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Trying IUI before IVF

IUI-vs-IVF-treatment.jpg

A new study suggests a few months of IUI might work just as well.

No surprises here. We have been advising our patients to consider intrauterine insemination (IUI) as an alternative to IVF for years.

A recent study again confirms the that IUI is a reasonable approach to treating infertility. Researchers in New Zealand found that women who did IUI along with oral medications (clomiphene was used in this study) for 3 months has similar pregnancy rates to those who went straight to IVF on their first treatment cycle.

So, why would one to go straight to IVF? IVF offers several advantages over inseminations:

  • higher pregnancy rates
  • shorter time to conception
  • ability to genetically test the embryos before putting them back
  • elimination of most multiple births when only one embryo transferred
  • the ability to freeze left over embryos for future use 

IUI also has some significant  advantages:

  • much less expensive (about 1/5 of the cost)
  • much less invasive
  • fewer drugs, fewer injections
  • no need for anesthesia
  • less stressful
  • lower multiple birth rates when oral fertility drugs are used and multiple embryos are transferred with IVF

All couples have a different comfort level when it comes to fertility treatment. Like most medical treatments, fertility treatments involve balancing the effectiveness and risks of the various options. This is an important discussion to have with your doctor.

Noise and fertility

Traffic noise may increase time to conceive: Princeton IVF blog

Could a noisy neighborhood be making it harder to get pregnant?

Danish study suggests couple who live in neighborhoods with lots of traffic noise may take longer to get pregnant.

A study from Denmark suggests that it may have some impact.

The researcher looked at 65,000 Danish women who delivered between 1996 and 2002, and interviewed them to determine, among other things, how long it took them to conceive. They also looked at the traffic volumes for their neighborhood to see if they could compare the two.

They found that for every 10 decibels of additional traffic noise, there was a 5-8% increase in the chance it would take more than six months to conceive. 

Fortunately, increased traffic noise did not affect a couples chances to take longer than a year to get pregnant. Infertility is defined as a disease in which a couple is unable to conceive after one year's time, so the traffic noise itself did not cause infertility.

They could not determine whether the delayed time-to-conception (TTC) was due to the male or female partner, and the this delayed TTC was not affected by other factors such as poverty or levels air pollution that could delay conception.

Editing embryos- fiction, science fiction or both?

Designer babies and gene editing: fiction, science fiction or both: Princeton IVF blog
Researchers in Oregon 

A recent report from Oregon describes how researchers edited the genes in a human embryo.

To many of us, myself included, it sounds a bit scary.

An article in the NY times argues that it is huge leap from gene editing to designer babies, since most human traits require the interaction between a number of genes and the environment

There are thousands of what are called single gene mutation disorders that this gene editing technology may be able fix. Examples of this include Cystic Fibrosis, Tay Sachs disease and Sickle Cell Anemia. These types of diseases are due to a single gene mutation which could potentially be repaired using this technology. Many of these disorders can currently be screened for and diagnosed (if anticipated) during the IVF process using Preimplantion Genetic  Diagnosis (PGD)

Picking out your child's height, or athletic or intellectual abilities are another story. Height alone is likely to controlled by tens of thousands of genes, of which less than a thousand have been identified. Even if all of the genetics could be worked out, the task of editing those genes would be enormous.

So, for now at least, designer babies are the stuff of science fiction.

Rhode Island mandates fertility preservation

First state mandates egg freezing insurance coverage: Princeton IVF blog

First state requires fertility preservation coverage from insurers

Egg freezing insurance coverage

What is fertility preservation?

It refers to obtaining, freezing and storing eggs, sperm or embryos for future use. 

Why would one want to preserve fertility?

There are several reasons:

  • If you are undergoing treatment for cancer or other diseases that require treatments such as chemotherapy, radiation or surgery which are likely to cause infertility.
  • If you need to defer having a baby but are concerned you may be too old when you are ready
  • If you do not have a partner, are concerned about waiting but not ready to use a sperm donor.

What is the signIficance of the Rhode Island law?

This is the first time in the US that fertility preservation insurance coverage has been mandated by law. A number of states do require treatment for infertility but not necessarily fertility preservation. That could change in the future.

Where can I learn more about the mandate?

Here is a link to the Rhode Island law.

What do I do if I am about to get chemotherapy and want to learn more?

This is a discussion you need to have ASAP with your oncologist and a reproductive medicine specialist. Ideally the process should happen before cancer treatment starts, and your oncologist will want to delay treatment as little as possible. If you are in our area and would like to see us at Princeton IVF, please call at 609-896-4984 or 609-896-0777 to set up an appointment.

 

Sperm selfies?

Testing for male fertility on your smartphone: Princeton IVF blog

Could your smartphone replace a semen analysis?

At home, iphone and android based sperm test kit

 

Can this device replace a semen analysis with your doctor? Maybe in the future.

Based on research from Harvard University, engineers have developed a new device for an at home "semen analysis." There are already at home sperm test kits available in stores, what is so unique about this one? Simply put, it is the smart phone. This device attaches to and taps the power of your iphone or android device through it's app, to analyze the data and give you a visual display of what the laboratory folks would see under the microscope.

The pros:

  • low cost
  • quick results
  • can be done at home without the awkwardness
  • you get to see what the actual sperm look like

The cons:

  • lacks the details your doctor may need (actual sperm concentration and motility)
  • unable to accurately determine morphology (another important part of the semen analysis)

The idea is a good one.

Reliable, inexpensive testing in a comfortable setting, and a way to determine when it's time to visit the fertility doctor or urologist. The reality is not quite there yet. The information is not quite enough to replace the formal semen analysis at a clinic, but with improvements in the software, it may well be in the future.

AMA calls Infertility a disease

AMA agrees Infertility is a diesase: Princeton IVF blog

It's official now. Infertility is now what we know it has been for years, a disease, not a problem or an inconvenience.

At the encouragement of the American Society for Reproductive Medicine, the American Medical Association has voted to call infertility a disease.

According to the ASRM, 

Infertility is NOT an inconvenience; it is a disease of the reproductive system that impairs the body's ability to perform the basic function of reproduction.

Now the AMA has accepted this fact.

Sperm counts are dropping

Sperm counts are declining across the west: Princeton IVF blog

A recent publication suggests that sperm counts may be declining all across the western world

Research suggest sperm quality is going down across the western world.

It is been all over the news lately.  Some in the media have even suggested this may bring our doom as a species. So, what's the real story behind this...


A recent paper published suggests that sperm counts may be declining in Western countries.  


While this is not entirely new, it is a continuation of a trend that has been noted for years.  This there has been a decline in sperm quality noted in the United States and other western nations. The authors compiled studies done over a number of years including:

  • 185 studies
  • over 42,000 men
  • between 1973 and 2011
  • from US, Europe, Australia and New Zealand

Over the 39 years, the sperm concentration dropped 52.4% and the total sperm count went down 59.3%, a hugh decline.

While this is concerning, it raises even more questions:

  • Have the counts really declined or is it just the techniques used to count the sperm?
  • If the counts are going down, is it actually affecting male fertility?
  • Is this a problem in the developing world or just in the west?
  • If this being caused by increasing obesity?
  • Is this being caused by something in the environment?

 

Only time and further research will answer these questions.

Your weight and your fertility

Your weight can affect your fertility: Princeton IVF blog
Being overweight can make it take longer to get pregnant in both men and women.

If either partner is overweight, it can harm your fertility

It has been know for for years that women who are overweight have a lower chance for success for IVF, and most fertility specialists encourage their patients who are overweight, to lose weight if possible, before treatment. So, the next logical questions is this: Does being overweight affect your chances of getting pregnant on your own even if you do not have infertility?

A study by National Institutes of Health (NIH) addressed that particular issue. The study was called the Longitudinal Investigation of Fertility and the Environment (LIFE) Study and they looked at couples who were both normal and with various degrees of being overweight to see how long it took them to conceive, commonly referred to as TTC. They looked about 500 couples from Texas and Michigan  and broke them down into 4 groups, normal weight (BMI 18-25), overweight (BMI 25-25), class I (BMI 30-34.9) and class II (BMI 35 and higher).  

The researchers found that in couples with class II obesity ( BMI > 35), it took 55% more time to conceive, than in normal weight couples.

It means that being significantly overweight not only affects your chances for pregnancy with fertility treatments such as IVF, it also makes it more difficult to conceive on your own.

New Jersey updates Infertility Law

New Jersey fertility coverage mandate expanded: Princeton IVF

Governor Christie signs updated NJ fertility mandate

At least in the past, New Jersey has had among the most generous insurance coverage for infertility treatment in the US. The legal mandate for this, the New Jersey Family Building Act, passed over a decade and a half ago, required NJ employers with certain exemptions, to cover fertility treatment up to and including IUI and IVF.

Unfortunately, changes in the health care system, such the Affordable Care Act (Obamacare) have affected coverage. Fortunately, New Jersey state employees and most NJ teachers continue to be covered under the mandate. There are some gaps in this coverage, particularly for single women and those in single sex/lesbian relationships.

With an act of the NJ state legislature and the signature of Governor Christie, that has changed. The infertility mandate has been updated to reflect the new ASRM definition of infertility and includes the following:

  • A male is unable to impregnate a female;
  • A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
  • A female with a male partner and 35 years of age and over is unable to conceive after 6 months of unprotected sexual intercourse;
  • A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of IUI (intrauterine insemination) under medical supervision;
  • A female without a male partner and over 35 years of age who is unable to conceive after 6 failed attempts of IUI under medical supervision;
  • Partners are unable to conceive as a result of involuntary medical sterility;
  • A person is unable to carry a pregnancy to live birth; or
  • A previous determination of infertility pursuant to the law.

This update in coverage becomes effective in August 2017 and only applies to New Jersey state employee and teacher plans.

At Princeton IVF, we participate in the affected New Jersey State Health Benefits Program and School Employees Health Benefits Plan that are affected by these new rules, including NJ Direct  from Horizon Blue Cross Blue Shield and Aetna for NJ state employees.

One millionth IVF baby born in the US

One millionth IVF baby born in US: Princeton IVF blog

In Vitro Fertilization US reaches a new record.

The one millionth IVF baby was born in the United States in 2016

The one millionth IVF baby was born in the United States in 2016

This year, the Society for Assisted Reproductive Technology announced that the 1 million IVF baby was born in the United States.  IVF has been around for over 30 years, and performed successfully at multiple clinics in the United States and worldwide since then.  Worldwide, there have been millions of babies born from IVF, but limited coverage in the United States has delayed reaching this milestone.

Delaying the diagnosis of PCOS

PCOS may take years to diagnose: Princeton IVF blog
PCOS-delayed-diagnosis.jpg

How long to does it take to be diagnosed polycystic ovarian syndrome?

Apparently a lot longer than you might expect...

A recent study from University of Pennsylvania suggests that women with Polycystic Ovarian Syndrome may not receive the proper diagnosis for years.

Women across the US and Europe were surveyed and this is what the researchers found:

  • in 1/3 of women, it took at least 2 years to make the diagnosis
  • almost of half of women had visited at least 3 health care providers before the diagnosis was made
  • 84 % of women did not believe they received enough information about PCOS at the time of their diagnosis

As a Reproductive Endocrinologist, this is both surprising and not expected.

In our practice, as in most fertility and gynecology practices, PCOS is one of the most common disorders that we see. It is the most common hormonal disorder in women of reproductive age and the ovulation problems associated with PCOS are the most common cause for infertility in women. So, as specialists, we are attuned to look for polycystic ovary, and are more likely to find it in its more subtle forms. We are also committed to educate our patients about their condition, what causes it, how it is treated and what other health implications it might have.

It is also very common for us to see women who were never told by their doctor that they might have PCOS, and only came to see us because they cannot conceive. Still others, looked up their symptoms online, realized they had PCOS and referred themselves.

Sometimes seeing a specialist can help.

Most of the time your OBGYN, midwife or even primary care physician can manage the symptoms of PCOS. If your symptoms are under control and have a good understanding of your condition, there is no reason to seek out help. If your symptoms not controlled, you are having trouble getting pregnant or you don't feel you have an adequate understanding of PCOS, seeing a sub specialist in Reproductive Medicine may be a good idea. 

 

 

New York: fertility treatment for all women?

NY Governor Cuomo expands fertility coverage: Princeton IVF blog

New York governor changes insurance rules

Governor Andrew Cuomo has instructed insurance companies in New York to cover infertility treatments on single women and women in same sex relationships.

New York is one of fifteen states, including our own, New Jersey, that requires insurance plans to include infertility treatment in their benefits. Typically, these mandates require a period of unprotected intercourse to kick in. In New York, the governor has eliminated that requirement for women in whom that is not an option.

It is unclear how impactful this change may be since New York's infertility mandate is rather limited. It has very limited coverage for IVF, and for insemination, the cost of donor sperm is high. Donor sperm is rarely if ever covered by insurance regardless on insurance mandates.

 

Here are 12 things to avoid telling your friend with infertility:

12 Things not to say to your friend with infertility: Princeton IVF blog
Dealing with friends who have infertility.

Infertility affects 1/8 couples, so chances are you either are having trouble getting pregnancy, had trouble in the past, or you know someone who currently is having difficulty. On this Infertility Awareness Week, here are some tips to be just a little more sensitive.

You should avoid saying these 12 things to your friend or colleague with infertility: 

1. Just relax.

Yes, stress does play a role infertility and stress reduction techniques can help couples conceive, but infertility is a medical diagnosis and seeing a fertility doctor can discover real problems that require treatment.

2. Minimize the problem.

Regardless of how you view it, research shows that the inability to get pregnant is one of the great stressors in life, up there with losing a job and being diagnosed with cancer. 

3. Worse things could happen.

Chances are your friend does not see it that way. 

4. Maybe you were not meant to be parents. 

Don't go there. Many couples with infertility see their condition as a divine punishment rather than what it is, a treatable medical disease. This will only reinforce their self doubt.

5. Why are you not doing IVF?  

IVF is the most effective treatment out there for infertility, but it is not for everyone. It can be expensive, invasive, stressful and conflict with some people's religious values. 

6. Just adopt. 

Adoption is always a reasonable option, but most couples take time to get there, and still others do not want children if they cannot have their own genetic children. 

7. You're young. There's still plenty of time.  

Younger women usually have an easier time getting pregnant, so if things aren't working, it's time to figure out why.  Yes, the chances for success are higher in younger women, but there are no guarantees.

8. Gossip.

Infertility is private. You wouldn't want someone talking about your medical problems to others.   

9. Crude remarks. 

Fertility problems deal with the most sensitive and personal parts of our lives. Don't assume your friend will find humor in it.

10. Complain about your own pregnancy. 

No matter miserable your pregnancy may be, your friend sees pregnancy as the greatest blessing she ever could hope for. Seeing other pregnant women is one of the most difficult challenges for women facing infertility.

11. Minimize their concerns because they already have a child. 

For many couples, a family is not complete with only one child, and it is just as common for couples to seek out help for child number two as for the first. Doctors refer to this as secondary infertility.

12. Ask whose fault it is.

Infertility is a couples thing. While oftentimes, it is one of the partners who has the problem, it takes two to have a baby. Sometimes even when it is a male issue, the female partner must go through most of the treatment. Assigning blame, is counterproductive and can cause considerable strain i a relationship. Don't add to it.

adapted from Resolve.org.

Israeli couple has a live birth after 18 attempts

Couple has baby on 18th attempt at IVF: Princeton IVF blog

When is it time to give up on IVF?

Israeli couple has triplets on 18th attempt at IVF

Most couples give up on In Vitro Fertilization if it fails after a few attempts, but not this Israeli couple.  

While research does show that most couples who do not give up will eventually be successful with IVF, many give up due to some combinations of physical, mental or financial exhaustion. In a testament to determination, an Israeli couple tried a total of 18 IVF cycles. On that final cycle, the Hanans became pregnant delivered triplets at 32 weeks of pregnancy at a hospital near Tel Aviv, Israel.

The man who showed the secrets of human life to the world

Photographer who revealed the origins of life: Princeton IVF blog
Swedish photographer Lennart Nilsson pioneering embryo images

This year, someone who revealed the secrets of human reproduction quietly passed away, and you probably never heard of him... 

The Swedish photographer Lennart Nilsson is not exactly a household name, but his photographs adorn the offices of many fertility clinics across the world and his images of human reproduction and early human life are known throughout the world.

Those pictures, such as the one above, were first published in a Life Magazine article in 1965 called “The Drama of Life Before Birth.” and later on in a book entitled “A Child Is Born.” His photos were even shown in the PBS series NOVA, in an episode entitled, "The Odyssey of Life."

Nilsson developed techniques for microphotography that enabled him to produce stunning images of something was at one time invisible, the origins of human life. Today we live in a world where IVF is widely available, images of human embryos, eggs and sperm can downloaded to your phone in seconds and every OBGYN has an ultrasound in his or her office.  These are just things we take for granted.

In 1965, what Nilsson did was truly amazing. He revealed to us a hidden world, and what he shared with the world was even more amazing than fiction, a glimpse of the world that fertility specialists and embryologists see every day.

Red wine, Resveratrol and PCOS

Could a chemical in red wine help you if you have PCOS: Princeton IVF blog

Could one of the compounds found in red wine help women with PCOS?

red-wine-resveratrol-pcos.jpg

Yes, it actually might help women with polycystic ovarian syndrome.

What is resveratrol?

Reservatrol belongs to a group of chemicals call polyphenols which are commonly thought to act as antioxidants. It is found in the skin of grapes, as well is in peanuts and some berries. Most resveratrol supplements sold in the US, actually come from a plant grown in Asia, rather than from grapes. It has been used as a supplement to help inflammation and diabetes.

Why might resveratrol be helpful for with PCOS?

Polycystic ovarian syndrome is the most common hormone disorder in women of reproductive age, and a common cause for infertility. The symptoms of PCOS are largely related to irregular cycles and excess levels of male-like hormones, but the underlying cause is related to how the body handles sugars. Most women with PCOS have a condition called insulin resistance as the reason for their disorder, and diabetes drugs such as Metformin are commonly used as treatment.  Since resveratol can help women with diabetes, it is possible that it may help women with PCOS as well.

A new study suggests resveratrol may be helpful.

Researchers at University of California- San Diego took women with confirmed PCOS and gave them resveratol supplements to see what would happen. They found that these patient's levels of male hormone including testosterone dropped significantly, suggesting that resveratrol may be doing this by reducing insulin resistance. The researchers did not look at whether their cycles became more irregular or more fertility.

So, should I start drinking red wine if I have PCOS and want to get pregnant?

Not a great idea, at least when you are or might be pregnant. It is possible (but still unproven at this time) that resveratrol may help promote fertility in women with PCOS. On the other hand, it is well known that alcohol, including red wine, when consumed by pregnant women can increase the risk of serious birth defects. It may be reasonable to have red wine before conception, but no OBGYN or  Fertility Specialist would recommend you drink once you might be pregnant.

Dr. Derman gives talk at Princeton University

Dr. Seth Derman discusses ethics of fertility treatment at Princeton University: Princeton IVF blog
Dr. Seth Derman lectures at Princeton University

Princeton IVF doctor speaks at Princeton University biomedical ethics seminar

Dr. Seth Derman was invited to address a group of students at Princeton University's Center for Jewish Life as part of the their Fellowship in Jewish Medical Bioethics. He discussed with a group of engaged, intelligent young women and men about what Reproductive Medicine specialists do  to help their patients have a child, and the exciting technology and fundamental ethical issues that go along with the territory. The students came away a better understand of the ethical and emotional issues that face couples undergoing fertility treatment.

Dr Derman discusses IVF and Assisted Reproduction with the Princeton Packet

HEALTH MATTERS: Assisted reproductive technologies available

By Seth G. Derman

What is in vitro fertilization with Dr. Seth Derman

 

This article previously appeared in the Princeton Packet  

Infertility – the inability to get pregnant or stay pregnant – is a common problem in the United States, affecting about 10 percent of women of childbearing age, according to the Centers for Disease Control and Prevention.

Fortunately, many couples can still realize their dream of having a child with the help of assisted reproductive technologies (ART), most commonly in vitro fertilization.

Princeton IVF in Lawrenceville, provides care for couples struggling with infertility and enables many women to deliver happy and healthy babies.

How does IVF work?

When most people talk about ART, they are referring to in vitro fertilization or IVF. IVF has been used for decades to help women get pregnant. In fact, the first IVF baby is now over 30 years old and has a child of her own.

With IVF, eggs are surgically removed from the body, fertilized with sperm and allowed to grow in the laboratory. In vitro literally means “in glass,” as the fertilization and early development happens in a laboratory dish.

Fertilization can occur naturally with the sperm selecting the egg or in cases where there are problems with the sperm, can be assisted with doctors inserting the sperm directly into the egg. After 3-6 days the embryos are inserted directly into the uterus.

While IVF was first developed to help women with missing or damaged fallopian tubes, it is now routinely used to treat infertility caused by many different problems such as sperm problems, endometriosis, unexplained infertility and any other type of infertility that does not respond to more conventional treatments.

Other methods of ART include gamete intra-fallopian tube transfer (GIFT), zygote intra-fallopian tube transfer (ZIFT) and tubal embryo transfer (TET). With these, the embryo is transferred to the fallopian tube through laparoscopic surgery instead of into the uterus, except with GIFT in which the eggs and sperm are inserted into the tube and fertilization occurs inside the body. With ZIFT and TET, fertilization occurs outside the body. These procedures are rarely performed today as their advantages in terms of pregnancy rates have been overcome by modern laboratory technology and improved methods of embryo transfer.

ART also refers to use of donor eggs and gestational carriers, which are variations of IVF.

Who is a candidate for IVF?

The majority of patients who are candidates for ART suffer from tubal problems, sperm problems, unexplained infertility or certain inherited genetic diseases, according to the Society for Assisted Reproductive Technology (SART). Candidates for ART generally have:

  • No evidence of premature menopause
  • At least one accessible ovary, and
  • A normal uterus

Menopause and ovarian function are irrelevant for candidates using donor eggs. SART recommends that all ART candidates should be in good health and have no medical conditions that would pose a serious health risk to themselves or the children they would carry.

How successful is IVF?

Success rates vary and depend on many factors. Some factors that can affect the success rate of ART include the following:

  • Age of the partners
  • Reason for infertility
  • Type of ART
  • If the egg is fresh or frozen
  • If the embryo is fresh or frozen

In addition, the clinic itself can have an impact on success rates, according to the CDC. Princeton IVF's affiliated Laboratory takes advantage of the latest in “clean room technology,” to help improve pregnancy rates.

A specialized ventilation and HVAC system allows for improved air quality, flow and temperature control. Air quality is further enhanced by the use of eco-friendly, low VOC (volatile organic compounds) paints and building materials. This type of technology can have an enormous impact on embryo quality, survival and clinical outcomes of IVF treatment, research has shown.

What are risks of IVF?

The biggest risk factor associated with ART is multiple fetuses, but that can typically be prevented or minimized in many different ways. Other risk factors include surgical risks from the egg retrieval, side effects of the fertility drugs for mom and risks associated with pregnancy.

And while ART can be expensive and time-consuming, it has enabled many couples to have children that would have otherwise not been conceived.

What is pre-implantation genetic testing?

Pre-implantation genetic testing (PGD) and pre-implantation genetic screening (PGS) can be used following IVF to diagnose genetic diseases prior to implanting the embryo in the uterus. Doctors can test a single cell from the embryo to determine chromosomal abnormalities that, among other things, can lead to miscarriage and birth defects.

Talk with your doctor

If you are one of the millions of couples struggling with infertility, talk with your doctor about ART. For many, it is a promising option that can help couples realize the joy of parenthood.

To learn more about Princeton IVF or to our physician from Princeton HealthCare System, call 609-896-4984 or visit www.princetonivf.com.

   Seth G. Derman, MD, FACOG, is board certified in gynecology and reproductive endocrinology. He is a fellow of the American College of Obstetricians and Gynecologists and a member of the medical staff at University Medical Center of Princeton at Plainsboro.

The inventor of clomid and his legacy

The legacy of the inventor of clomiphene, Frank Palopali
Frank Palopali invented the fertility drug Clomid.

The story behind the first fertility drug, Clomid.

As the year draws to a close, the newspapers, TV stations and other media outlets will share stories about individuals whom we lost in the past year. We will hear stories about great artists, musicians, athletes, politicians and others, about how they lived their lives and how their life's work impacted our own lives. It is likely these accolades will miss out on someone whose impact on world of reproductive medicine and generations of couples suffering from infertility. That man was Frank Palopoli.

Who was Frank Palopali? 

Frank Palopali was a research chemist at the Merrell Dow Company. He was the leader of the team that developed clomiphene (Clomid) one of the most commonly used fertility drugs in the world. His work in the laboratory started back in the 1950's and first clinical trials of clomiphene were published in 1961. In 1967, Clomid was approved by the Food and Drug Administration and it became available to the public.

So, why was Clomid such a big deal? 

In this age of high tech, highly effective fertility treatments, IVF with genetic testing and the like, it is somewhat difficult to understand why an  inexpensive pill you pick up at Walmart for less than $10 might be such a big thing, but it was a huge breakthrough. If you look back to the world of women's reproductive health care 50 years ago, most fertility treatments were relatively ineffective and more often than not involved major surgery. For instance, the treatment of polycystic ovarian syndrome (PCOS) at the time involved in operation called the ovarian wedge resection. The gynecologic surgeon would make it open incision in the abdomen (similar to a cesarean section) and remove a wedge-shaped portion of the ovary, and then stitch the remaining ovary back together before closing the abdominal incision. Like other major surgeries, recovery from this operation could take weeks or months, but the benefit, if any, was very short term, just a few months afterwards. Additionally, eggs were inevitably lost in the process and scar tissue could develop on the surface of the ovaries, both of which could harm a woman's future fertility.

With the invention of clomiphene it was now possible to treat PCOS with just a pill. It completely revolutionized the treatment of infertility caused by problems of ovulation, and ovulation problems such as irregular cycles are among the most common causes of infertility in women. No longer would costly and invasive procedures be required, at least for most women with PCOS. While future inventions such as injectable fertility drugs, alternative methods of ovulation induction and IVF would bring success to many more people, it all started with the development of Clomid.

Over past nearly half a century since this time, millions upon millions of women all over the world have been able to have children and grow their families because of this invention. The number of couples helped by clomiphene actually dwarfs the number of those helped by IVF.

How does Clomiphene work?

Clomiphene is an anti-estrogen. It is part of a class of drugs called SERMs (selective estrogen receptor modulators) which include tamoxifen (Nolvadex) and reloxifene (Evista), drugs which are used to breast cancer and menopausal symptoms. Clomid works by blocking estrogen, the main female hormone. By blocking estrogen from working at the brain and pituitary gland (the master gland at the base of the brain), it tricks the body into sensing that there is no at there is no estrogen around. As a result, the hormones (FSH and LH) that stimulate the ovary, start to rise. This rise in hormones then kickstarts the process of the egg starting to grow and begins the path towards ovulation.

What are clomiphene's side effects?

It is easier to understand the side effects of clomiphene when you understand how it works. Because Clomid is anti-estrogen, it can cause hot flashes, headaches, breast discomfort and other symptoms that we normally associate with menopause. Because it stimulates the follicles (the cysts which contain the eggs) to grow, it can cause discomfort in the abdomen and increases the risk of multiple births. There are also concerns about whether clomiphene increases the risk of ovarian cancer, though most of the studies suggest it safe that when use for a brief period time. This is another reason to seek out the care of a fertility specialist early in the course of your treatment.

What is clomiphene used for?

The original and most common use for clomiphene is to help women who don't ovulate regularly, to produce and release eggs, become pregnant or hold on to a pregnancy. Clomiphene is also that used to help women produce multiple eggs to help improve the chances for success with insemination (IUI) and IVF. Clomiphene has also been used in men to assist in their fertility. This medication is intended to be used under the guidance of us physician experienced in their use.

How much is the price of clomiphene?

Like any other medication, the cost of clomiphene varies from pharmacy to pharmacy. Generic clomiphene in the typical starting dosing (50 mg) frequently sells for less than $10 at large retailers such as Walmart or Target. In the US, this medication always requires a prescription.

How many days after Clomid do you ovulate?

This a common question without a straight forward answer. Most women will ovulate around day 14 of the cycle, give or take a few days. Since clomiphene is usually taken day 3-7 or days 5-9, that means about 5-7 days after the last pill. However, some women will ovulate earlier, some later or not at all. At our center, we like to monitor everyone on clomiphene to make sure we get the timing right, and not delay pregnancy any longer than necessary.

Clomid success rate- how well does it work?

When used for to help infertile women with irregular or absent menstrual cycles, clomid enables about 80% of women to ovulate when used over a period of time. About half of these women will go on to conceive. This is actually quite good when you realize that natural conception in normal fertile women is only about 20-25%. The success rates when using clomiphene for other causes of infertility (unexplained, male infertility, endometriosis, etc.) is lower. 

Can clomiphene be used in men?

Clomid is sometimes used to treat male infertility, though it is considered an "off-label" use. Since its use and its effectiveness in men is somewhat more controversial than its use in women, it is best prescribed and managed by a urologist with special expertise in male fertility.

Dr Derman featured in Princeton Packet

Infertility causes and solutions in the Princeton Packet: Princeton IVF blog

YOUR HEALTH: Infertility: causes and solutions

By Stephanie Vaccaro

Dr. Derman talks about the causes and treatments for infertility

This article recently appeared in the Health Matters Column of the Princeton Packet...

   So You Want to Have a Baby?

   Infertility is defined as the inability to conceive after engaging in unprotected sex for one year, according to the Centers for Disease Control and Prevention.

   What causes fertility problems?

It can be a number of factors. Dr. Seth Derman of Princeton IVF and Delaware Valley OBGYN, said that approximately 40 percent of the fertility issues he sees are due to male problems, 40 percent are due to female problems, and 20 percent a combination of both partners.

   ”The exact cause of male infertility is a little harder to diagnose because it’s not well understood,” Dr. Derman said. “With female infertility, the most common cause is ovulation problems, which usually show up as irregular cycles. Polycystic ovarian syndrome is the most common of these.”

   Fertility problems can be caused by endometriosis. They also can be linked to damage to the fallopian tubes, which can be caused by previous sexually transmitted diseases. This is particularly a problem in women who have had prior Chlamydia infections.

   And sometimes infertility has no identifiable cause.

   What options exist for treatment?

   ”Well, it depends what’s wrong,” Dr. Derman said. “If there’s an ovulation problem, usually the treatment is fairly simple with fertility drugs. These are medications that induce ovulation, such as clomid or letrozole.”

   ”For tubal problems — the treatment is usually surgery or IVF (in vitro fertilization),” Dr. Derman said. “IVF is clearly the most effective treatment for these problems.”

   Oftentimes the most effective option involves treating the female partner. IVF allows for the sperm to be injected directly into the egg, and is the most effective treatment for male infertility. “The poorer the husband’s sperm the more likely the couple will need more invasive treatment such as IVF,” Dr. Derman said.

   A less invasive alternative to IVF is insemination, in which sperm is injected up into the uterus. In contrast, IVF involves fertilization of the egg outside of the body, and the transfer of that embryo into the woman’s womb. It is also much more effective than insemination. When patients have unexplained infertility, insemination is oftentimes done first, and if that doesn’t work then they may try IVF, Dr. Derman said.

   What are the odds of success?

Typical fertile couples have a 20 to 25 percent chance of getting pregnant each month. Infertile couples have a 3 percent chance when trying on their own. IVF increases the odds of having a child to twice what it would be in a fertile couple. Those numbers can vary based on age.

   IVF is very often successful in the first or second cycle, particularly in young women. If it isn’t successful, it’s not unusual for a couple to try three or four times, according to Dr. Derman.

   Who pays for IVF?

In New Jersey, the Family Building Act (August 2001) requires companies with more than 50 employees to cover fertility testing and treatment, including IVF. There are exceptions in the law, and since the passage of healthcare reform, those exceptions have gotten even larger.

   Some of the other treatments can be relatively inexpensive. “For instance, treatment using fertility pills and some monitoring is not terribly expensive,” Dr. Derman said.

   When should you go see a fertility doctor?

   ”Generally, over 35, we recommend coming after six months,” Dr. Derman said. “If they are under 35, one year is the right time.”

   What should you expect when you go see a fertility doctor? When patients go to see Dr. Derman for the first time, the first stage in the process is to try to understand why they are unable to conceive. After getting a detailed history, tests will be ordered, which include testing to make sure their eggs are not running out, to make sure their tubes are open, to make sure the ovulation process is going well and that the sperm is normal. After getting a clearer picture of what is going on, they can better determine the next steps.

   ”Not everybody with infertility needs IVF, even though it is the most effective treatment out there,” Dr. Derman said. “IVF is the last thing that we do, not the first thing.”