WESTMED Reproductive Services

Welcome to WESTMED Reproductive Services, one of the practice’s newest specialties offered, with offices in Westchester in our new, beautiful 3030 Westchester Avenue office in Purchase. There is also a convenient location in Manhattan with onsite andrology, endocrinology and IVF laboratory.


We Care For Patients With

 

 

Infertility

 

Infertility has traditionally been diagnosed when a couple has been trying to conceive without contraception for one year.  Reasons to seek a fertility consultation prior to trying for a year include known or suspected problems with fertility, such as a known problem with the male partner’s sperm, irregular or anovulatory menstrual cycles, or to follow the recommendation that patients over 35 years of age should be seen for a workup after six months of trying.

 

There are many possible causes of infertility, but the primary causes include ovulation dysfunction, in which the woman does not release an egg every month in the normal time frame.  Cycles that are over 35 days in length, irregular cycles or no cycles at all resulting in no menstrual periods fall into the category of ovulation dysfunction.  The most common cause of ovulation dysfunction is Polycystic Ovary Syndrome or PCOS, but other causes include hormonal abnormalities such as thyroid disease and over- production of prolactin.  Also women who are thin, exercise heavily, or are under a lot of stress may develop ovulation dysfunction.  The workup and treatment of ovulation dysfunction will be discussed further in the website in the section on fertility workup and ovulation induction.

 

Tubal factor is another common cause of infertility in which one or both fallopian tubes are blocked or damaged.  The fallopian tubes are responsible for picking up the egg that is released from the ovary at ovulation, and it is the site where the egg is fertilized by the sperm.  The fertilized egg or embryo is then transported by the fallopian tube into the uterine cavity, where it can implant and form a normal pregnancy.  If the tubes are blocked or damaged, the normal pick-up, fertilization or transportation process can be obstructed, leading to either infertility or ectopic (tubal) pregnancy.  The most common causes of damage to the tubes include infections such as chlamydia and gonorrhea, as well as, endometriosis, a common disorder in which uterine lining tissue flows back through the fallopian tubes and implants behind the uterus, on the ovaries or the tubes.  Inflammation from endometriosis can cause scarring or adhesions around the tubes or can result in the complete blockage of one or both tubes.  Additionally, any prior pelvic surgery can cause tubal adhesions or blockage.  The workup and treatment of tubal factor is discussed further in this website in the sections on the workup of infertility.

 

Male factor refers to when the sperm count, motility (percent swimming), or morphology (percent normal shape), prevent sufficient sperm from getting to the fallopian tubes and fertilizing the egg.  Up to 35% of couples with infertility suffer from some degree of male factor.  Male factor is determined by the evaluation of a semen analysis or sperm count.  If abnormal, an examination with an urologist is often advised.  Treatments including intra-uterine insemination (IUI), in which sperm is concentrated and placed into the uterus through a simple vaginal exam, or Intra-cytoplasmic sperm injection (ICSI), an IVF procedure in which a single sperm is injected into an egg will successfully treat nearly all cases of male factor infertility.  Details are discussed further in the sections on the workup and treatments offered for infertility.

 

Unexplained Infertility is the fourth main category of infertility causes.  Unexplained infertility is assigned when all the initial testing for ovulation, tubal patency, and male factor return as normal.  Unexplained infertility does not mean that there is no cause of the infertility.  In fact, some of the most common occurrences associated with infertility would fall into this category, such as diminished ovarian reserve (low number of eggs), advancing reproductive age and endometriosis.  Fertility treatment is quite successful for unexplained infertility, and the approach is often directed by the women’s age, ovarian reserve testing, and how long the couple has been trying to conceive.  Common treatments include clomiphene citrate and IUI, letrazole and IUI, FSH injections and IUI, as well as, in vitro fertilization.  All these treatments are reviewed in detail in the appropriate section on what we offer to patients.


 

Recurrent Pregnancy Loss

 

Recurrent Pregnancy Loss has been traditionally defined as three consecutive first trimester losses, but we now recommend a workup and possible treatment after two early miscarriages. There are numerous possible causes of recurrent miscarriage (RPL), yet the majority of cases reveal no definitive cause. Many repeat miscarriages may be due to the incidental loss of a chromosomally abnormal embryo found in 20-50% of early pregnancies depending upon the women’s age.

Common findings thought to contribute to recurrent miscarriage (RPL) include: uterine anomalies (congenital malformations), predominately septate uterus, as well as fibroids affecting the uterine cavity, and uterine scarring. In addition to uterine causes, genetic abnormalities such as chromosomal translocations in either the male or female partner can cause recurrent losses. Immunologic disorders such as the anti-phospholipid syndrome are a treatable cause. There is a debate about the role of inherited blood-clotting disorders, but it is still common to test for these as they are easily treated. Uncontrolled diabetes and other endocrine or medical disorders can contribute to recurrent miscarriage as well as several uterine infections. Additionally, there may be male or sperm-related factors, such as the man’s age, that could contribute to repetitive miscarriage.

Once a woman has had two miscarriages, it is wise to undergo a thorough evaluation to discover and treat any of the known and preventable causes of miscarriage. Even if the problem is not easily treated, the workup allows us to calculate a patient’s risk of future miscarriage, and often to simply offer reassurance that the testing is normal, and it is well advised to try to conceive again. In patients with one miscarriage and one poor obstetrical outcome such as preterm delivery, stillbirth, or second trimester loss, a similar workup should be offered. In general, treatment for recurrent pregnancy loss includes hysteroscopic repair if a uterine defect is detected, heparin therapy for anti-phospholipid syndromes or low molecular weight heparin for thrombophilias and hormonal therapy or replacement for endocrine causes. If genetic causes are detected, the couple may achieve much higher live delivery rates with in vitro fertilization with pre-implantation genetic diagnosis or screening, where a lethal translocation can be screened out, or the normal complement of chromosomes can be confirmed prior to transferring the embryo.

Fertility Preservation

 

Fertility preservation with freezing or cryopreservation was initially utilized for patients prior to undergoing cancer treatments. Freezing of semen samples has been available for over 50 years, and freezing of embryos from an IVF cycle has been available since the 1980s. Technical difficulties in freezing eggs delayed widespread use of oocyte cryopreservation until about 10 years ago. With the widespread use of vitrification as a freezing technique, egg or oocyte cryopreservation has become quite successful, with thaw survival rates of mature eggs now over 90% at the laboratories we utilize. This has markedly changed the use of fertility preservation to include young, reproductive-aged women who hope to maintain their reproduction options in the future even if they are not ready to get pregnant.

Oocyte cryopreservation will allow a young woman, ideally less than 35 years old to store her own oocytes. Even if she waits a decade or more to have children, she should have essentially the same pregnancy success rates she would have if she underwent IVF at the time of egg freezing. If a couple is choosing to delay childbearing, embryo cryopreservation, in which a fertilized egg is grown to the blastocyst stage, can also be performed, providing even greater certainty about the chances of success in the future.

WESTMED Reproductive Services currently offers oocyte cryopreservation with the internationally recognized NYU embryology team at its site at the Greenwich Hospital IVF center in Greenwich, CT, and will be opening soon with a highly successful oocyte cryopreservation laboratory in Manhattan.

Heritable Genetic Disorder

 

In vitro fertilization and pre-implantation genetic diagnosis can be utilized to screen out nearly all known inherited genetic disorders prior to transferring the embryo. Genetic disorders that Dr. Keltz has previously successfully screened out prior to embryo transfer include, sickle cell anemia, Gaucher’s, Tay-Sachs, cystic fibrosis, polycystic kidney disease, Huntington’s Disease, Fragile-X syndrome, spinal muscular atrophy and neurofibromatosis, among other more rare disorders. One limitation of Pre-Implantation Genetic Diagnosis (PGD) is that enough embryos need to develop in order to have a good chance of having a good quality embryo available for transfer. One that is both free of the genetic disorder and has normal chromosome screening. We always recommend concomitant comprehensive chromosomal screening as the embryo biopsy has already been performed, and we want to transfer a single healthy unaffected embryo.

Polycystic Ovary Syndrome and Androgen Excess

 

Polycystic Ovary Syndrome, often referred to by its acronym PCOS, is the most common disorder affecting reproductive-aged women, and it affects between 5% and 10% of all women. Women come in seeking help for PCOS for two primary reasons: First, they may be suffering from irregular menstrual cycles and unwanted excess hair or acne prior to wanting to start a family, or, second, they may have irregular menstrual cycles and have trouble conceiving when they want to start a family.

To make the diagnosis of PCOS, two out of three of the following criteria are required: irregular menstrual cycles, symptoms or lab tests suggesting increased male hormones, and the classic ultrasound appearance of polycystic ovaries. In addition to making the diagnosis of PCOS, it is important to exclude other far less common syndromes that can present similarly, such as congenital adrenal hyperplasia and Cushing’s syndrome, or a tumor in the ovary or adrenal gland which is producing excess male hormone.

PCOS is likely due to insulin resistance, in which the body’s cells are less able to respond to insulin and take in circulating glucose. This is particularly evident in patients who are overweight and have additional insulin resistance due to their weight. But it may well be the cause even in thin women who have no signs or laboratory tests that can confirm insulin resistance. It is of note that not only is it more difficult for women with PCOS to get pregnant, but once pregnant, they are at higher risk for pregnancy- related diabetes, and are at an increased risk of developing Type 2 diabetes as they get older.

Treatment for PCOS is tailored to the patient’s goals. If a patient is simply looking to reduce the unpleasant androgenic side effects, the combination of birth control pills and an anti-androgen, such as spironolactone is highly effective. If insulin resistance is severe and the patient wants to lose weight, we often consider insulin-sensitizing agents, such as Metformin along with appropriate diet, weight loss, and nutritional counseling. If pregnancy is desired, we often start with an ovulation-induction agent such as clomiphene citrate or letrazole, and may add Metformin either if there is significant insulin resistance or a very high AMH. Due to the common multi-follicular response to gonadotropins in women with PCOS, we tend to reserve the injectable stimulation medication for IVF, which is generally highly effective in women with PCOS.

For those women who have PCOS and fail IVF, Dr. Keltz has been performing pioneering research on the use of Trans-Vaginal Ovarian Drilling, (TVOD). The procedure is similar to an oocyte retrieval for IVF, but is performed when the ovaries are suppressed. It involves a single puncture of each ovary and multiple passes of the needle under suction through the entire stroma of each ovary. Like other ovarian diathermy procedures, TVOD breaks the hormonal cycle that may lead to lower quality oocytes and anovulation.

Endometriosis

 

Endometriosis is a common disorder often resulting in painful menstrual periods, pelvic pain at other times in the cycle, as well as infertility. Roughly 10% of all women develop endometriosis, most commonly in their late twenties, but it tends to continue throughout the reproductive years, into the mid-forties. Endometriosis is highly associated with both chronic pelvic pain as well as infertility, affecting from 30-70% of women who undergo laparoscopy for either pelvic pain or unexplained infertility. Endometriosis is defined by the deposition of endometrial glands and stroma (tissue normally found inside the uterine cavity that sloughs with each menses) outside of the uterus, most commonly behind the uterus in the pelvis. The most common mechanism for the formation of endometriosis is the backflow of endometrium at the time of menses, which either implants and grows in the pelvis or induces other pelvic tissues to differentiate into endometrial tissue.

Diagnosing endometriosis can be challenging, and generally requires laparoscopy. Laparoscopy is a procedure in which a scope is placed into the abdomen generally through the umbilicus (belly button), to look for and biopsy the endometrial lesions on the ovaries, behind the uterus, on the bladder or elsewhere in the pelvis or abdomen. Tests that may suggest endometriosis include, ultrasound that may show the classic echogenic ovarian cysts, or endometriomas, that are common in advanced cases of endometriosis. Also fluid and nodules behind the uterus, or evidence of ovaries stuck to the uterus may be seen in endometriosis. In minimal-mild cases of endometriosis there generally are no obvious signs on ultrasound. But mild endometriosis is less likely to be causal in chronic pelvic pain or infertility. An elevated CA-125 is common in cases of moderate to severe endometriosis, and is particularly elevated when there is significant adenomyosis, or infiltration of endometrial tissue into the muscular wall of the uterus.

Most of the treatment of endometriosis involves laparoscopy removal of the endometriosis, which is discussed in further detail in the website’s discussion of minimally invasive procedures. Medical therapy for endometriosis--whether causing pelvic pain or infertility--is at least as important. Several medications have been confirmed to reduce the pelvic pain of endometriosis including GnRH agonists that turn off the ovarian stimulation that makes the estrogen that stimulates endometrial growth. Also a variety of synthetic progesterones, including norethindrone acetate, depo-provera, and progesterone containing IUDs are effective as they reduce the number of receptors for estradiol on the endometrial tissue. This same mechanism is employed by weak male hormones, such as Danazol, that treat endometriosis. Or estrogen production can be turned off by an estrogen-production blocker or Aromatase inhibitor such as letrazole. There are many options with a variety of pluses and minuses, available to treat endometriosis. We believe the best outcomes are achieved when an expert who focuses on both the surgical and--more importantly--the medical/hormonal management of endometriosis gets consulted early in a patient’s management.

While laparoscopic removal of endometriosis provides a small benefit in the treatment of unexplained infertility, and laparoscopic tubal repair may provide significant benefit to fertility in select cases, it is not imperative to make the diagnosis of endometriosis with laparoscopy in all women with infertility. Often non-invasive fertility treatments will work despite undiscovered endometriosis, and when there is significant or irreparable tubal damage from endometriosis, IVF is the mainstay of treatment. We recommend limiting laparoscopy to those infertile patients with unexplained infertility, some pelvic pain, and evidence of endometriosis on ultrasound.

 

Fibroids

 

 

Leiomyomas, often called fibroids or myomas, are the most common benign uterine tumors. Fibroids develop in over 50 percent of women of African descent and affect almost 40 percent of all women, but often these fibroids do not cause any symptoms. As in real estate, the most important factor in the significance of fibroids is their “location, location… location”, with size a distant second, along with the number of fibroids. Fibroids that occupy the uterine cavity (submucosal) will almost always cause excessive bleeding and are causal for both infertility and recurrent miscarriages. Fibroids that distort the uterine cavity but are within the wall (intramural) and not within the uterine cavity may cause increased bleeding, and reproductive problems. Fibroids that are pushed to the outside of the uterus and do not distort the cavity usually have no effect on fertility or miscarriage, but if large enough, can present problems during pregnancy.

The diagnosis of fibroids is generally made on pelvic exam and confirmed with an ultrasound. Symptoms associated with fibroids include heavy bleeding with the menses, painful periods or pressure symptoms and urinary symptoms. Fibroids that impact on the uterine cavity can cause recurrent miscarriages and may contribute to infertility. As the impact of the fibroid or fibroids on the uterine cavity is the most important predictor of its clinical significance, further imaging of the uterine cavity is an important next step in assessing fibroids once they have been diagnosed. The imaging test of choice is a sonohysterogram, also known as a saline infusion sonogram (SIS). This test combines transvaginal sonography with saline instilled into the uterine cavity that provides precise definition of the uterine cavity as well as imaging of the fibroids and their location in reference to the uterine cavity. Additionally, by obtaining a three-dimensional measurement of the cavity distortion, enlargement of the uterine cavity due to fibroids can be assessed.

There are many modalities to treat uterine fibroids, but it should be noted that after sonohysterography, most fibroids do not require any treatment. Surgical treatment of fibroids includes hysteroscopy myomectomy for fibroids in the cavity, laparoscopic or robotic myomectomy for fibroids in the wall of the uterus, and some large or partially cavitary fibroids may benefit from open myomectomy. Additionally, in women who no longer want to conceive, treating fibroids and bleeding with combined hysteroscopic myomectomy and endometrial ablation for cavitary myomas, or uterine artery embolization or MRI-guided sono ablation for large intramural myomas may be the most appropriate option. The surgical approach to fibroids will be described in greater detail on the website in the section on treatment options.

Uterine Polyps

 

Uterine polyps are one of the most common findings during the workup for abnormal bleeding, recurrent pregnancy loss or infertility. Traditionally, polyps were not thought to be commonly associated with infertility, perhaps affecting only 5% of cases. Newer studies, however, have documented the crucial impact of removing polyps on fertility outcomes, for example, a randomized trial prior to IVF from Valencia Spain. Also, this decision is supported by an older study we published in the Obstetrics and Gynecology from St. Luke’s-Roosevelt in Manhattan on both spontaneous and treatment-associated pregnancies in infertile woman. In our study, size did matter, with polyps below one cm not affecting fertility. But the Spanish study published in Human Reproduction found a negative effect from polyps on IVF outcome--no matter how small.

Due to this data, it has become standard to assess for polyps using sonohysterography (SHG or SIS) among women with abnormal uterine bleeding, inter-menstrual spotting, recurrent miscarriages or infertility prior to initiating fertility treatment. Polyps can be easily removed with hysteroscopy performed either in the office or in an ambulatory procedure setting, and requires no incisions. While polyps must be checked for cancerous or pre-cancerous changes, they are almost always benign in reproductive-aged women.

Uterine Anomalies

 

Uterine (Mullerian) Anomalies, or the abnormal development of the shape of the uterus since birth, are another very common finding that require attention in women suffering from recurrent miscarriages, poor obstetrical history and possibly infertility, although the association with infertility is less clear. Uterine anomalies are congenital or occur prior to birth. The most common anomaly includes uterine sub-septums and an arcuate uterus. One of these two anomalies may be found in 5-10% of women.

The other uterine anomalies, which in total affect less than 1% of the population, include two completely separated uteri known as a uterus didelphys, connected but separated uterine horns known as a bicornuate uterus, a single uterine horn or unicornuate uterus, T-shaped uterus (which in the past was associated with DES exposure but still occur sporadically), and the absence of a uterus or Mullerian Agenesis. All these anomalies may be associated with the absence of one kidney. Except for agenesis, which causes infertility, the other anomalies are associated with miscarriage or obstetrical problems. They are often associated with an increased rate of endometriosis.

The best diagnostic tests for anomalies include either a combination of sonohysterography and 3D sonography, or pelvic MRI. Treatment recommendations depend on the obstetrical history, the extent of the septum, or volume of the current cavity. Septums and T-shaped uteri are quite easily repaired with placement of a hysteroscope through the vagina and cervix, utilizing a small scissors to cut the band of tissue that forms the septum. Patients can be back to work the next day.

Intrauterine Scarring and Asherman’s Syndrome

 

Scarring of the inside of the uterus is a fairly common cause of recurrent miscarriage and loss of menses, and may cause infertility. Scarring of the uterus is most commonly associated with either a miscarriage or retained placental tissue that required a dilatation and curettage to either stop the bleeding or remove pregnancy-related tissue. If someone requires a dilatation and curettage after a full-term pregnancy, around 30% of those women will develop severe intrauterine scarring. When uterine scarring leads to complete absence of menstrual blood flow, amenorrhea, it is called “Asherman’s Syndrome” after the doctor who first described the phenomenon.

Other possible causes of intrauterine scarring include procedures to remove fibroids that are located in the uterine cavity. Additionally, intrauterine scarring tends to occur more often in women who are thin and who have irregular periods, and may be associated with some infections. The diagnosis of intrauterine scarring usually involves both sonography and X-ray hysterosalpingography. Treatment of intrauterine scarring can be completed during a minor procedure called a hysteroscopy with very fine small scissors. Patients then take estrogen orally to help regrow the uterine lining over the scarred areas. On occasion when the scarring is severe, it takes more than one hysteroscopic procedure to completely open the cavity, and may take considerable time to regrow the uterine lining.

 

Pelvic Pain

 

 

Pelvic pain is the most common reason for women to see their gynecologist, and is responsible for fully 10% of all visits to the gynecologist. Pelvic pain is considered chronic if it lasts for more than 6 months. It can be focal or experienced in one spot in the lower abdomen, or it can be a general crampy pain radiating throughout the pelvic region. The most common findings and probable causes of chronic pelvic pain are endometriosis, endometriosis of the uterine wall called adenomyosis, chronic pelvic infection, post-operative pelvic adhesions, bowel symptoms and frequently nothing anatomic is found.

The diagnostic tests for chronic pelvic pain include careful physical exam, sonography, occasionally MRI is helpful, and sometimes laparoscopy is indicated to further diagnose or treat the cause of the chronic pain. In addition, lifestyle changes are an important part of helping women with chronic pelvic pain. This includes regular exercise, healthy diet, sometimes medication to help with sleep or mood issues and work adjustment. Most women with chronic pelvic pain can be medically managed well, and it is rare to require long-term narcotic pain medication, which has the additional downside of lowering pain tolerance. Dr. Keltz has written several studies and review articles over the years and has managed hundreds of patient with chronic pelvic pain and often endometriosis, along with their general gynecologist.

 Abnormal Uterine Bleeding

 

Abnormal uterine bleeding is defined as excessive bleeding during the menstrual cycle, either very heavy bleeding or lasting more than seven days. Abnormal uterine bleeding also includes any bleeding in between the normal menses. Abnormal bleeding is quite common and has many possible causes including fibroid tumors, endometrial polyps, endometriosis or adenomyosis (endometriosis of the uterine wall), hormonal abnormalities that affect the ovulatory cycles, such as PCOS, thyroid disease, simple inflammation of the endometrium or cervix, and potential precancerous changes, such as endometrial hyperplasia or cancers of the cervix or uterus.

The standard diagnostic workup for abnormal uterine bleeding includes a gynecologic and speculum exam, ultrasound and likely sonohysterography (ultrasound with saline placed in the uterine cavity) and when indicated, endometrial biopsy. The most appropriate treatment for abnormal uterine bleeding depends on the findings. Sometimes simple oral contraceptives will suffice. Sometimes fibroids or polyps need to be removed or the endometrium ablated with minimally invasive hysteroscopy or laparoscopy. In certain cases, the uterus may have to be removed, but we very rarely find this to be necessary.

Ovarian Cysts

 

Ovarian cysts are a common finding in reproductive-aged women (16-50) and are a common reason for referral to our reproductive specialists. The most common cysts are called functional cysts, and include an enlarged follicular ovarian cyst or corpus luteum cysts. These cysts will generally resolve within three months and generally require no further treatment than oral contraceptive pills. The common cysts that do not resolve on their own in young women include first dermoid cysts, which are fat and hair-containing cysts that have a classic appearance on sonogram and--if necessary--MRI. We generally do not recommend removing dermoid cysts in reproductive-aged women unless they are associated with pain or twisting of the ovary, or have gotten significantly larger than five cm. Sometimes prior to IVF, it is prudent to remove a dermoid cyst that is likely to be ruptured at the time of egg retrieval. Dermoid cysts are almost always benign.

The second most common cyst in reproductive-aged women, which may require reproductive minimally invasive surgery, are endometriomas or cysts formed in the ovaries that contain endometriosis. If these cysts are found along with infertility or pelvic pain, minimally invasive removal should be considered if the cysts are greater than three cm and the patient has had no prior surgery. Otherwise, endometriomas can be followed with sonography unless the cysts grow to well over five cm.

Other common benign (non-cancerous) ovarian cysts include mucinous, serous and endometriod cystadenomas. If these cysts are simple in appearance, they can generally be followed with ultrasound.

Ultrasound is the best way to detect a concerning or malignant cyst, but there is no definitive test. Complex appearance and blood flow patterns within the cyst are the best way to predict a possible malignancy along with several blood “tumor” markers. While an ovarian cancer in a young, reproductive-aged woman is a very serious concern, it is important to realize that malignant cysts in this population are very rare. Among many thousands of reproductive-aged women, I have found persistent ovarian cysts on sonography, with perhaps 10 having a borderline or invasive ovarian cancer.

Premature Ovarian Failure

 

Premature ovarian failure, or early menopause, is defined as the loss of the menstrual cycle, along with an elevated blood FSH level at an early age. This finding is due to the early loss of functional follicles and eggs before the age of 40. Premature ovarian failure is particularly rare before age 30 and requires a more intensive workup. This would include checking the patient’s chromosomal makeup to look for absence or partial absence of one of the X chromosomes or very importantly, partial presence of a Y chromosome and only one X chromosome. Additionally, some autoimmune disorders are associated with premature ovarian failure, as are FMR gene defects associated with the Fragile X pre-mutation or surgeries on the ovaries, or some cancer treatments.

Premature ovarian failure is one of the most challenging and emotionally draining reasons to see a reproductive specialist. The unfortunate reality is that if the FSH is already very high (>30) and the menses are irregular or have stopped altogether, egg donation is almost always the only option to achieve a pregnancy regardless of the patient’s age. If a risk for premature ovarian failure can be predicted, such as a very young woman 18-25 years of age with a known Mosaic Turner’s syndrome (partial absence of one of the X chromosomes) or a permutation of Fragile X 50-100 repeats and low AMH, egg cryopreservation may be necessary to preserve fertility.

 

Menopause

 

 

The management of women going through the menopausal transition is most often handled by general OB/GYNs. However, some patients seek advice from a reproductive endocrinologist, and some reproductive endocrinologists focus on menopause management. The most common concerns associated with menopause are due to the reduced circulating estrogen levels when the woman’s ovaries stop developing follicles that produce estrogen. Symptoms from the reduction in estrogen levels most commonly include vasomotor symptoms or hot flashes that occur during the menopausal transition. As the low-estrogen state continues, there are often problems with vaginal dryness and atrophy as well as increased complaints related to leakage of urine. Another problem that may develop during the menopausal years due to loss of estrogen is reduced bone density, including osteopenia and osteoporosis.

All of these symptoms were commonly treated in the past with estrogen replacement therapy either with or without progesterone. Due to concern about precancerous changes in the uterine lining from estrogen alone, a daily combination of estrogen and progesterone in a single pill was quite commonly used until about 15 years ago. At that time, data from the Women’s Health Initiative came out. WHI was primarily looking to show that in addition to reducing the symptoms of low estrogen, hormone replacement would also help reduce heart disease. A reduction in heart disease was not found, and there was some increased risk of heart disease in the first year when using daily combined estrogen and progesterone. Additionally, as had long been suggested by non-randomized studies, there is a small increase in breast cancer associated with the combined use of both estrogen and progesterone. This study led to a sudden shift from the promotion of combined hormone replacement therapy for all women to its being avoided in almost all women.

This extreme swing from overuse to never using was unfortunate, as estrogen is still the best treatment for hot flashes. Estrogen alone without progesterone may be cardio-protective if started during the menoapausal transition, and estrogen alone did not increase--and in fact decreased--breast cancer in the WHI data. For patients with hot flashes or other symptoms that cannot or hope to avoid estrogen therapy, there are many other effective options. For patients who wish to get additional counseling on the management of their menopausal symptoms or concerns, a reproductive endocrine consultation may be helpful.

We Offer:

  • Comprehensive Infertility Work-Up
  • Intrauterine Insemination
  • Management of Fertility Medications
  • In Vitro Fertilization
  • Oocyte Cryopreservation
  • Oocyte Donation
  • Sperm Donation
  • Intra-Cytoplasmic Sperm Injection
  • Pre-implantation Genetic Diagnosis
  • Comprehensive Chromosome Screening
  • Family Balancing 

Minimally Invasive Reproductive Surgery

Advanced Laparoscopy:
  • Tuboplasty and Tubal Anastamosis
  • Resection of Endometriosis
  • Ovarian Cystectomy or Salpingectomy
  • Myomectomy

Advanced Hysteroscopy:
  • Myomectomy/polypectomy
  • Treatment of Asherman’s Syndrome
  • Tubal Cannulation
  • Metroplasty for Uterine Septum
  • Endometrial Ablation

 
 
 Keltz' Team 2015

WESTMED Reproductive Services is directed by Dr. Martin D. Keltz, who has over 20 years of experience in Keltz Wider Imagetreating women and couples suffering from reproductive problems, such as infertility, recurrent pregnancy loss, endometriosis, uterine fibroids, septums and scarring. Dr. Keltz also focuses on women with menstrual irregularities, PCOS and unwanted hair or acne. Dr. Keltz is a leader in reproductive diagnostics and therapeutics, including sonohysterography, stimulated cycles with intrauterine insemination, in vitro fertilization, comprehensive chromosomal screening, and oocyte cryopreservation for fertility preservation. In addition to having performed thousands of all these office procedures, Dr. Keltz is one of the top minimally invasive reproductive surgeons in New York, having performed 200-300 laparoscopic and hysteroscopic procedures each year for abnormal uterine bleeding, fibroids, pain and endometriosis, ovarian cysts, pelvic adhesions and dilated tubes, as well as uterine scarring and uterine septums.


Dr. Keltz, the founding physician for WESTMED Reproductive Services, had been the director of the Continuum Reproductive Center and the Division of Reproductive Endocrinology at St. Luke’s and Roosevelt Hospitals from 1995 through 2014 when consolidation with Mt. Sinai resulted in the closure of the CRC and its IVF laboratory. Dr. Keltz graduated magna cum laude from Harvard College in 1985 and obtained his medical degree from the NYU School of Medicine in 1989. He completed his obstetric and gynecologic training at NYU and Bellevue in 1993, and completed his subspecialty training in reproductive endocrinology and infertility at Yale University in 1995. In addition to his active practice in assisted reproduction, Dr. Keltz has been extensively involved in research and teaching in reproductive disorders. He has over 40 peer-reviewed publications and 50 abstracts on subjects ranging from sonohysterography and minimally invasive procedures to in vitro fertilization and comprehensive chromosomal testing. Dr. Keltz is currently an associate professor of obstetrics and gynecology at the Icahn School of Medicine at Mt. Sinai.

 






3030 Westchester Avenue
Purchase, NY 10577
(914) 607-6270




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               WESTMED Medical Group's 3030 Westchester Avenue location

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