distress. The Yale PCOS Program helps women manage bothersome cosmetic concerns with medical interventions, lifestyle modifications, and psychological support and counseling.

Hirsutism
Hirsutism is the excess growth of coarse, visible body hair, which can be evident on the upper lip, around the jaw, on the cheeks, and sometimes on the chest, stomach and upper thighs. Increased male hormone levels and insulin contribute to hirsutism in women with PCOS. Treatments include:
• Anti-androgens* (Flutamide, Finasteride and Spironolactone) – to decrease the male hormone’s effect on hair growth
• Vaniqa (Eflornithine) cream – to reduce facial hair
• Birth control pills* – to decrease production of male hormones
• Non-pharmacological options – such as shaving, bleaching, waxing, electrolysis and laser hair removal

Acne
Acne is common in women with PCOS and is caused by elevated male hormone and insulin levels. Treatments include:
• Anti-androgens* – to counter the effects of the male hormone on skin
• Benzoyl peroxide – a common over-the-counter ingredient used in creams and lotions to treat mild to moderate acne
• Topical retinoids* – prescription creams formed from Vitamin A that help unclog pores and increase cell turnover
• Topical antibiotics – creams, lotions or gel pads that reduce inflammation by killing bacteria

Hyperpigmentation
Hyperpigmentation (Acanthosis nigricans) causes thickened, darkened skin patches that commonly affect the nape of the neck, armpits, skin under the breasts, and the groin. Insulin resistance causes this condition, which improves with adequate treatment of the underlying endocrine disorder. Treatment may include:
• Weight loss
• Dietary/pharmaceutical control of insulin resistance (such as Metformin)
• Topical exfoliants (e.g., lactic acid, tretinoin, urea-based medications)

Hair loss
Hair Loss (Androgenic alopecia) in women with PCOS is commonly due to a male hormone imbalance.
Treatments include:
• Minoxidil (Rogaine) – the only FDA-approved treatment for female pattern baldness, used topically on the scalp
• Anti-androgens* (Finasteride) – to counter the effects of the male hormone on hair loss

Excessive body weight
Approximately 50% of women with PCOS are overweight, due to an imbalance in caloric intake and caloric expenditure.
Management options include:
• Nutritional counseling – Individualized nutritional plans are created based on the patient’s preferences to ensure long-term compliance
• Physical activity counseling – Detailed assessment of patient’s lifestyle and individualized counseling to achieve optimal caloric expenditure
• Therapy – For certain patients, medical and/or surgical weight loss (bariatric surgery) and psychological counseling may be considered; treatment plans are individualized
* For women who are not pregnant and are not trying to get pregnant

Weight problems, cosmetic concerns, and distress regarding body image and infertility can be a source of tremendous stress for women with PCOS. Studies have identified that women with PCOS may be more likely to suffer from anxiety and depression. Chronic stress itself may contribute to some of the symptoms of PCOS (such as irregular menses) and be detrimental to fertility success. In recognition of the importance of the emotional component of PCOS, the Yale PCOS Program offers psychological support and counseling to complement medical, nutritional and lifestyle management strategies, and to help improve overall well-being in women of all ages diagnosed with PCOS. Psychological counseling options are available on site with our experienced counselor to help patients cope with:
• Menstrual irregularities
• Concerns related to self-image resulting from weight-related problems, acne, excessive body hair or hair loss
• PCOS-related infertility

Adolescents with PCOS may be especially prone to psychological and emotional distress from symptoms of PCOS. We offer a comprehensive program of psychological counseling and support for adolescents and their families to help cope with a PCOS diagnosis.

Signs and symptoms of polycystic ovarian syndrome (PCOS) can often be seen as a girl progresses through puberty. Although irregular menstrual cycles are part of the normal course of puberty, girls with PCOS are more likely to exhibit exaggerated symptoms such as:

• Irregular menstrual cycles for longer than a year
• Increased androgen production resulting in unwanted hair growth or scalp hair loss
• Increased body mass and insulin resistance
• Delay of more than two years between onset of puberty and occurrence of menses
• Early appearance of pubic hair prior to puberty
• Heavy uterine bleeding
• Acne
• Depression
• Weight gain

At the Yale PCOS Program, our medical practitioners include Ob/Gyns specializing in adolescent medicine. During a young woman’s first appointment, we strive to establish a physician/patient relationship that ensures the patient’s and family’s comfort and confidence in discussing any health issues and concerns. Discussions are individualized to the adolescent’s needs and include a review of:

• Normal pubertal development and menstruation
• Healthy eating habits and body image
• Preventive healthcare including the HPV vaccine and reproductive hygiene (including pregnancy and sexually transmitted infection prevention, if appropriate)
• PCOS-related concerns

Assessment of PCOS-related symptoms consists of a thorough medical evaluation, including a detailed medical history, nutritional assessment, physical examination, laboratory testing and an abdominal ultrasound (if appropriate). Treatment is individualized to the needs of each adolescent and tailored to her life stage. Similar to adult women, therapies for adolescents with PCOS include:

• Lifestyle modifications including diet and exercise to lessen the
symptoms of PCOS by improving insulin insensitivity and lipid levels, managing weight, and increasing self-esteem
• Birth control pills to regulate menstrual cycles and reduce androgen levels, which improves acne and excessive body hair, and may have a beneficial effect on overall body image
• Insulin sensitizing agents such as Metformin to lower insulin levels and improve metabolic problems associated with PCOS
• Anti-androgen treatments to decrease unwanted hair growth
when non-medical treatments are ineffective
• Psychological support for adolescents and families to help cope

What is Endometriosis?

The name comes from the word "endometrium," which is the tissue that lines the uterus. During a woman's regular menstrual cycle, this tissue builds up and is shed if she does not become pregnant. Women with endometriosis develop tissue that looks and acts like endometrial tissue outside the uterus, usually on other reproductive organs inside the pelvis or in the abdominal cavity. Each month, this misplaced tissue responds to the hormonal changes of the menstrual cycle by building up and breaking down just as the endometrium does, resulting in internal bleeding.

Unlike menstrual fluid from the uterus which is shed by the body, blood from the misplaced tissue has nowhere to go, resulting in the tissues surrounding the endometriosis becoming inflamed or swollen. This process can produce scar tissue around the area which may develop into lesions or growths. In some cases, particularly when an ovary is involved, the blood can become embedded in the tissue where it is located, forming blood blisters that may become surrounded by a fibrous cyst.

A staging system has been developed by the American Society of Reproductive Medicine (formerly the American Fertility Society). The stages are classified according to the following:
Stage Level of Severity
Stage I minimal
Stage II mild
Stage III moderate
Stage IV severe

The stage of endometriosis is based on the location, amount, depth, and size of the endometrial implants. Specific criteria include:

* the extent of the spread of the implants
* the involvement of pelvic structures in the disease
* the extent of pelvic adhesions
* the blockage of the fallopian tubes

The stage of the endometriosis does not necessarily reflect the level of pain experienced, risk of infertility, or symptoms present. For example, it is possible for a woman in Stage I to be in tremendous pain, while a woman in Stage IV may be asymptomatic. In addition, women who receive treatment during the first two stages of the disease have the greatest chance of regaining their ability to become pregnant following treatment.

The causes of endometriosis are still unknown, although many theories abound. One theory suggests that during menstruation some of the tissue backs up through the fallopian tubes into the abdomen, a sort of "reverse menstruation", where it attaches and grows. Another theory states that certain families may have predisposing genetic factors to the disease. Current research is also looking at the role of the immune system in activating cells that may secrete factors which stimulate endometriosis.

How is endometriosis diagnosed?

For many women, simply having a diagnosis of endometriosis brings relief. Diagnosis begins with a gynecologist evaluating a patient's medical history and a complete physical examination including a pelvic exam. A diagnosis of endometriosis can only be certain when the physician performs a laparoscopy (a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the physician can often determine the locations, extent, and size of the endometrial growths.).

Other examinations which may be used in the diagnosis of endometriosis include:

Biopsy- a procedure in which tissue samples are removed (with a needle or during surgery) from the body (often during a laparoscopy) for examination under a microscope; to determine if cancer or other abnormal cells are present.

Ultrasound- a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.

Computed tomography (CT or CAT scan)- a non-invasive procedure that takes cross-sectional images of internal organs; to detect any abnormalities that may not show up on an ordinary x-ray.

Magnetic resonance imaging (MRI)- a non-invasive procedure that produces a two-dimensional view of an internal organ or structure.

What can be done to ease the pain of endometriosis?

Simple tips that can help ease the pain of endometriosis include rest, relaxation, and meditation; warm baths; prevent constipation; regular exercise; use of hot water bottle or heating pad on your abdomen.

Treatment for endometriosis

Specific treatment for endometriosis will be determined by your physician based on:

- Your overall health and medical history
- Current symptoms
- Extent of the disease
- Your tolerance for specific medications, procedures, or therapies
- Expectations for the course of the disease
- Your opinion or preference
- Your desire for pregnancy

In general, treatment for endometriosis may include

- "Watchful waiting" - to observe the course of the disease
- Pain medication - such as ibuprofen or other over-the-counter analgesics
- Hormone therapy, including:
- Gonadotropin-releasing hormone agonist (GnRH agonist), which stops ovarian hormone production, creating a sort of "medical menopause"
- Danazol, a synthetic derivative of testosterone (a male hormone)
- Oral contraceptives, with combined estrogen and progestin (a synthetic form of progesterone) hormones, prevent ovulation and reduce menstrual flow
- Progesterone alone

Surgical techniques which may be used to treat endometriosis include:

Laparoscopy- (also used to help diagnose endometriosis) a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the physician can often remove the endometrial growths.

Aparotomy- a more extensive surgery to remove as much of the displaced endometrium as possible without damaging healthy tissue.

Hysterectomy- surgery to remove the uterus and possibly the ovaries.

Sometimes a combination of therapies are used, such as conservative surgery (laparoscopy or laparotomy), along with hormone therapy.

Some women also benefit from alternative treatments used in conjunction with other medical and surgical therapies for the treatment of endometriosis.

These include:

- Traditional Chinese medicine
- Nutritional approaches
- Homeopathy
- Allergy management
- Immune therapy

It is important to discuss any/all of these treatments thoroughly with your physician, as some may conflict with the effectiveness of others.

Where are endometrial implants often found?

Endometriosis is most often found in the ovaries, but can also be found in other places (indicated above in purple), including:

- The fallopian tubes
- Ligaments that support the uterus
- The internal area between the vagina and rectum
- Outer surface of the uterus
- In the lining of the pelvic cavity

Occasionally, the implants are found in other places, such as:

- Intestines
- Rectum
- Bladder
- Vagina
- Cervix
- Vulva
- Abdominal surgery scars

While any woman may develop endometriosis, the following women seem to be at an increased risk for the disease:

- Women who have first-degree relative (mother, sister, daughter) with the disease
- Women who are giving birth for the first time after age 30
- Caucasian women
- Women with an abnormal uterus

The following are the most common symptoms for endometriosis, however, each individual may experience symptoms differently.

Symptoms of endometriosis may include:

- Pain, especially excessive menstrual cramps which may be felt in the abdomen or lower back
- Pain during intercourse
- Abnormal or heavy menstrual flow
- Infertility
- Fatigue
- Painful urination during menstrual periods
- Painful bowel movements during menstrual periods
- Other gastrointestinal problems (i.e., diarrhea, constipation, and/or nausea)

It is important to note that the amount of pain a woman experiences is not necessarily related to the severity of the disease - some women with severe endometriosis may experience no pain, while others with a milder form of the disease may have severe pain or other symptoms

The Egg Donation Process

Once a woman has been accepted as an egg donor, she will take a series of fertility drugs (some of which must be injected) to stimulate her ovaries to produce many eggs at one time. While using the drugs, she will be scheduled for several medical tests (blood tests and ultrasounds), and after her eggs have matured they will be removed using a needle and ultrasound probe. The eggs will be fertilized with sperm from the intended father or a sperm donor in our state of the art embryology laboratory and will incubate for two to five days. A number of the fertilized embryos will then be transferred to the recipient’s uterus and a pregnancy test will be performed 9 to 12 days after the transfer.

Becoming an Egg Donor

Becoming an egg donor means that you are giving another woman the opportunity to achieve pregnancy, experience childbirth, and realize her dream of building a family. Egg donation can be the answer for women who have unsuccessfully tried other infertility procedures or for women who were born without ovaries, whose ovaries have been removed, or whose ovaries may have been may have been damaged by radiation or chemotherapy.

Donors may be anonymous or they may be known. Anonymous donors are recruited from local communities, are carefully screened, and their identities remain anonymous throughout the entire donor process. Known donors may be a family member, relative, or friend of the recipient.

Making the Right Choices When it Comes to Multiples

Fertility experts walk a fine line between dream fulfillment and medical failure as they try to help their patients become pregnant while avoiding high-order multiple births.

The recent birth of octuplets to a California woman receiving infertility treatment has raised questions about the practices used by infertility doctors. Dr. Pasquale Patrizio, director of the Yale Fertility Center, discusses the safeguards in place to ensure that nothing similar happens here.

Q. What is your reaction when you hear a story like the one about the woman in California giving birth to octuplets?

A. I am not happy. High order multiple births (triplets or more) resulting from in vitro fertilization (IVF) are considered medical failures. Besides the known pregnancy complications of multiple births—preterm labor and the many health concerns related to premature delivery—there is also the issue of how are you going to raise these children. If someone comes to me and already has six children, like in this particular case, I have a duty to refer this patient to social service. If she’s asking me to transfer eight embryos, something is not right.

Q. IVF treatments can cost $10,000 a piece. What do you do if a patient comes to you and says, “I don’t’ have a lot of money for IVF treatments. Could you please implant as many embryos as possible to improve my chances of getting pregnant on the first try?”

A. We have to follow the guidelines developed by the American Society of Reproductive Medicine. It’s simply not okay to transfer six or seven embryos into a woman who is younger than 35 and has a good prognosis for a successful pregnancy. So, it doesn’t matter if the woman requests that I implant all the embryos. I’m not going to honor that request.

Q. What are the guidelines?

A. For a woman younger than 35 with a good prognosis, the guidelines say one embryo if the transfer is performed on day five after egg retrieval, with a maximum of two if the transfer is performed on day three. The older the woman, the more embryos we’re allowed to transfer. At 40, you can transfer three or four tops. For patients 42 or older, you can transfer up to 5. If someone goes beyond this, you really need a valid justification, and it’s very, very rare.

Q. But these are just guidelines, right? They’re not mandatory?

A. Right. We voluntarily file annual clinic summary reports with the Society of Assisted Reproductive Technologies (SART). The reporting rate is about 95 percent, so we’re doing a pretty good job of making our data available for public scrutiny and information.

Q. What do you report?

A. The age of the woman, the number of cycles started, the number of retrievals, the average number of embryos transferred by age group, the number of pregnancies, the number of deliveries, the number of multiple births and the number canceled cycles. Centers can also be audited, which is one way we protect citizens from cheaters. If a center makes up numbers and is caught, there can be sanctions.

Q. Would there be less pressure from patients to implant multiple embryos if insurance for infertility treatment were better?

A. It’s possible. In Belgium and some other European countries, insurance pays for treatment, and insurers tell you how many embryos you can implant. In the United States only 15 out of the 50 states [including Connecticut] mandate insurance coverage for infertility. Somebody should do a study on whether states that cover infertility have fewer multiple births than states that don’t.

Q. Does competition among centers add to the temptation to implant more embryos to keep the pregnancy success rate high?

A. There’s definitely pressure on centers to compete, and patients do their homework about clinic success rates. There are 425 fertility clinics in the United States, but the number of cycles of IVF has flattened, because the baby boomer generation is now older.

Q. Is the number of high order multiple births going down?

A. The number is indeed going down. The number of triplets is now around 2 percent. A few years ago it was 3.5 to 4 percent, and in 1996 it was 7 percent. The average number of embryo transfers has been decreasing, too, from an average of four in 1996 to 2.6 now.

Q. What about selective reduction (targeting one or more fetuses in a multifetal pregnancy for termination) as a way of avoiding multiple births?

A. We try not to go there, but since women are very well-informed about infertility treatments and procedures, sometimes they ask you, “Please implant three embryos. If they all survive, I’ll have a selective reduction.” I’m personally not very comfortable with this concept. I only want to use it as a last, last, last resort.

Q. Does an incident like the California octuplets undermine the credibility of your field?

A. Yes, of course. You see how much ink has been spent on this issue, and it makes us, as a professional group, look bad. There is so much hard work by a team of professionals behind the scenes to help couples achieve what is perhaps one of the most important reasons we are on the planet: to reproduce, to have offspring.

Q. With all that has been written about the octuplet case, has anything been lost in the debate?

A. What has been lost is the sacrifice, the hours and hours of work that have gone into creating a treatment for infertility that is successful and the incredible amount of joy we have been able to bring to families.

Q. Besides implanting more embryos, what else can be done to improve an infertile couple’s odds of having a baby?

A. Research is being done on identifying the best embryo to implant, trying to find markers of embryo implantation potential. We’re also looking at methods for identifying the best egg.

Q. How is that research going?

A. I predict that five years from now you’ll see many more single-embryo transfers. There has to be a coalition of events: technological advances, better insurance coverage, less competition among clinics, but I am convinced that in a few years, this is going to happen, and higher order pregnancies from IVF will be history.

—Jennifer Kaylin

Photo by Jennifer Kaylin

To find out more about the Society for Assisted Reproductive Technology or to view clinical survey reports from any center in the United States, go to www.sart.org.

The Octuplet Pregnancy

The recent birth of an octuplet pregnancy, reportedly from the transfer of six embryos into a young woman has raised serious questions about the practices of fertility centers. The Yale Fertility Center has never practiced in such a cavalier and dangerous fashion. The serious consequences of high order multiple gestation guarantee significant impairment in the children born from these pregnancies. Moreover most will not even survive. The American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) have longstanding guidelines that govern the appropriate number of embryos to transfer under normal circumstances. These rules were clearly violated in the recent case in California.

One way for the public to asses the quality and safety of an infertility practice is thorough examination of SART data. This is publicly available through the SART web site and from the Centers for Disease Control and Prevention (CDC). Pregnancy rate per cycle can be assessed as well as the number of multiple gestation pregnancies. While there is no category for octuplets on the SART form (as this may never have happened previously), the number of twins and triplets can be identified. Another telling figure is the average number of embryos transferred. SART specifies that this should be no more than two in young women with high quality embryos. While this number may reasonably be higher when age, embryo quality or prior failures are taken into account, it should be well under three on average. In the case of the octuplets these numbers suggest a practice that is well outside of the SART recommendations. In that California practice the average pregnancy rate was low and the number of embryos transferred was shockingly high.

As Clinical Director of SART, I can assure you that action is being taken to prevent future occurrences of higher order multiples. We do not want this episode to tarnish the reputation of the vast majority of our member clinics that practice responsible medicine. This case has highlighted the need to improve the quality assurance processes that SART has in place. We will be more vigilant in identifying unsafe situations in order to prevent these types of negative outcomes.

Starting with the most recent data released earlier this month, SART will identify outlier programs that are consistently not compliant with embryo transfer guidelines and have high order multiple pregnancies. SART will identify all cycles in which the number of embryos transferred in young patients exceed guidelines and will require an explanation for the guideline deviation. Programs that have consistently poor pregnancy outcomes will be offered assistance from SART to help them improve. If they do not respond or fail to demonstrate a real effort to reduce the number of embryos transferred, SART membership will be revoked.

At Yale we have a high pregnancy rate, the only program in our state to have a greater than 50% pregnancy rate in any age group. We do this with an average number of embryos transferred that is well less than three. I can assure you that patients at Yale are receiving high quality and safe IVF treatment from leaders in the field.

Vitamin D: Sunlight Can Be Good for You

Evidence is growing that Vitamin D is crucial to many aspects of health—and that deficiency is extremely common, even in seemingly healthy people. The vitamin’s best-known role is in building bone, but low levels also appear to be associated with diabetes, heart disease, and infertility, among other diseases. “When you start looking at the data, the health benefits of D appear to be at every cellular level, in multiple organs,” said Lubna Pal, M.B.B.S., director of the Reproductive Aging and Bone Health Program.

Pal and her colleagues studied the health records of over 400 healthy pre-menopausal women and found that an astonishing 79% of them had low vitamin D levels. She found a link between low vitamin D levels and abnormal levels of blood sugar, insulin, inflammatory markers, and body mass. Such markers are associated with a higher risk of cardiovascular disease and diabetes. Women who were not Caucasian had lower levels of vitamin D, while more physically active women had higher levels.

In a previous study, Pal checked levels of vitamin D in the ovaries of 84 women undergoing fertility treatments. Almost two-thirds of the women had low levels, and those who achieved pregnancy had, on the average, higher levels of vitamin D than those who didn’t.

Vitamin D is made by the skin when touched by sunlight; it is also found in some foods. “We’re becoming more under-the-shade workers [and are] not getting our daily allowance,” said Pal. She suggests spending 10 minutes in the sun each day.

PCOS in Adolescents

Signs and symptoms of Polycystic Ovarian Syndrome (PCOS) can be seen during a girl’s pubertal transition. Although the normal pubertal course involves irregular menstrual cycles, increased androgen production, and increased body mass and insulin resistance, these processes are often exaggerated in girls with PCOS. A delay of greater than two years between the onset of puberty and the occurrence of menses may indicate PCOS. Furthermore, one early sign of PCOS may be the early appearance of pubic hair in young girls, prior to puberty. Adolescents with PCOS can present with a variety of symptoms which tend to start gradually, and can include irregular menstrual cycles, heavy uterine bleeding, acne, depression, weight gain, unwanted hair growth, or scalp hair loss.

One of the hallmarks of PCOS is irregular menstrual cycles. While it is normal for a young woman to experience irregular menstrual cycles for the first 6 to 12 months after her first menses, it is abnormal if the irregularity persists beyond 12 months. These young women deserve evaluation to determine a cause of their irregular cycles. In the past, young women were often prescribed oral contraceptives (birth control pills) to regulate their menstrual cycle, without any evaluation. However, due to the long-term health risks associated with PCOS, the ability to make this diagnosis in adolescents will hopefully improve the long-term health of these young women.

Similar to adult women, medical therapies for adolescents with PCOS include birth control pills, insulin sensitizing agents, and anti-androgen treatments. Treatment is individualized to the needs of each patient, and is tailored to where she is in her pubertal course.

Yale PCOS Program: A “One-Stop Shop” for Women with PCOS

Because Polycystic Ovarian Syndrome (PCOS) affects more than just the ovaries, Yale experts are teaming up to form a PCOS center for excellence. Clinicians at the Yale Program for PCOS will not only treat PCOS but also address problems that may accompany this diagnosis including fertility problems, body weight and body image issues, high cholesterol, insulin resistance and risk for diabetes, high blood pressure and risk for heart disease. The result will be what Dr. Pinar Kodaman, calls a “more holistic approach.”

“Beyond improving the overall health of women with PCOS, our goals are to help the patients take charge of PCOS,” says Dr. Lubna Pal, director of the Yale PCOS Program. During a single convenient appointment, patients will undergo evaluation by our team of expert physicians and nutritionists. Management strategies will be individualized to the needs of each patient. Risk profiles for heart disease and diabetes will be determined through detailed assessments, including tests that reflect the most advanced research into the disorder. Health goals will be identified (target weight, cholesterol, blood pressure, blood sugar, vitamin D level) and our team will work with each patient to ensure that these goals are met.

Each of the Yale Ob/Gyn physicians at the Yale PCOS Program brings her own expertise to the table:
Adolescents and teenagers with symptoms of PCOS (such as menstrual irregularities, excessive facial and body hair and acne) will benefit from Dr. Beth Rackow’s expertise in adolescent gynecology and menstrual disorders.

Utilizing combinations of lifestyle modifications and medications, Dr. Kodaman will focus on reducing risks for cardiovascular disease while Dr. Pal concentrates on issues of insulin resistance and diabetes.

Dr. Stephen Thung, a Yale Maternal-Fetal Medicine specialist with a special interest in the management of gestational diabetes and hypertension in pregnancy (common in women with PCOS), joins the team as a resource for preconception consultation for patients deemed at high risk for pregnancy-related problems.

Amy Krystock, a registered dietitian, employs a total lifestyle modification approach, utilizing customized diet and exercise programs for women with PCOS.

Dorothy Greenfeld, LCSW, provides an invaluable resource for psychological support, helping patients overcome the stress of PCOS symptoms and diagnosis.

By combining our efforts and expertise, we hope to be able to address the health needs of women of all ages diagnosed with PCOS. “I can foresee a teenager with PCOS being cared for at our center through her reproductive years into menopause,” says Dr. Pal.

Octuplets Case Sparks Ethics Uproar Over IVF Excess and Patient Screening Fertility groups want a closer look at the doctor's actions, but oppose more

This article that appeared in American Medical News on February 15, 2009 written by Kevin B. O'Reilly featured commentary from Pasquale Patrizio. MD, MBE, HCLD, Yale Fertility Center Director.

What began in late January as a feel-good story of a California medical team's Herculean efforts to deliver octuplets after a 31-week pregnancy quickly morphed into a controversy over the medical ethics of fertility practices.

The octuplets' mother, 33-year-old Nadya Suleman, said in an interview on NBC's "Today" that her physician transferred six embryos and two split. Suleman is single, unemployed and has six other young children. All were conceived through in vitro fertilization at the same clinic, she said. For each pregnancy, her doctor transferred six embryos, Suleman said.

If that is true, the physician's actions went well beyond American Society for Reproductive Medicine guidelines, society president R. Dale McClure, MD, said in a statement. The Medical Board of California is investigating, and the ASRM has offered to aid the inquiry. The AMA referred requests for comment to the ASRM.

"What was done is clearly irresponsible, clearly unethical, and it placed the life and health of the mother as well as the fetuses at great risk," said Samuel H. Wood, MD, PhD, a La Jolla, Calif., reproductive endocrinologist. "It's simply the wrong thing to do."

For a woman younger than 35 with a previous successful IVF cycle, the ASRM recommends transferring one embryo -- two at most. The society says pregnancies with four fetuses or more pose huge risks, including a 95% chance of pre-term labor and delivery, and a greater than 60% chance of preeclampsia. One in 10 such pregnancies results in gestational diabetes mellitus.

Pasquale Patrizio, MD, director of the Yale Fertility Center in Connecticut, said he would not have transferred so many embryos in a patient "for any reason. I don't understand why such a decision was made. No matter how much a patient may insist on a transfer of such a large number of embryos, it is out of the question and the request should not be honored at all."

Suleman, who said she has occluded fallopian tubes, told "Today" she dreamed of having a "huge family" and her goal with this pregnancy was to have one more child. She refused to selectively reduce the embryos when she learned six had been implanted successfully.

As of early February, the eight low-birth-weight babies were being tube fed donated pasteurized breast milk and monitored in the Kaiser Permanente Medical Center in Bellflower, Calif., where they were born. The hospital said the babies were expected to remain for several more weeks.

Regulation the answer?

The fertility practice Suleman named in her interview, West Coast IVF Clinic Inc. in Beverly Hills, Calif., is a member of the Society for Assisted Reproductive Technology. SART is an ASRM affiliate that represents more than 85% of U.S. fertility clinics and describes itself as a "governmental watchdog for ART" with quality-assurance expertise.

SART has contacted the clinic's medical director, Michael M. Kamrava, MD,to learn more about the medical circumstances of the case before taking any action, which could include revoking the clinic's society membership. Dr. Kamrava, an ob-gyn who was shown treating Suleman in a 2006 Los Angeles TV news show, declined requests from AMNews for an interview.

The Suleman case shows the fertility industry's self-regulation is insufficient, said Debora L. Spar, PhD, author of The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception, which examined the market for reproductive technology. She said government should set rules on how many embryos can be transferred.

"Most people are agreeing this was an extreme case," Spar said. "That is exactly what regulation is best suited for. It defines the extreme and unacceptable behavior. Even if you took the ASRM guidelines, I think what this case shows is that even reasonable guidelines are not necessarily followed by unreasonable practitioners, and it is those unreasonable practitioners that you have to worry about."

The California medical board's decision to investigate may not prevent similar cases, Spar said. "We don't want regulation after the fact. We want regulation beforehand."

Fertility doctors said the proportion of high-order multiple births has dropped, thanks to better methods of culturing embryos and ASRM guidelines on transfers. The percentage of IVF cycles resulting in triplets or more fell 69%, to 4.3%, from 1997 to 2005, the last year for which data are available from SART and the Centers for Disease Control and Prevention.

"This particular case is a big problem, but I don't think we have a big problem generally," said James A. Grifo, MD, PhD, program director of the New York University Fertility Center. He said regulation could have unintended consequences, contending that a 1992 law requiring the CDC to publicly track clinics' success rates perversely encouraged physicians to increase the number of embryos they transferred to improve the odds.

"We passed the guidelines and made recommendations for what doctors should do, adjusting for the fact that not all patients are the same," said Dr. Grifo, a past president of SART. "Medicine is not formulaic. If it were, then why do we need doctors? We should just go to a computer."

Screening patients

Others said the case -- Suleman now is the sole parent to 14 children younger than 8 -- highlighted the need for more screening of prospective parents seeking reproductive technology services.

"I would like to see a mandatory psychological evaluation," said Arthur L. Caplan, PhD, director of the University of Pennsylvania Center for Bioethics. Caplan noted that such screening is standard for living organ donors and patients seeking bariatric surgery. "We need to look at what steps we can take to ensure they will be competent parents."

The ASRM published guidelines in 2004 saying fertility clinics could "withhold services from prospective patients on the basis of well-substantiated judgments that those patients will be unable to provide or have others provide adequate child rearing for offspring." The guidelines do not call for routine screening or home studies.

Fertility specialist Dr. Wood said he has referred a number of prospective parents for psychological counseling. At the same time, some doctors fear trampling on their patients' autonomy.

"I don't feel comfortable being in a position to tell a couple, or a woman, 'You're not going to do any more, because you have enough kids,'" said Yale's Dr. Patrizio. "It's not morally correct because it's not my reproductive right; it's her reproductive right. If she wants to have a large family -- do it one at a time or, at the max, two at a time. But it's her choice."

The Octuplets Saga

Malleability and fragility of human ethics is exemplified in the recently unraveled octuplet saga. The community in general and reproductive endocrinologists in particular are striving to comprehend the circumstances that fostered the practitioner’s poor judgment, deviance from guiding principles of practice and above all, an utter disregard to the wellbeing of a clearly “vulnerable” patient and her family!

Disregard of the woman’s psychological wellbeing and social circumstances are unpardonable, and yet pale against the reckless act of transferring multiple (six!!) embryos in a young woman of proven fertility for whom selective embryo reduction was not an option. Not only were the subspecialty specific guidelines (The American Society for Reproductive Medicine Society for Assisted Reproductive Technology offer clear guidelines regarding the number of embryos to transfer in an ART cycle to ensure against undue risk of high order multiple pregnancies) ignored, but also dismissed was the essence of the Hippocratic oath! While detailed explanations may never be available for the case under study, a need for introspection is quite apparent. In a consumer driven society where service is expected, nay demanded for a fee, these events may very well reflect thoughtless compliance to a pressing customer’s demands.

In times when economic successes more than intellectual prowess or integrity may define progress, it is simplistic to expect the medical community to stay immune to social pressures and be self shepherded within practice “guidelines”. Indeed, in a society where irrational demands of a few may be met by an occasional, the case of octuplets following assisted reproductive technology identifies a need for moving beyond the realm of “guidelines” to incorporate “reasonable requisites” to ensure wellbeing of an emotionally vulnerable population, i.e. those coping with a spectrum of psychological, social and economic stresses that remain intrinsic to a diagnosis of infertility.

Yale Egg Donor/Surrogacy Program

Yale Fertility Center has extensive experience helping an infertile or same-sex couple finding an appropriate egg donor. Finding the right donor may take some time, but YFC offers flexibility during the process. “We make sure that you’ve got the donor you’re comfortable with,” says Dorothy Greenfeld, LCSW, Clinical Professor and psychological counselor at YFC. Couples meet with Greenfeld and discuss donor traits that are important to them. She then goes over YFC’s donor profiles with the intended parents. Though donation is strictly anonymous, the intended parents receive a great deal of information about the egg donor. In addition to health information, height, weight, and hair and eye color, as well as those of the donor’s relatives, couples learn about her education, her occupation, and her reproductive history, including details of any previous egg donations.

In contrast to the practice at some other egg-donation programs, couples at YFC are not placed on a waiting list for eggs, and they may decline a particular donor if they wish. What is the typical egg donor like? “They’re women who have often been touched by infertility in some way,” says Greenfeld. “They have a godmother who was infertile or they’ve worked with women who are infertile.” Successful egg donors tend to be active, educated young women who are in school or who are young mothers themselves. They know they face a months-long process that involves uncomfortable procedures, but they want to help others have babies, and they view donating eggs not as “giving away a baby” but as a way of giving the gift of a family to a couple in need.

Potential egg donors must be aged 21–30, in good physical and psychological health, and have at least a high school education. All potential YFC donors undergo extensive health screening by YFC faculty, as well as a psychological evaluation by Greenfeld.

In Vitro Fertilization

In vitro fertilization(IVF) involves fertilization outside the body in an artificial environment. This procedure was first used for infertility in humans in 1977 at Bourne Hall in Cambridge, England. To date, thousands of babies have been delivered worldwide as a result of IVF treatment. Over the years, the procedures to achieve IVF pregnancy have become more successful and affordable.

To accomplish pregnancy as a result of IVF, several steps are involved:
- Stimulation of the ovary to produce several fertilizable oocytes (eggs)
- Retrieval of the oocytes from the ovary (from the vagina)
- Fertilization of the oocytes and culture of the embryos in the IVF Laboratory
- Placement of the embryos into the uterus for implantation (embryo transfer or ET)

What Types of Infertility Might Be Helped by IVF? Absent fallopian tubes or tubal disease that cannot be treated successfully by surgery. Endometriosis that has not responded to surgical or medical treatment. A male factor contributing to infertility, in which sperm counts or motility are low but there are enough active sperm to allow fertilization in the laboratory. Unexplained infertility that has not responded to other treatments. Infertility secondary to sperm antibodies. Due to the high success of IVF and intrauterine embryo transfer, GIFT (Gamete Intra Fallopian Transfer) and ZIFT (Zygote Intrafallopian Transfer) techniques are rarely used in current practice. Intracytoplasmic Sperm Injection (ICSI) is a relatively new micromanipulation technique developed to help achieve fertilization for couples with severe male factor infertility or couples who have had failure to fertilize in a previous in vitro fertilization attempt. The technique involves very precise maneuvers to pick up a single live sperm and inject it directly into the center of a human egg. The procedure overcomes many of the barriers to fertilization and allows couples with little hope to achieve a successful pregnancy. At Yale the ICSI procedure was first used in 1994 and the first successful birth was achieved in 1995.

The ICSI Process

ICSI is a tool available in the IVF laboratory to achieve fertilization. The initial steps in preparation for ICSI are the same as for IVF:
- Stimulation of the ovary to produce several fertilizable oocytes (eggs)
- Retrieval of the oocytes from the ovary (through the vagina
- Fertilization of mature oocytes with ICSI
- Placement of the embryos into the uterus for implantation (embryo transfer or ET)

Fertilization by ICSI means that the micromanipulation specialist picks up the single live sperm in a glass needle and injects it directly into the egg.

Assisted Reproduction Options for Same-sex Couples

The Yale Fertility Center (YFC) has for many years helped men and women become parents—and that includes same sex parents. Both lesbians and gay men who want children can seek treatment at YFC, where the available services include artificial insemination, egg donors, and gestational surrogates, or carriers. “More and more gay men are choosing to become fathers through surrogacy and donation,” says Dorothy Greenfeld, LCSW, a counselor at YFC. In addition, marriage is legal between same-sex couples in Connecticut, and many same-sex couples within either partnerships or marriages feel ready for children.

Greenfeld is the first person potential parents meet at YFC (except for those needing help only with insemination). She administers a psychological evaluation and gives them a detailed picture of what to expect from the long process of achieving parenthood. Part of her job is to ask the questions that potential parents may not have asked themselves.

For example, male couples often decide before going to YFC which of them will be the sperm donor. But Nature might not cooperate, and Greenfeld wants them to be prepared. “You might be very clear about who’s going to produce the sperm, but you might also be the guy who can’t produce the sperm,” she points out.

The Center works with couples to come up with individual solutions for their particular situation. Some seek simply an egg donor, a gestational surrogate to carry the pregnancy, or sperm. But more complex scenarios are possible. One lesbian couple at YFC achieved the “dream scenario,” in which one partner provided the egg and the other carried the pregnancy. And one pair of fathers had twins—one twin from each father’s sperm—with the help of a surrogate mother. Whatever arrangement is made, YFC requires that at least one potential parent be biologically connected to the child, providing either eggs, sperm, or womb.

Prejudices persist about gay parents, including fears that they will be less nurturing or that their children are less likely to marry, but these are subsiding amid recognition that gay couples make good parents. Greenfeld has written about the need to overcome such myths. “So many [gay] men have spent their life dreaming about being dads,” said Greenfeld, “and often say things like ‘I just didn’t think it would be possible.’” But the children of the proud gay and lesbian parents who conceived with YFC are proof that it is.