Archive for Infertility News
Today I will talk about why some women go in for an HSG and leave being told the test could not be done.
This is such a common problem, and it is usually all about the same thing. It’s about technique. The correct technique makes it easy, a different technique makes it unnecessarily difficult.
There are 2 ways to do a HSG. Remember the goal in performing a HSG is to get the dye in the uterus and then have it flow out of the tubes. To achieve this, many doctors slide a catheter through the cervix up into the uterus. This is the problem. If the cervical canal is narrow, whether naturally or as a result of some scarring after surgery, the catheter can’t get in easily. This results in pushing harder, and this causes pain, and pushing harder still may just jam the catheter against the side of the cervix. This leads to failure.
The second and easier way, for both the doctor and patient, is to put the dye in a syringe and put a soft cap on the end that snugs up against the cervix. We call this cap an acorn. The canal through the cap brings dye from the syringe to the cervical canal and up towards the uterine cavity.
Imagine trying to blow up a long skinny balloon by first shoving a straw half way in; it’s not so easy to get that straw through. But if you blow it up by just puffing into the hole (I know some of these balloons are hard to blow up but I’m just trying to illustrate the point) things go much easier.
Here are 2 pictures. Each has graphics that are a little different, but they are both drawings of HSGs, both represent a different way to do an HSG.
In the first, a catheter has been shoved through the cervical canal into the uterus. You can see the catheter inside with that little balloon at the tip. The balloon is designed to prevent the dye from backing up and coming out of the cervix. This makes sense, but there is a better way. In the second picture, the instrument is just pressed against the cervix, and that blocks the dye from coming out backwards. As you can see, nothing is shoved through the cervix. The dye finds its way into the uterus just form the pressure.
Even if the canal is very narrow, it does not matter, because the fluid dye will still have no problem following the path of the cervix. The same is true if the uterus is very ante-verted or retro-verted (tilted forward or backwards), both of which can make it very hard for the catheter to slide through the cervix and into the uterus. I’ll talk more about tilting soon in my upcoming blog about cervical stenosis.
I frequently see patients who some to see me having failed an hsg, meaning the test never got off the ground going because the catheter could not get into the uterus. The test was overly painful and there were no results to show for it.
All I do is repeat the test using the plug in the second picture and the test easily gets done. Occasionally I need to open the very end of the cervix in the place where the plug goes, but that’s much easier than needing to dilate the entire cervix to accommodate the full balloon catheter.
So if you had trouble with the HSG and live around NY, I would be happy to give it a go. Otherwise get the HSG done elsewhere, but ask first if they use the balloon. To be fair, even using my technique, rarely, rarely it still can’t be done and in that case I may need to dilate the cervix in the office or operating room.
Thanks for reading and please read the disclaimer from 5/17/06.
Dr. Licciardi
Posted on July 23, 2010 | Filed under Infertility News | Permalink
Wow, what a relief to know that what we have been saying for years is now finally officially stated. Any sperm morphology over 3% is considered normal.
How did this change come about? The World Health Organization (WHO) determines the normal parameters for semen including volume, count, motility, forward progression and morphology. The WHO published their guidelines in 1987, with updates in 1992 and 1999. The original “normal” cutoffs were based on estimates from old data, some of it dating back to the 1950’s. There were inconsistencies in the way data was collected, ie the sperm studied was collected and analyzed in many centers, but there was little regulation of how the tests were being performed. Plus there was not clear data on the history of the men.
This time the semen tests were performed using similar protocols in all of the testing centers. Plus, some history was obtained from the men, mostly related to fertility status.
4500 men in 14 countries on 4 continents were tested. Australia, China, Denmark, Germany, Chile, Singapore, France, the UK, and the USA were some of the countries included.
Men were placed into one of 4 groups.
Fertile men. All men in this group had initiated a pregnancy sometime in the 12 months preceding testing. This was the most important group because the researchers could establish normal values based on men know to have fertile sperm.
There were 3 other groups evaluated. To save a little confusion, I’ll summarize and say 2 groups were a little more random in nature and the fertility status of the men was mostly unknown. The 4th group was also fertile, but the time since last pregnancy was unknown and may have been longer than 12 months.
The results.
The normal fertile men’s sperm had the following results.
Volume: The median (midway between the lowest and highest results) was 3.7 cc, but anything over 1.5 cc was considered normal
Concentration: the median was 73 million but anything over 15 million was considered normal
Motility: the median was 61%, anything over 40% being normal
Morphology: the median was 15%, anything over 3% was deemed normal.
Some important points.
You may have noticed that morphology is not the only parameter with a new normal value. Volume was at 2.0 cc, now it is at 1.5cc. A normal count was 20 million, this changed to 15 million. Motility was 50%, now it’s 40%. The normal morphology had the biggest change, as it went from 15% to 4%.
Keep in mind that in this group, all of these men were fertile, so even men with levels lower than the new definition of normal had working sperm. The normal values were established mathematically. If you were in the upper 95% of the fertile people you were deemed normal. The bottom 5% of the fertile people was deemed abnormal. This 95%/5% cutoff is the system used to define cut offs for other tests such as TSH, Prolactin and many others.
When comparing the different groups of men there were very slight differences in volume, count, etc, but hardly worth mentioning. Fertile men did have slightly higher volume and counts then men whose fertility status was unknown. Morphology was mostly similar in the different groups. Remember, there was no group of men who had established infertility, so in this study there is no way to compare normal fertile men to known infertile men.
And even though we have no details on the women, knowing that they became pregnant in the past year is probably all the information we need.
So now you know. Any morphology over 3% is considered normal. If your doctor tells you otherwise, ask him if he has seen the new WHO guidelines.
To take it one step farther, can there really be difference between 4% and 2%? I doubt that there is a difference between having 96% abnormally shaped sperm and 98% abnormally shaped sperm. So as I have said before, at our practice here at NYU, morphology is not considered with much respect, except in some rare cases where the sperm is unusually abnormal.
I hope this helps.
For those of you who want more details, here is the link.
www.who.int/reproductivehealth/topics/infertility/cooper_et_al_hru.pdf
Dr. Licciardi
Posted on July 2, 2010 | Filed under Infertility News | Permalink
So you’ve been trying to get pregnant and it’s taking longer than you think it should. Now what? Sounds simple, you probably have a local gynecologist who you have been seeing for your checkups. Why not start there?
This may not be a bad idea at all. A general gynecologist could quite possibly be a very good fertility start. She has your history and may be conveniently located. But how can you tell she is good?
It boils down to 2 things: diagnosis and treatment.
Let’s start with diagnosis. If you have been trying 6-12 months, and you doctor says relax and try for 6-12 more months, relax your relationship with him. Of course he will occasionally be right and some people will be successful by just hanging in there, but most following his advice will still not be pregnant, and will be that much older.
Even if you want to wait, you should strongly consider at least having some basic simple testing. You can keep trying on your own as the testing proceeds, but at least you will acquire some important information. Once you get some answers, you will have the power to decide how to proceed.
Now what tests are we talking about? The gold standards are the HSG (hysterosalpingogram), semen analysis, and day 2 or 3 blood testing for FSH and estradiol (estrogen). All of these tests can be finished within a few weeks, and within that time you will have your bundle of information. Now some of this is a little simplistic because many of you have very complicated problems, but most people just starting out do not. And if the testing is systematic and is done quickly, you will all be on the right track.
You do need someone good to read your HSG. Many doctors will not look at your films; they will just read the report. This becomes less material when the report is normal, but much more significant when the report is abnormal. If you are told its normal, odds are it is. However, if you are told it’s abnormal, then you may need to take things one step further, usually by getting a second opinion, preferably with an RE. If you are told it’s normal and you continue without conceiving, you should have someone else have a look at it.
That’s the basic testing, sounds simple and it is.
What about the treatment side? For example, let’s say the HSG really is abnormal and you are told you need surgery on your uterus or tubes? Who should do your surgery? Your GYN or an RE? Many generalists are excellent surgeons, and some REs are terrible.
How do you know where to go for quality surgery? And let’s extend the question to “How do you find any good doctor?” Whether it’s a generalist or Reproductive Endocrinologist, how do you know who is good?
This is one of the most difficult questions in medicine. I would start by doing some of your own investigation.
What about those best doctors lists? This could be a good place to start because many doctors on those lists are good. However if you show a list to a good doctor who is very familiar with the people listed he will really wonder how some of them made it on. And I don’t know too many fertility doctors that are not on the “Best Doctors in America” list. That’s not a list of the super-best doctors in America, it’s a complication of all if the doctors who are on the best local doctors lists. So there is no cut to make the America list. Most of those lists give a high priority to chairmen and division directors, again most of whom are good, but holding one of those positions is not an automatic for quality. Some lists are assembled through other doctors voting, and some of that could be politically biased.
You may have local infertility organizations that could make suggestions. This is tough because although I think these groups do an excellent job, I have been involved with at least one group who referred to their biggest supporters. But it might be good to at least find out which doctors are on their list.
What if the doctor is in all the medical societies? Medical societies are very important organizations that provide education and networking, but unless you have a criminal record, almost all societies allow members in. So you will see most doctors with impressive lists of their fancily named societies, but membership is usually about paying your dues and getting your certificate. There are usually no entrance criteria that represent quality control.
What about board certification? There is no excuse not to be boarded in OBGYN. Most of us are. What if you are going to a specialist, does he need to be boarded in Reproductive Endocrinology? This is usually important but there are some excellent physicians who have good reasons for not being boarded in RE. Maybe they are young and are waiting to become eligible. Maybe they are a little older and trained before getting certified was the thing to do. I would say that if your doctor is not, you need to carefully evaluate other criteria.
Does it matter where she did her training? Again hard to say, but better programs are more likely to turn out better physicians. Some of this may have to do with recruitment. The places with the best training reputations can more easily recruit the smartest and most caring people. So just by getting the best, they will turn out the best. The problem for you is knowing which training programs are the best. There are many renowned institutions that just have bad programs. It’s not uncommon to have a hospital with a great program in one specialty and a very bad program in another. And sometimes things change quickly within a program, so the training can become worse before the reputation changes. Magazines do publish the lists of top hospitals, and I don’t think there are many bad places that make those lists. However, there are many excellent places that don’t get the nod.
Nurses can be a good referral source because they see the doctors work every day. But a referral from a nurse may not be a slam dunk. I have seen nurses refer to their better friends, or to the doctor who is popular because he frequently brings in pizza.
Nurses know who operates the most, but not about their daily functioning and this brings us to the next point.
Is a doctor who operates at high volume the best surgeon for you? Maybe. A doctor who operates frequently may be really wonderful and have a massive referral base that keeps him in the OR frequently. They can be more experienced and confident and have fewer complications. However, some busy surgeons are busy because, for whatever reason, they over-operate. And some of these doctors have not gained from their experiences and maintain a higher complication rate. They may feel their procedures are indicated, but others may not. Getting back to the nurse, he sees what’s happening in the OR but he does not know about how the patients have been worked up and how they are followed after surgery.
There is one good trick that only works in a teaching hospital: ask a resident. No one knows the skills and limitations of your doctor better than a resident. The resident is in the hospital all day long and is involved with the workups, surgeries and recoveries. They are constantly communicating with your doctor. And believe me the residents have very strong opinions about each of the doctors they work with. Now it is hard to get hold of a resident, but ask around, may be a friend of a friend knows one. Plus, many hospitals have departmental web sites that list the residents, and some may list contact information. Because they are young, tired and stressed, sometimes the residents are a little too opinionated, and they may know about some of the doctor’s personal issues that don’t affect you. If you have a doctor and want their opinion, you don’t need to hear the doctor is the best of the best. You do want to hear that she is solid, not that she is below average or worse.
What if your only source is your friend who became pregnant after seeing the doctor she recommends to you? This is not enough at all. Many questionable doctors get some of their patients pregnant. It doesn’t mean that they are good. Just like there are some of the best doctors who just can’t be successful with everyone. This is probably one of the most common ways couples find fertility doctors, but it is the least reliable. So if you are told about a doctor, use other sources to validate the person.
Check the available medical misconduct sources in your state. Your doctor should not be listed there. There is also the National Practitioner Database. This is different than misconduct; it lists the cases where your doctor was sued. Even the most excellent doctor can have a few things listed; it’s the nature of the beast, the way of the world. Most doctors are non-malicious hard workers who can run into a bad outcome, but this should happen only very occasionally, and if they have any cases listed the list should be very short. Some of the doctors who take care of the most complicated cases are more likely to be sued. That being said you must avoid the frequent fliers.
And then there’s the internet. Have you ever stayed at a nice hotel and enjoyed the experience? Go to the internet and check the reviews, you would be surprised by all the negative comments. But, the average of the reviews would at least be close. So yes, the internet chats are some of the best places to find doctors, especially if you repeatedly read similar concrete reasons why a doctor is good or bad. I have heard of administrators going undercover on the sites to steer business to their doctor, so watch for that.
More on the best doctor for you next time,
Dr. Licciardi
Posted on June 6, 2010 | Filed under Infertility News | Permalink
PCOS and Ovarian Drilling.
Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because the do not always work. Plus are alternative ways to stimulate ovulation including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option. Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling. So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin. What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.
Other PCO Topics
Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.
When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.
Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.
Egg quality clomid vs FSH? Probably similar.
Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.
Sperm Topics:
Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.
Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.
Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.
Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.
Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.
Miscarriage
What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.
Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.
Frozen Embryos
Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.
What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.
General Topics
Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.
Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.
Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.
What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.
How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.
Thanks for reading and don’t forget the discalimer posted 5/17/06.
Dr. Licciardi
Posted on May 14, 2010 | Filed under Infertility News | Permalink
What if you are on drugs for an IVF cycle and there is a low number of follicles? Should you do cancel and have an iui (provided there is sperm and at least one tube is open) or should you have the retrieval?
The number of eggs is less important the younger you are. So at age 31, 4 eggs still results in an excellent pregnancy rate. At age 41, 3 eggs is much worse than having 10. So is there a “cutoff” number? Not really, and if there is it will vary from program to program. There are no strict guidelines for who should be retrieved and who should not. In most cases, when there are 1-4 eggs developing, the doctor will say that the odds with IVF become so low that it’s not worth the cost and effort of the IVF, so the better thing to do is the iui.
There was a very interesting paper presented at the last meeting of the American Society of Reproductive Medicine. One IVF center compared the pregnancy rates for women who decided to cancel to iui vs. those who decided to have the retrieval, when 1-2 eggs were present. Those women who continued on and had their retrieval had a higher pregnancy rate than those who had the iui. Now the rates for IVF were still in the single digits, but the rates were better than the iui numbers. So IVF is better than cancelling to IVF, but the odds of getting pregnant from that retrieval is quite low. Would you have a retrieval if your odds were 2% with iui but 5% with IVF? Some patients would, some would not.
I have mentioned before that we all know or suspect that there are IVF programs who cancel the 3 eggers because they are worried about lowering their statistics. I think there is less of that going on. I see patients being informed of their odds and then be allowed to make the decision. And the threshold may be different depending on your perceived potential. If it’s your first try and the doctor really thinks that a different protocol will do you better, cancelling makes more sense. If you have been cancelled for 3 follicles, and after protocol changes you make 3 again, well you make 3 and that’s it, so retrieve away.
What about multiple egg issues at the same time?
For example there are some women who make a large percentage if immature eggs, have low fertilization rates and have low embryo quality. Others have different mixes such as high rates of polyspermy, low rates of normal fertilization and poor embryo development. Others have mature eggs that do not fertilize without ICSI despite normal sperm, and then poor embryo quality. Is there one basic problem with the eggs that is leading to a completely bad scenario? This may be, but we don’t know what it is. The reality is that most women with a large percentage of immature eggs do pretty well with the ones that are mature. And women who have polyspermy, do pretty well with the eggs that fertilized normally. But for some of you, everything seems to be wrong despite protocol changes and changes with icsi, in hcg timing and day of transfer. Yes there may be a missing link resulting in multiple problems at once. It’s a matter of trying a few times and keeping all of your options open.
Persistently elevated prolactin levels need a full workup, which usually means an MRI of the pituitary.
What if your FSH is a little high and your AMH is a little low, but you have a good number of resting follicles and make a good number of eggs for IVF?
Those hormone tests are more about predicting egg number than quality. I believe the numbers have less of an effect on egg quality. Others may disagree, ask your doctor.
What if you suffer from autoimmune disorders and are having trouble conceiving? Is there a relationship?
Overall women with autoimmune disorders seem to be as fertile as anyone else. High risk OB practices are busy dealing with pregnancy complications of Lupus, RA and others. However, there are so many unknown factors related to fertility and the immune system, it does make one think that there may be a relationship when pregnancy is not occurring. I have seen a few cases of relatively young women with autoimmune disease who are very poor responders. I think there is a relationship between their disease and antibodies to their ovaries. Unfortunately there is still no good test to measure ovarian antibodies. There are good tests for thyroid antibodies, adrenal gland antibodies, but not yet for the ovary.
Here are a couple sperm questions.
Sperm counts that go from 100 million to zero then up again? He needs to be evaluated for intermittent obstruction: a blockage somewhere that occurs some of the time. Also could be intermittent retrograde ejaculation. Send him to a reproductive endocrinologist.
What if the urologist finds low counts and motility and does a thorough workup and tells you the numbers are what they are, can’t be increased and recommends IVF. You are always welcome to get another opinion, but it sounds like this guy is honest and he is telling you what most men are told. I believe in seeing a urologist because sometimes surprises are identified, but in most cases of very low counts and or motility, nothing is found and the only answer is IVF.
Yes ovarian hyperstimulation and ovarian torsion are related.
Torsion becomes more likely as the ovaries enlarge and become heavier. This increases the chances of the ovary rolling over and twisting on its stalk. Torsion with clomid can happen, but it’s much rarer because the ovaries have fewer follies and are smaller and stay lighter.
Thanks again for reading and please read disclaimer 5/17/06.
Dr. Licciardi
Posted on April 18, 2010 | Filed under Infertility News | Permalink
Good day to all of you. As you have seen, the last few entries were on egg freezing. If you are not interested in egg freezing, but want to know more about IVF, I think you will learn a fair amount about regular IVF from the egg freezing entries.
I am in the “catch up” phase, so you will see a few more FAQs answered. I’ll start with a little case from my recent day in the office.
The question leading to the topic was, “Can you be a poor responder and get pregnant on your own? “ So al little story about a couple I saw this week. She was a poor responder with borderline FSH levels, normal tubes and a favorable age. He had low sperm counts. They had been through IVF. I suggested that he see a urologist because there maybe something that can be done to improve his counts. She still ovulates every month, so by upping the odds on the sperm side, maybe they could get lucky and get pregnant on their own. My statements were very surprising to them. They were told that because of her “fertility status”, meaning her FSH was a little high, pregnancy could not occur naturally, so why bother with the sperm. This may be close to accurate but it is not completely true. Unfortunately, many couples with significant fertility problems never get pregnant, but for some the pregnancy rate per month is not zero. Even if its ½ percent per month, after a year, a few women with normal tubes, borderline FSH levels and good sperm will get pregnant (age helps). Can you count on it? No, but if there is something fixable, you might as well explore the options. I do hope they do take the advice. This is also the reason that some doctors suggest a laparoscopy after many failed IVF cycles. Even if the odds of tubal disease are low, correcting a small problem may improve the odds of a spontaneous pregnancy down the road.
Here are some surgery questions.
If you have severe endometriosis and pain with a history of multiple laparoscopies, and you are at the end of your rope, is a hysterectomy the answer? This is too complicated for me to give any hard advice here. The options are to get another opinion from a doctor is an established endometriosis laparoscopy doctor, who can maybe improve your pain without a hystersctomy. Maybe even someone who is not in your area. On the other hand, there are some women who say the hysterectomy was the best decision they ever made, and some who are neutral and some who are not happy with the results.
Is a laparoscopy through 3 incisions better than a laparoscopy where the doctor only used 2 incisions? Impossible to say. Some surgeons are really crafty using only 2, some need 4. Sometimes a doctor who usually uses 2, will need to use 3-4 in the really tough cases. But redoing a laparoscopy just because only 2 incisions were used does not make sense.
What if there is a hydro on hsg and at laparoscopy the tube does not fill with dye? Should the doctor assume the tube developed proximal occlusion and just leave it? I think not. For some reason, sometime tubes just to not fill with dye at the laparoscopy. Even normal tubes sometimes do not fill, but a post op hsg shows normal tubes. So if they are hydros at hsg, but closed at laparoscopy, your doctor should consider removal.
Is it normal to have a myomectomy and have some fibroids left behind at surgery? This does happen, but I do not leave any behind. I could see rare cases of fibroids left behind for a couple of reasons. Fibroids on the cervix are more dangerous to remove because the cervix is where the uterine arteries bring blood to the uterus, so around the cervix there is more blood flow and more chance for heavy bleeding during the operation. Also, if there are very thick intestinal adhesions attached to a fibroid, separating the intestine from the fibroid may cause excessive bleeding or damage to the intestines. That being said, leaving fibroids behind should be reserved for the most extreme cases. I have not left a fibroid in 15 years. The doctors I work with do not leave in fibroids. However I am aware of doctors who routinely leave in some of the smaller or difficult to reach fibroids, and I do not know if this is the best thing. A myomectomy is not minor surgery. In many cases, smaller fibroids get bigger. So if your problems are bad enough that you need the myomectomy, getting them all is the best thing. It is also true that the doctor may do a great job getting them all out, and sure enough, 3 months later a scan shows another fibroid. This is harder to explain, but probably there was a very small one that could not be seen, and it that grew after the initial surgery.
Clomid, IUI and PCO
Do you need to get a period before starting clomid? If you have either post pill amenorrhea or hypothalamic amenorrhea, it will be hard for you to get a period anyway. You probably will not bleed after provera. So in my patients, I do not require that they bleed. Also, you may not respond to clomid. Clomid causes the pituitary to release its stores of FSH and LH. Women with hypothalamic amenorrhea, because their brain makes no GnRH, do not have FSH stored in the pituitary. That being said, it may be worth trying because sometimes it does work and it’s much easier and less expensive than the injections. I have been pleasantly surprised by some nice responses and pregnancies in women who should not have responded.
Can you have polycystic ovaries and have low ovarian reserve? No they are the opposite. Women with PCO have many many eggs and are not close to menopause. Now women with PCO eventually lose their eggs to and get to menopause, but if you are told now that your ovaries are PCO on ultrasound, you do not have low ovarian reserve.
If IVF is not in your future, does it matter if you do iui with Menporur or FSH? It probably does not matter.
Are progesterone levels important to measure in the luteal phase during a natural cycle. Very few infertility doctors feel this is important. It has not been shown well that levels matter, plus they change throughout the day.
What if your follicle size looks good, but it’s Friday and your doctor wants to try to get you to Monday for the iui? Not so good. In some cases it may be fine, but in others it’s not the right thing to do. The fertility doctor you work with really needs to provide services 7 days a week. Many say they will, frequently resort to doing things a little late or early because they are not as staffed as they say. It’s probably true that a little late or early here and there actually may not make a difference, but more than a little is a problem.
Miscarriage
Does having a miscarriage after iui mean IVF should be your next step? As hard as it is to lose the pregnancy, the delay is sometimes the worst part. It took you a while to get pregnant, then you may have waited a few weeks to confirm the status of the pregnancy, then there is waiting 1-2 months after the miscarriage. There are tons of factors that will go into your decision of how to proceed, but the frustration of the miscarriage process does push many people into IVF.
If you are in the process of an early miscarriage, should you have a D and C? There are pros and cons of the d and c vs. waiting for a natural bleed. A d and c should not be automatic. Go over your questions with your doctor and you will both come up with the best course of action.
4 biochemicals in a row with a normal uterus? Your age is important, along with any miscarriage tests your doctor feels is necessary, especially the karyotype. This is a tough one. It is true that implantation is at least starting, and this is a positive. But finding cause may not be possible. I hope it works out.
IVF and Stimulation Questions
Should you avoid pregnancy if you are starting an IVF cycle with day 21 Lupron or Synarel or Buserelin? The stock answer is yes. However there are many women who have become pregnant while on those meds. If you do become pregnant, make sure you get luteal support with progesterone and maybe estrogen. Ask your doctor.
Does it help to take estrogen for luteal support in an IVF cycle? Probably not. There have been studies showing no improvement. There is even scientific evidence that estrogen may be unnecessary in the luteal phase. Some clinics routinely prescribe the estrogen; I tried it for a while in select cases with no improvement. I have had a little success using estrogen in women who have luteal bleeding despite progesterone. It’s used in medicated frozen cycles and DE cycles because the ovaries in those cases make no hormones (no estrogen or progesterone) so we add both hormones during their cycles.
Should you try IVF again if you are 29, have an FSH of 12 and make 8 eggs with 2 fertilized? Yes. I have been getting many comments from young women, some with high FSH levels, who are failing first cycles. Get to the best clinic possible and have your doctors come up with possible improvements for your cycle. Age is key. A high FSH in a 27 year old woman, or even a 36 year old, is not as telling as it may be with a woman in her 40’s.
What can I suggest to up your odds for the FET? Most FETs are pretty routine. Sometimes we suggest thawing more than you need and picking the best for transfer. Not everyone wants to do this. Some would rather thaw few so they can get more cycles out of what they have frozen. Either way is ok; see what your doctor says.
Hopeless after failed iuis, 2 fresh IVFs and one FET cycle? You do have to take into consideration age and FSH levels and embryo quality. It’s rarely hopeless. Maybe less hope, but not none. Know your stats, get another opinion and take it from there.
Can a para-ovarian cyst interfere with IVF or implantation? Probably not.
What if you are an established young poor responder who has had multiple failed IVFs. In addition there is a question about your uterus, meaning the was a scar but hysteroscopies and hsgs are now normal? This depends somewhat on the thickness of your lining on ultrasound. I have said before, and still believe, the lining thickness may be less important than we once thought, but of course everyone’s story and uterus are a little different. If you want to carry and our uterus is “acceptable” then donor egg without carrier is what most women would do, and probably with a very acceptable pregnancy rate. If you feel strongly that carrying is not important, just getting that baby asap, consider a carrier. However, donor egg, carrier is not guaranteed either.
I am hearing from women who have premature surges during antagonist cycles. I have not had this so I don’t know why people are having this problem. Antagonist should start at a follicle size of 13 mm (some clinics use 12 mm). Sometimes the estrogen levels do fall a little when the antagonist is started, but this fall does not mean there has been premature ovulation. So if the estrogen falls (but not by too much), but the follicles still grow, and the estrogen level goes up the next day, that’s all ok. There has not been a surge.
How long after the last depot lupron shot do you need to wait for IVF? The depot shot is supposed to stay in your body 4 weeks, but may be in a little more. Ask your doctor about this one but probably if you start 4 weeks after your last shot, but the time you are retrieved it will be 6 weeks after the shot.
What’s the doctor doing at my transfer, and why is there a delay? You can’t see what’s going on at the transfer, but any of your questions at the time should be answered. Doctors have certain catheters they like to start with. If they have trouble getting the catheter through the cervix, they may ask for another type. They should keep you informed.
Breastfeeding during IVF. FSH levels in breast milk will be higher than during a natural cycle. I really can’t comment more than that. There are some women who do IVF while breastfeeding.
Can a varicocele repair correct azospermia? I am not a urologist, but I have not had an azospermic patient develop sperm in is ejaculate after a varicocele. I’m not saying it can’t happen. It is also possible that the counts could go up without surgery.
What about a period that lasts for months with a completely negative workup? Make sure you do not have a bleeding disorder. Some women have vascular abnormalities if the uterus that cause constant bleeding. Maybe an MRI will help.
Thanks for reading, read disclaimer 5/17/06, and talk to you soon.
Dr. Licciardi
Posted on March 31, 2010 | Filed under Infertility News | Permalink
Once again, some of this also applies to regular IVF.
Just as not every follicle gives up an egg, not every egg we get is usable. This mostly has to do with egg maturity. We can’t use an immature egg, it will not fertilize later. For those of you familiar with in vitro egg maturation (IVM), I don’t want to get into that whole thing here. Suffice it to say, IVM had a very limited role with very limited success.
Basically, getting an egg to mature after we retrieve it is of little value, we count on the eggs to mature in the ovary before we get them. We need tree-ripened fruit.
Most retrieved eggs are mature but 10-20% may not be. So if say you get 15 eggs, having 3/15 immature is typical. Like anything else we talk about, variations exist. Some women, no matter how we change their drugs or increase the number of days on drugs, end up with ½ or more of their eggs immature. This is an exception, as is the case when every egg is mature.
Less often we have another small problem: atretic eggs. Atretic eggs are basically just dead eggs. This is much rarer than immature eggs. Another rare problem is a cracked zona (cracked shell). These also are not very viable.
So the point here is that if your doctor sees 15 follicles it does not mean there are 15 eggs to use. By the time you account for eggs that don’t get retrieved, immature and atretic eggs and eggs with cracked shells, you should still be left with about10 that are usable. But it could be more or less depending how the chips fall.
And away they go, into the deep freeze, for months or years (decades?. You work, you live and then one day you decide the time has come to attempt pregnancy; you go to the bank and make your withdrawal. This is another spot for potential attrition.
Not every egg survives the thaw, but most do. One of the many really nice papers on egg freezing recently published by NYU’s own Drs. Grifo and Noyes ( Fertility and Sterility Volume 93, Issue 2, 15 January 2010, Pages 391-396) shows that about 92% of eggs survive the thaw. If they survive we can attempt fertilization.
There are 2 ways to fertilize eggs, one is to mix the eggs and sperm together and let the sperm swim in: this is used when the sperm counts and motility are close to normal. The other is, under the microscope, to pick up a sperm and inject it into the center of the egg: this is used when the sperm counts and/or motility is low. This is called ICSI (inter cytoplasmic sperm injection). For some reason, eggs that have been frozen require ICSI to develop into good embryos. The requirement for ICSI is not a big deal; it seems to work quite well, although it does add to the cost of the procedure. But to continue with a familiar theme, not every egg that has ICSI fertilizes. The same study above shows that 79% of eggs that get ICSI normally fertilize, which is very similar to the rate for fresh eggs.
So the 10 that were frozen are now fewer. You could have 10, but the number may be more like 9, 8, 7, 6, or even 5. And we’re not done yet.
Fertilized eggs need to grow in the lab for another 2-4 days before the transfer. I have a number of blogs that describe embryo and blastocyst development, starting on December 14, 2008. There you will see the changes that take place as things progress from egg to embryos as the the days in culture. You can see the difference between good and bad embryos. Naturally you would like to have nice good looking embryos. And as the story goes, not every fertilized egg makes it to a nice embryo.
Reading this one would think that it’s impossible to have a good outcome from egg freezing, but in reality most women have an average egg yield and enough nice embryos to have an average chance for pregnancy. But again, there is variation. The luckiest women have high egg number high fertilization rates and many really nice embryos, and even some extra embryos for freezing. In other scenarios, there are many eggs and embryos, but they do not develop well.
There is a bit of a waiting game to get your results. In fresh IVF, you know within a few days where you stand. With egg freezing, you will not know how many good embryos you have until you thaw the eggs maybe years later.
We do not yet know how many eggs we will need to thaw later. We may feel comfortable enough to thaw 4-6 and try with those. However, as we accumulate more data, we may find that you need to thaw more to have a good chance. This is important because if you have 8 eggs frozen, thawing 4 at a time can give you 2 chances, but thawing all 8 will give you only one. And then there will be a question about how many embryos to put in your uterus, the recommended number may change with time so this is just something to keep in the back of your mind.
Here’s another question. Should you do any “fertility” or “preconception” workup prior to freezing your eggs? The question here is should you have any tests that may effect you ability or decision to get your eggs/embryos back later. For example, should you have a hysterogram to look for abnormalities in your tubes or uterus before egg freezing? Should you have any genetic tests, cystic fibrosis for example, before freezing your eggs? This you should you discuss with your doctor. In actuality, there are very few things that would keep you from getting your eggs back later. If you are a carrier for cystic fibrosis, you probably will still want to become pregnant with your eggs, providing you screen your partner or donor. If you doctor is minimally good at ultrasound, she should be able to tell you if you have a major abnormality of your uterus without a hysterogram. Most women are still candidates for pregnancy even with an abnormal uterus. However, this is very important to review your history and the potential tests with your doctor. I have had women who wanted to have all the tests done before egg freezing, but not everyone does.
Costs. There are a number of cost centers associated with an egg freeze cycle. There is the cost of the egg freeze cycle. This is the fee that the IVF center charges for the ultrasounds and blood tests associated with your cycle. It includes the retrieval procedure and the egg freezing.
What does in not include? You first need to see the doctor and he usually performs an ultrasound. This is separate. There are the optional tests described above, but there are mandatory blood tests that check your thyroid, prolactin, hepatitis status and others. Your insurance may be more likely to pay for theses but you need to check.
You will most likely need anesthesia for your retrieval procedure; in many cases this this is an extra fee of $1000 or more.
There are also yearly charges to store your eggs, which usually kick in after the first year.
Plus there are real costs, in the thousands, associated with getting your eggs back. This requires the thaw, lab handling, ICSI, ultrasounds, blood tests and the embryo transfer. If you have extra nice looking embryos, you may be allowed to freeze some of them, but again there is an extra cost, and a thaw transfer cost again.
OK, I think that’s almost everything you need to know about egg freezing. I hope it helps.
Thanks for reading, and read the disclaimer 5/17/06. Looks like spring may finally arrive.
Dr. Licciardi
Posted on March 5, 2010 | Filed under Infertility News | Permalink
Hello Everyone,
I have been asked by a researcher to help recruit people to participate in her infertility study. I have spoken to her and she seems dedicated to a very good and important project. Please consider taking her survey. The information is below. This study was approved by the University of Texas internal review board.
Have you and your partner been undergoing treatment for primary infertility?
If so, please consider participating in an online study of the impact of an infertility diagnosis on marriage.
1. You are eligible to participate if you are a married heterosexual couple
2. You do not have any biological or adopted children living in your home
3. Either you, your spouse, or both has received an infertility diagnosis (unexplained infertility qualifies as a diagnosis)
4. You are currently receiving medical treatment for infertility, have done so in the past six months, or plan to do so in the next 6 months
5. Both you and your partner are willing to participate and have access to the internet.
Participation in the study will involve completing an online survey focused on your experience of infertility, your self-perceptions, and your feelings about your marital relationship. This is expected to take no more than 15-20 minutes per spouse.
Participants will receive a voucher good for a pair of free movie tickets upon the completion of the surveys by both partners.
To participate, please send an e mail to: morray@mail.utexas.edu
Elizabeth B. Morray, MA
Doctorial Candidate
Counseling Psychology
The University of Texas at Austin.
Posted on February 24, 2010 | Filed under Infertility News | Permalink
Sperm Fragmentation Assay : is it Useful?
It’s just an additional test that may give additional insight . Like many test in infertility it delivers results in relative terms i.e one may have a REDUCED chance of fertility if the test is abnormal (as opposed to all or nothing) . Having said so most still decide to use their own sperm even if the test is abnormal and take their (albeit reduced) chances . This is the reason why i do not use the test as much because i don’t offer it to people who under no circumstances would use donor sperm . For others the test helps as it may offer some insight in why a cycle did not work. so if you go for he route of donor sperm at least you know that you made the decision based on scientific evidence as opposed of trial and error. A couple of scientific articles below.
Reprod Biomed Online. 2010 Jan;20(1):114-124. Epub 2009 Nov 10.
Sperm chromatin structure assay and classical semen parameters: systematic review.
Castilla JA, Zamora S, Gonzalvo MC, Luna Del Castillo JD, Roldan-Nofuentes JA, Clavero A, Björndahl L, Martínez L.
Reproduction Unit, Hospital ‘Virgen de las Nieves’, E-18014 Granada, Spain; Sperm Bank CEIFER, Granada, Spain.
The present study is based on a PubMed search and compares the clinical validity of classical semen parameters (CSP) and the sperm chromatin structure assay (SCSA) in different clinical contexts. The PubMed database was searched using keywords on the sperm diagnostic test for pregnancy in three clinical scenarios: (i) couples attempting to conceive; (ii) couples who had been attempting to conceive for 12months without success; and (iii) couples treated with intrauterine insemination (IUI). There was a considerable heterogeneity among the studies included. For couples attempting to conceive following a SCSA that produced an abnormal result, the likelihood of male factor infertility ranged from a pre-test value of 7.5% to a post-test value of 32.1% [95% confidence interval (CI) 15.7-54.5], while after CSP with an abnormal result, the post-test probability was 17.3% (95% CI 11.8-24.5). For a pre-test prevalence of male factor infertility of 50%, the post-test probability of male factor infertility after an abnormal test is very similar for both SCSA and CSP. In couples treated with IUI, the clinical validity of SCSA is higher than that of sperm morphology alone, but not enough to introduce SCSA as a test in male infertility work-up. Copyright © 2009 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
Toxicol Appl Pharmacol. 2005 Sep 1;207(2 Suppl):532-7.
Environmental toxicants cause sperm DNA fragmentation as detected by the Sperm Chromatin Structure Assay (SCSA).
Evenson DP, Wixon R.
HCLD, Department of Chemistry and Biochemistry, South Dakota State University, Brookings, SD 57007, USA. scsa@brookings.net
Studies over the past two decades have clearly shown that reproductive toxicants cause sperm DNA fragmentation. This DNA fragmentation can usually be detected prior to observing alterations of metaphase chromosomes in embryos. Thus, Sperm Chromatin Structure Assay (SCSA)-detected DNA damage is viewed as the molecular precursor to later gross chromosome damage observed under the light microscope. SCSA measurements of animal or human sperm consist of first obtaining a fresh or flash frozen neat semen sample in LN2 or dry ice. Samples are then sent to a SCSA diagnostic laboratory where the samples are thawed, diluted to approximately 1-2 x 106 sperm/ml, treated for 30 s with a pH 1.2 detergent buffer and then stained with acridine orange (AO). The low pH partially denatures DNA at the sites of DNA strand breaks and the AO-ssDNA fluoresces red while the AO-dsDNA fluoresces green. Flow cytometry measurements of 5000 sperm/sample provide statistically robust data on the ratio of red to green sperm, the extent of the DNA fragmentation and the standard deviations of measures. Numerous experiments on rodents treated with reproductive toxicants clearly showed that SCSA measures are highly dose responsive and have a very low CV. Different agents that act on germ cells at various stages of development usually showed sperm DNA fragmentation when that germ cell fraction arrived in the epididymis or ejaculate. Some of these treated samples were capable of successful in vitro fertilization but with frequent embryo failure. A 2-year longitudinal study of men living a valley town with a reported abnormal level of infertility and spontaneous miscarriages and also a seasonal atmospheric smog pollution, showed, for the first time, that SCSA measurements of human sperm DNA fragmentation were detectable and correlated with dosage of air pollution while the classical semen measures were not correlated. Also, young men spraying pesticides without protective gear are at an increased risk for elevated sperm DNA fragmentation. Extensive DNA fragmentation probably cannot be repaired by the egg and the spontaneous abortion rate is approximately 2x higher if a man has more than 30% of sperm showing DNA fragmentation. DNA fragmentation is an excellent marker for exposure to potential reproductive toxicants and a diagnostic/prognostic tool for potential male infertility.
Posted on February 23, 2010 | Filed under Infertility News | Permalink
Thanks to all of you who voted for the Infertility Blog. It was recognized as the Best Infertility Blog by you, and the people at Wellsphere. Their Logo is now on the side of this blog.
Thanks again and more to come.
Dr. Licciardi
Posted on February 10, 2010 | Filed under Infertility News | Permalink
Ovulation Timing Questions
If your cycles are 55 days, are you ovulating? Most likely, probably around day 41. However, it is possible that you are not, so you must confirm through your doctor.
What if your cycles are 28-31 days but a progesterone test proves ovulation day 11? Very unusual, but it does not mean you are infertile. Check for ovulation a little earlier using the LH kit to see when it starts and to see if this is a consitant issue.
Is there a problem with 70 day cycles? Yes. You can try to track ovulation but when do you start to do so? If your cycles are always 70, check a progesterone day 60. If it shows ovulation at least you have that. It’s just harder to time things with such a long cycle, and you really don’t have many ovulations per year. If you want to get pregnant, get some help.
Miscarriage Questions
If you are having miscarriages on clomid, will IVF up your odds of going to term? Different doctors will give you different opinions. The IVF option will sit differently with different patients. We aren’t sure if IVF will reduce your miscarriage risk. So the answer is probably no, your odds will be the same with or without clomid. However there may me a play to try IVF with PGD. This option you really need to talk about with your doctor.
Does having an early miscarriage predict further pregnancy loss? Usually not. The odds are still excellent for having a baby in the next pregnancy if you had had only 1 miscarriage, or even 2-3 for that matter.
Will you ever conceive again after trying 3 iuis that resulted in one ectopic and 2 miscarriages? And suppose one of the tubes was removed? If the remaining tube is open, your odds would be excellent of conceiving again. But don’t wait too long before getting help.
Is there a relationship between a long follicular phase and miscarriages? Most likely no.
IVF Questions
Is it better to transfer a fair quality embryo on day 2 or let it grow to day 3 or day 5? Does the uterus provide an advantage over the Petri dish? Unless the lab is really bad (these days there are few really bad labs), then it does not matter. Now that’s’ if there are only 1-2 embryos. If there are more, going to day 3 will help you select the better embryos for transfer. Lab differences are more of a factor when going from day 3 to day 5.
What if the sperm is normal and you are not fertilizing? Should you try donor egg? If you wish, but the problem is more likely related to the sperm. Of course, unless you try donor sperm or donor egg you would not know, but if you look at a 100 patients who are having your problem, almost always the sperm is the issue.
If you are a poor responder, will adding clomid to an IVF cycle give you more eggs? It is one of the options. I make it may last, I put Estrogen prime of microdose first, then maybe clomid. Clomid sometimes makes the uterine lining thinner.
Is there a weight limit for IVF? It depends on the program. The fact is, people are getting bigger and doctors are getting more used to dealing with the big problem. However, it may be important to meet with the anesthesiologist who would be taking care of you during your retrieval. More important than your weight is the configuration of your neck and throat. They want to be sure that if you have trouble breathing, they can get a tube down without a problem. And let’s not forget that your doctor may be less worried about the retrieval and more worried about you and your baby during and after the pregnancy. It has been clearly shown that obesity is bad for pregnant women and bad for babies to be in the short and long term.
If you’re a poor responder, will dexamethasone produce more eggs? This has not been shown to be the case.
Do frozen embryos make healthier babies than fresh? There was one article that somehow came to this conclusion. We do not think there is a difference.
What if a “dominant follicle” seems to be the problem? Dominant follicles come in a variety of forms. Some women are very poor responders and only make one follicle. I have heard this referred to as a dominant follicle. More commonly, a dominant follicle means that you have the potential to make many follicles, but for some reason, only one is big and the others remain small. There are strategies to try to reduce this phenomenon but they may or may not work. We believe that in a natural cycle, the dominant follicle may be selected before the period even comes, so by day 2 the body has already laid out its plan for that month, and stimulating the ovary with drugs may not be able to alter that plan, leaving you with a low number, or just one dominant follicle. So by using oral contraceptives or lupron to turn off the ovary system for a little while, we may be able to stop the dominant follicle pre-selection and give more than one follicle a chance at becoming dominant. However, most of the time, the difference is not extreme
25 years old and not pregnant after an IVF cycle with nice embryos? In the end you will probably be fine. As I have said many times, get to the best program possible. Even at the best programs, these things happen.
What if you have a low AMH level (a sign of poor ovarian reserve) but have many resting antral follicles as seen by ultrasound and make many eggs during stimulation. In your case, the AMH is just dead wrong. As far as we know the AMH is not predictive poor egg/embryo quality, just egg numbers. AMH is promising as a way to measure reserve, but there are a few problems, most of us are not comfortable yet using if for a definitive diagnostic tool. In many cases it does give us correct information, but we need to fine tune the testing and result interpretation.
Interesting question. If a clinic is more aggressive in bring patients to IVF early without much other treatment, will their IVF success rates be higher than clinics that get some people pregnant first with clomid or FSH? Will doing IVF on fertile people make a clinic look better? I would say in a few case yes, this makes sense. In fact overall, since IVF seems to work well enough for most people, more people are doing IVF after shorter intervals of clomid or FSH. However it depends on the IVF success rate differences between the 2 clinics. If there is a small difference, I would point to the selection. If there is a big difference, IVF quality is a big part of the discrepancy.
How do you know if the clinic does a good job with blastocyst culture? Try asking what percentage of transfers are blastocyst for your age group, then ask the delivery rates for blast vs. day 3. Of course check their SART statistics. If they have very good pregnancy rates but do much blast, that may be fine. However also check on the number of embryos they put back. If they have good rates with a higher number of embryos returned and a higher number of triplets, that’s not so good. One of the goals of blastocyst culture is to take advantage of the natural selection process so that by day 5 the best embryos will stand out. If we can see which ones are better, we can put fewer in and reduce the odds of multiples, while maintaining higher pregnancy rates.
IUI Questions
When should you do the iui after the trigger shot? Ovulation will take place 36-38 hours after the shot. There is not a specific time that has been shown to be better. The sperm may be available to fertilize for at least 2 days. The egg is good for about 1 day. So it is reasonable to have the iui performed 24 hours after the trigger.
What if it seems on FSH you are ready too early? Even though you may be ready on the early side, the egg or eggs are probably not affected. However, if it is early there is less harm in waiting an extra day or 2 to give the hcg. I have not heard this to be more effective than just giving the hcg at the usual follicle size, independent of the cycle day.
Should you see an RE or should you let your general OBGYN handle the clomid? It depends on your threshold. If it’s really that more convenient and less expensive, and you are not in a super rush, a few months with your generalist is fine. Otherwise, get to the RE.
Donor Egg Questions
One of my most difficult questions. What if you are doing donor egg with a proven donor and your embryo quality is not great, even when splitting the eggs ½ donor sperm, ½ partner sperm? Clearly all avenues have been explored. If you have not already, and wish to continue, consider another opinion. Now I have seen proven donors give disappointing results in subsequent cycles. It is true that a young donor is more likely to make a baby with embryos that don’t look as good, so maybe the proven donor made fair embryos last time and made a baby. We have been surprised when there are pregnancies from poorly looking donor embryos, but thankfully we see it now and then.
Tubal/Uterine Questions
What about a second surgery for a septum, may it be necessary? Occasionally, more likely with a larger septum. Sometimes at surgery the cavity looks fully repaired but an HSG 2 months later shows there is still a good piece remaining. In this case maybe the upper septum scars together making it appear it was never cut. Or maybe it was never cut, which could be for 2 reasons. Maybe the doctor cut and cut and cut and was really pleased and observed there was a little piece left but felt almost it was gone, and that it was ok to leave a little. He may have wanted to avoid cutting too much, which would increase his chances of perforation. And many women do just fine with a small piece left, as long as it is not too big. But leaving a small percentage may still be leaving a substantial amount. To cut more and reduce the odds of perforation, the doctor can use an ultrasound during the surgery to watch the uterus and the septum, to help cut most of the septum but not perforate.
Another reason for finding some septum after the surgery is that there may be times when the pressure of the fluid used to distend the uterus during hysteroscopy pushes the and remaining septum up towards the muscle layer, making the inside of the cavity look smooth and normal. Yet, once the pressure is relieved by removing the fluid, a bit of the septum bulges back down into the cavity of the uterus. This is theoretical on my part, but I am guessing it does happen this way.
If you have proximal occlusion and your tube is opened, will it stay open? If it was really blocked and you have a procedure to have it opened the odds are about 70% that it will stay open.
Thanks for reading and please read the disclaimer from 5/17/06.
Dr. Licciardi
Posted on January 31, 2010 | Filed under Infertility News | Permalink
Again, this entry has many elements that apply to standard fresh IVF cycles.
Here we’re trying to close in on the real question, “If you do egg freezing, will it help you have a baby?”
Well, it will really does help if you can make some eggs. Sorry if that sounds too obvious, but the more you make the better your odds of this whole thing working years down the line. Just as with any IV F cycle, egg production is based on the number of eggs that are still in your ovaries, and how they respond to the medications.
Much of this is loosely related to a woman’s age but there are a number of other factors involved. The dose of drug can have an effect on the number of eggs produced; the more drug the more eggs, but only to a point. In other words, if your ovaries are full of eggs, a dose of 450 units per day may be way too high and lead to danger, but a dose of 225 might get you 15-20 without much of a risk. However, if your egg reserve is marginal, 225 may make 6 eggs, 450 may make 8, but going over 450-600 probably will not get you any more.
There are papers and book chapters written about how to stimulate ovaries to get the maximum response in women with limited ovarian reserve. For today let’s just say that one of the hardest things we do is try to get the ovaries to produce more eggs than they want to. There are numerous stimulation protocols that we try, and sometimes we get more eggs than expected, but sometimes we get fewer. In very many cases, it may be that it wasn’t the doctor’s choice of medications; it was just the woman’s body being more or less cooperative during that cycle.
Testing for ovarian reserve is one way to get a general guess about your response, but it’s not always helpful. A bad ovarian reserve test is not good news; a favorable result does not guarantee results. There are many of you reading this who despise ovarian reserve testing and some of you who have proved doctors wrong, having babies after being rejected for bad day 3 blood tests. I understand this. I think the testing is should at least be performed to give you a general idea about your prognosis so that the expectations can be based on all available information. Included in this is an ultrasound examining the antral follicle count. Again, not a perfect test, but it will help you get closer to answering the question, “Will this help me?”
You will not know about your egg production until after you start your cycle. Let’s say you have had your consultation and testing and things look reasonably positive, so you decide to give it a go. Fine, but you need to know a few more things. Especially if you have never been on the fertility injections before, the number of follicles that you develop will be a mystery until you are on the drugs for 5-8 days. By then your follicles will have begun to grow and your doctor can count them up and let you know how you are doing. Unfortunately, some women will be producing a low number of eggs.
Follicle number does not equal egg number. We see follicles on ultrasound; we get eggs from the follicles. We never really know how many eggs you will get until we try to take them out on the day of retrieval, but we have certain expectations. If we see 10 good sized follicles, we expect to get 8-10 eggs. There are endless examples of variations. For instance, let’s say you are ½ way through the stimulation and it looks like there are 5 follicles. But there may be others that look very small, maybe too small, but over next few days the small ones may catch up, giving you say 9-10 decent follicles on the day of retrieval. Another possibility is that you have 5 good ones and 4 tiny ones at retrieval, and even the tiny ones that never caught up in size, still give up good eggs (this is not typical).
The opposite could also happen. Your doctor may see 10 follicles and only retrieve 5 eggs. How is this possible? It’s not uncommon to have fewer eggs than follicles. Some doctors feel that there are some follicles that do not have eggs in them. I think this is possible but not very common. It may also be that the egg is in the follicle but it just does not come out through the needle. This I think is more common. Generally the egg is very loosely attached to the inside of the follicle, but if it’s stuck to the inside, it may evade the needle.
So how many eggs do you need to have a successful egg freeze (or fresh ivf cycle for that matter)? Again the too obvious answer is the more the better. However 10-15 is a good yield. More than that is a bonus. It is true 30 may be better than 15, but most women do not make 30 so that should not be your goal. Estimates in the 10-15 range usually do not prompt much patient/doctor discussion, however when the estimate is lower, the talks become more frequent and important.
Usually your doctor is close enough with the pre-retrieval estimate, so assume it will be close. If a low number is estimated you will need to make a decision, with the help of your doctor, about having the retrieval or not. Yellow flags should rise if you are told there are less than 10 follicles, and red flags should rise if you are told there are 5 or less.
Overall there is just no absolute egg number cut-off for cancellation. Some programs may have strict guidelines, but most do not. We all understand the dilemma. If there are few, your odds of success are lower, however if there are few, it means your fertility may be passing. Getting, say, 4 eggs now may be better than nothing, because as months pass, you may make fewer in the future. Stopping without the retrieval, and restarting in a short amount of time, using a different protocol, would probably be the best choice. However, even with making changes you may have the same or even fewer next time. Now I picked 4 follicles as just one example, but the discussion needs to be tailored for 3,5,6,7 etc. Your age, previous response and your desires all need to be taken into account each time.
Your doctor needs to take the information above and formulate your chances of not just getting eggs, but of getting a baby from your egg freeze cycle. This applies to all cases, good egg production or not.
You will get the most accurate information if you are using an egg freezing practice that has results, not just freezing experience. Experience and results with the thaw and transfer is very important; you need a program with a track record. You need to know their experience in going from eggs to babies. Many busy egg freezing programs have no results because they have not thawed any of their eggs yet. Others have done less than a handful of cases.
I do want to refer you to the NYU Fertility Center web site section on egg freezing.
http://www.nyufertilitycenter.org/egg_freezing.
Spend some time going through all of the pages, the information is very helpful.
Thanks to the fantastic research and efforts of the doctors listed there, NYU is known for its egg freezing practices and results. I could summarize the site here, but in the interest of accuracy, go directly there to get it from the horse’s mouth. The results are frequently updated.
The breakthrough, as mentioned on the site, is that we believe that our egg freezing success rates will remain similar to our fresh IVF success rates. Therefore, it will help if you have your eggs frozen at a program with excellent fresh IVF pregnancy rates. If their fresh IVF rates are low, their egg freezing rates will probably be low too.
Not all egg freezing programs can show good data to support good results (2 out of 4 pregnant is not enough.) There are a few who can, so if you are interested in egg freezing, you need to seek out the good ones. Details are sparse, so I really only know about NYU. Odds are there is not a quality program near where you live, so if you can swing it, it may be worth traveling.
Even the NYU rates need to be clarified. Most of the studies at NYU and elsewhere on egg freezing have been performed with good prognosis, younger women. We are not positive that older women’s eggs will freeze and thaw well. They probably will, but there is no data yet to prove the case. We don’t know how long eggs will last in the freezer. We do know there have been children born from sperm and embryos frozen for over a decade, so eggs should be able to last at least as long, but again there is no proof yet. Egg freezing is very new and still considered experimental you do need to freeze your eggs at the right place.
We and other doctors can not completely predict the landscape 5-10 years down the road. We are optimistic that our pregnancy rate estimates are correct. However there is a chance that due to unforeseen circumstances, the rates will be lower. You just need to know this going in. It may also be possible that the outcomes will be better than we had hoped.
Next time we will cover what you should know about what happens after the eggs are retrieved and how the cost structure works.
Thanks for reading and don’t forget to read the disclaimer entry 5/17/06.
Dr. Licciardi
Posted on January 17, 2010 | Filed under Infertility News | Permalink
Again, this entry has many elements that apply to standard fresh IVF cycles.
Here we’re trying to close in on the real question, “If you do egg freezing, will it help you have a baby?”
Well, it will really does help if you can make some eggs. Sorry if that sounds too obvious, but the more you make the better your odds of this whole thing working years down the line. Just as with any IV F cycle, egg production is based on the number of eggs that are still in your ovaries, and how they respond to the medications.
Much of this is loosely related to a woman’s age but there are a number of other factors involved. The dose of drug can have an effect on the number of eggs produced; the more drug the more eggs, but only to a point. In other words, if your ovaries are full of eggs, a dose of 450 units per day may be way too high and lead to danger, but a dose of 225 might get you 15-20 without much of a risk. However, if your egg reserve is marginal, 225 may make 6 eggs, 450 may make 8, but going over 450-600 probably will not get you any more.
There are papers and book chapters written about how to stimulate ovaries to get the maximum response in women with limited ovarian reserve. For today let’s just say that one of the hardest things we do is try to get the ovaries to produce more eggs than they want to. There are numerous stimulation protocols that we try, and sometimes we get more eggs than expected, but sometimes we get fewer. In very many cases, it may be that it wasn’t the doctor’s choice of medications; it was just the woman’s body being more or less cooperative during that cycle.
Testing for ovarian reserve is one way to get a general guess about your response, but it’s not always helpful. A bad ovarian reserve test is not good news; a favorable result does not guarantee results. There are many of you reading this who despise ovarian reserve testing and some of you who have proved doctors wrong, having babies after being rejected for bad day 3 blood tests. I understand this. I think the testing is should at least be performed to give you a general idea about your prognosis so that the expectations can be based on all available information. Included in this is an ultrasound examining the antral follicle count. Again, not a perfect test, but it will help you get closer to answering the question, “Will this help me?”
You will not know about your egg production until after you start your cycle. Let’s say you have had your consultation and testing and things look reasonably positive, so you decide to give it a go. Fine, but you need to know a few more things. Especially if you have never been on the fertility injections before, the number of follicles that you develop will be a mystery until you are on the drugs for 5-8 days. By then your follicles will have begun to grow and your doctor can count them up and let you know how you are doing. Unfortunately, some women will be producing a low number of eggs.
Follicle number does not equal egg number. We see follicles on ultrasound; we get eggs from the follicles. We never really know how many eggs you will get until we try to take them out on the day of retrieval, but we have certain expectations. If we see 10 good sized follicles, we expect to get 8-10 eggs. There are endless examples of variations. For instance, let’s say you are ½ way through the stimulation and it looks like there are 5 follicles. But there may be others that look very small, maybe too small, but over next few days the small ones may catch up, giving you say 9-10 decent follicles on the day of retrieval. Another possibility is that you have 5 good ones and 4 tiny ones at retrieval, and even the tiny ones that never caught up in size, still give up good eggs (this is not typical).
The opposite could also happen. Your doctor may see 10 follicles and only retrieve 5 eggs. How is this possible? It’s not uncommon to have fewer eggs than follicles. Some doctors feel that there are some follicles that do not have eggs in them. I think this is possible but not very common. It may also be that the egg is in the follicle but it just does not come out through the needle. This I think is more common. Generally the egg is very loosely attached to the inside of the follicle, but if it’s stuck to the inside, it may evade the needle.
So how many eggs do you need to have a successful egg freeze (or fresh ivf cycle for that matter)? Again the too obvious answer is the more the better. However 10-15 is a good yield. More than that is a bonus. It is true 30 may be better than 15, but most women do not make 30 so that should not be your goal. Estimates in the 10-15 range usually do not prompt much patient/doctor discussion, however when the estimate is lower, the talks become more frequent and important.
Usually your doctor is close enough with the pre-retrieval estimate, so assume it will be close. If a low number is estimated you will need to make a decision, with the help of your doctor, about having the retrieval or not. Yellow flags should rise if you are told there are less than 10 follicles, and red flags should rise if you are told there are 5 or less.
Overall there is just no absolute egg number cut-off for cancellation. Some programs may have strict guidelines, but most do not. We all understand the dilemma. If there are few, your odds of success are lower, however if there are few, it means your fertility may be passing. Getting, say, 4 eggs now may be better than nothing, because as months pass, you may make fewer in the future. Stopping without the retrieval, and restarting in a short amount of time, using a different protocol, would probably be the best choice. However, even with making changes you may have the same or even fewer next time. Now I picked 4 follicles as just one example, but the discussion needs to be tailored for 3,5,6,7 etc. Your age, previous response and your desires all need to be taken into account each time.
Your doctor needs to take the information above and formulate your chances of not just getting eggs, but of getting a baby from your egg freeze cycle. This applies to all cases, good egg production or not.
You will get the most accurate information if you are using an egg freezing practice that has results, not just freezing experience. Experience and results with the thaw and transfer is very important; you need a program with a track record. You need to know their experience in going from eggs to babies. Many busy egg freezing programs have no results because they have not thawed any of their eggs yet. Others have done less than a handful of cases.
I do want to refer you to the NYU Fertility Center web site section on egg freezing.
http://www.nyufertilitycenter.org/egg_freezing.
Spend some time going through all of the pages, the information is very helpful.
Thanks to the fantastic research and efforts of the doctors listed there, NYU is known for its egg freezing practices and results. I could summarize the site here, but in the interest of accuracy, go directly there to get it from the horse’s mouth. The results are frequently updated.
The breakthrough, as mentioned on the site, is that we believe that our egg freezing success rates will remain similar to our fresh IVF success rates. Therefore, it will help if you have your eggs frozen at a program with excellent fresh IVF pregnancy rates. If their fresh IVF rates are low, their egg freezing rates will probably be low too.
Not all egg freezing programs can show good data to support good results (2 out of 4 pregnant is not enough.) There are a few who can, so if you are interested in egg freezing, you need to seek out the good ones. Details are sparse, so I really only know about NYU. Odds are there is not a quality program near where you live, so if you can swing it, it may be worth traveling.
Even the NYU rates need to be clarified. Most of the studies at NYU and elsewhere on egg freezing have been performed with good prognosis, younger women. We are not positive that older women’s eggs will freeze and thaw well. They probably will, but there is no data yet to prove the case. We don’t know how long eggs will last in the freezer. We do know there have been children born from sperm and embryos frozen for over a decade, so eggs should be able to last at least as long, but again there is no proof yet. Egg freezing is very new and still considered experimental you do need to freeze your eggs at the right place.
We and other doctors can not completely predict the landscape 5-10 years down the road. We are optimistic that our pregnancy rate estimates are correct. However there is a chance that due to unforeseen circumstances, the rates will be lower. You just need to know this going in. It may also be possible that the outcomes will be better than we had hoped.
Next time we will cover what you should know about what happens after the eggs are retrieved and how the cost structure works.
Thanks for reading and don’t forget to read the disclaimer entry 5/17/06.
Dr. Licciardi
Posted on January 12, 2010 | Filed under Infertility News | Permalink
Hello to everyone again.
This blog is a segue into Egg Freezing. I realize that for most of the infertility community, egg freezing is not applicable, but I do get many questions about it. Plus, I suspect that many of you are the family fertility experts or the neighborhood fertility pros, unfortunately your struggles have made you experts, and you too may face questions about the topic. Some of this also applies to regular IVF, so it’s worth a read through.
If you wish you can start with the blog from 3/11/08, which goes over many of the basics and positive aspects of egg freezing.
I am writing today because a good understanding of IVF and egg freezing requires you to know the fine print. It’s not that the fine print is bad news; it’s just part of the full disclosure. This installment will deal with drug and procedure complications of IVF, which also applies to egg freezing. More specific egg freezing blogs will follow.
From a patients perspective, 95% of egg freezing is just like any other IVF cycle, which is summarized as follows. A woman takes 1-2 hormonal injections per day for about 2-3 weeks (depending on the protocol), and during that time she needs office monitoring, about every other day, where blood tests and ultrasounds are performed. We use the information from the monitoring to adjust the drug dose if necessary and to tell us when the right time is to remove the eggs. Once the time is right, a retrieval is performed. This is a procedure done usually in the office, but some programs have it done in their hospitals. It’s done under intravenous sedation, which means the woman is totally asleep, feels and remembers nothing, but is not intubated and breaths on her own. Using the ultrasound for guidance, a needle is passed through the vagina, into the ovaries and into one follicle at a time. A suction machine pulls the fluid from the follicle into a test tube, and in the fluid is one cell that’s the egg. Usually eggs are retrieved from follicles on both ovaries.
The test tube gets handed to the embryologist in the adjacent lab, who finds the egg in the fluid and then does the rest.
The retrieval procedure takes about 20 minutes, and when done you wake up right away. You are watched in the recovery room for one hour, and off you go home. The next day you would get a phone call to confirm the number of eggs that were retrieved and the number of eggs that were frozen (yes, in many cases there is a difference).
Sounds pretty simple? For most women but not all, it actually is relatively easy, but it requires time and of course money (we’ll get to that).
There are potential complications with any IVF or Egg freeze IVF cycle, but they are rare.
One is ovarian hyperstimulation. This is where the ovaries are very sensitive to the medications and become too large. Normally, the unstimulated ovaries are about the size of walnuts, and the medications may make them the size of lemons. This can be a good thing because if you are going through the trouble of the procedure, you would like to get as many eggs as you can, but within reason. Problems occur when the ovaries become too large, whereby they may leak fluid, and this fluid can spread to the abdomen and lungs and result in hospitalization. Very sick women may develop problems with their liver and kidneys and be at a high risks for blood clotting in their legs, lungs and other places.
What is happening is that as the fluid goes to places it’s not usually found, it leaves the circulatory system, making the blood thicker than usual. So there is too much fluid in the abdomen, but not enough in the bloodstream. The treatment keys are properly managing the fluid imbalances. If there is extra fluid in the abdomen or lungs, drainage is usually appropriate. If the blood becomes too dry, we need to add a little fluid there.
I realize this sounds hideous, but in fact severe ovarian hyperstimulation is very very rare in IVF and even rarer in women who freeze their eggs. Early pregnancy makes hyperstimulation worse, and since no immediate pregnancy will become of egg freezing, the odds of hyperstimulation become remote. I’m not saying it can’t happen, and mild and moderate forms of hyperstimulation are more common, but severe forms would be exceedingly rare. Plus a good infertility clinic should be able to treat this complication safely.
Still with me? What about the retrieval?
Well there’s the anesthesia. In my 20 years of being involved with 15,000 plus cycles, I have never seen a complication related to the anesthesia. Next topic.
What else? Well, we do push a needle into the abdomen, so there is a potential for bleeding and infection. The odds of needing a transfusion are less than 1 per thousand. The odds of getting a significant pelvic infection requiring hospitalization and IV antibiotics are similarly low. Women with a history of pelvic infection should receive prophylactic antibiotics at the retrieval to reduce their risk, because women with a past infection are more likely to get a second.
And then there’s torsion. The ovaries are inside your pelvis hanging by their blood vessels, not too different from the way testicle hangings on the outside. As the drugs increase the size of your ovaries, they get heavier and may make them more prone to spinning around, twisting the vessels and chocking off the blood supply. You would know this is happening because it causes severe pain and nausea. Torsion can happen before the retrieval or after. It can even happen 1-2 months into the pregnancy (the ovaries of pregnant women may remain large for a couple of months after the drugs are stopped. This is because the hCG from the pregnancy stimulates the ovaries to retain their cysts to make more progesterone until the placenta takes over).
Of course for egg freezing, there is not an increased risk of torsion during a pregnancy because the pregnany will get started with the ovaries normal sized. Ovary-enlarging fertiltiy drugs are not used for the thaw cycle.
Torsion is rare event, occurring in less than 1 in 1000 cases. The ovary can be untwisted via an emergency laparoscopy. If it is untreated, the ovary can die from lack of circulation. However, we have not had this happen to anyone. The key is to call your doctor if you have pain. Losing an ovary does happen with torsion, but the usual scenario here is pain in a woman who is not undergoing fertility treatment, but develops any type of ovarian cyst that enlarges the ovary. Typically, she has pain for a while and is told to wait and see, and then she finally is told to go to the busy emergency room where she is given pain medications. Then many more hours go by waiting for the GYN consult, and by the time they get her to the operating room it’s too late. In the infertility world, your first phone call sets off the alarms and you are evaluated and treated in plenty of time.
And there the ectopic pregnancy. Check out the the ectopic bogs starting 5/31/07.
So that’s the yucky drugs and needles part.
Next time we talk about the pitfalls of egg freezing will try to answer the question, “Will egg freezing help me?”
Thank you, and please read disclaimer 5/17/06.
Happy Holidays!
Dr. Licciardi
Posted on December 22, 2009 | Filed under Infertility News | Permalink
Hello again. Here is the latest entry.
Can a small hydrosalpinx prevent pregnancy? Yes it can and it can prevent pregnancy when trying on your own or with iui (assuming the other tube is normal) , or with IVF. Now a small one is less likely to be problematic, but the studies showing hydros are a problem do not differentiate between small and large. It is not mandatory that hydros be removed, but the pros and cons of removal should be discussed with your doctor.
Does a 44 yo a woman who makes 14 eggs have a higher pregnancy rates than most women in her age bracket? Absolutely. For women in their 40’s, egg number is strongly related to odds of conception. It may be that bigger the reserve the healthier the eggs are in general, or it may be that the more you have, the high the chances of finding at least one good one. This is less important in younger women, whose odds are good even with a lower egg number.
Should you have a second laparoscopy soon after a first in order to do more fixing and cleaning up? These are options but there are others. Back in the day before IVF worked well, this scenario was common, but today if the first laparoscopy looks that bad we recommend IVF. Now this does not mean surgery should be out of the question, it’s just that odds are if the pelvis is so bad, a second surgery will not help much. You really have to try to get a sense of what the doctor feels the improvement will be after a second surgery vs. IVF. If IVF is not an option for you, then the surgery may make sense. It’s a little strange that all of the fixing up was not performed at the first surgery, but there may have been very good reasons for stopping the first time.
Why give 5,000 units of hcg instead of 10,000, and are there any problems with this? It has to do with hyperstimulation. You cannot have significant hyperstimulation without the hcg injection. The hcg stays in your system for at least 10 days, stimulating and stimulating the ovaries to make progesterone, but the stimulation keeps the ovaries big and can push them to hyperstimulate. So it makes sense to maybe give less if we are worried about hyperstimulation. If we give half the dose we may be lowering your risks. Again, makes sense, however, I have not seen much written showing that ½ the dose is any safer. It is possible that if you try to take less you will not get enough. Now if you have a good vial that really has 10,000 units, and you are a good mixer, then ½ the dose should be enough. But it may be that some vials do not contain the full 10,000 units. Sometimes the extra mixing instructions are just too confusing and for one of a number of reasons 5,000 units do not make it into the syringe and into your body. This is why we measure the hcg level the day after the hcg injection. A few times per year someone in our practice has a blood level of the zero the day after the injection. The most common reason for this is the injection of air, which occurs by not putting the needle into the liquid before withdrawing. The second most common problem is the injuction of water only, which happens if you forget to mix in the powder. Believe me, both of these happen mopre than we would like. The water only problem can’t happen when using the premixed. Sometimes the there is some hcg in the blood, but the level is really low. If we get numbers under 50, we give another shot but go with the original retrieval time. If the level is zero, we give the hcg that evening and make the retrieval one day after the original day.
Can you exercise while trying to conceive? Sure. However you cannot if your ovaries are enlarged from fertility drugs. If you are unsure when the stopping time is, ask your doctor every time you have a scan.
I am reposting this question because it’s really well written and it applies to a large number of fertility patients who are starting out. My comments are in bold:
So my hubby and I have been doing infertility testing for a year. I had a miscarriage at about 7 weeks about 2.5 years ago and have been unable to get pregnant since. I did a 6 month study through the national institute of health where they gave me either a placebo or low-dose aspirin and a fertility monitor, all with no success of pregnancy. My hubby’s done 3 semenalyses, (which have proved to be normal. . . he had an abnormal count of about 30% on one, but the rest were fine and the counts were fine), we both did the antisperm/antibody test most of us to not do this test, it just has not been shown to be helpful which turned out normal, he did the hamster test and got 100% penetration never done anymore, an ultrasound which proved to be normal good, as well as blood tests for both of us that have proved to be normal.
My cycle varies between 25-33 days, but always falls within that window, just varying lengths within that window no problem. I recently did an HSG test and it showed no blockages excellent.
Our next step in the process is a post coital test antiquated, a blood draw at a certain point in the cycle, and a sample of my uterine lining antiquated to see if it’s thick enough at that point in the cycle to be viable for a baby.
My dr. said that at that point, if everything’s normal, we can proceed with IUI. However, he did say that we should consider doing a laparoscopy to check for possible endometriosis. He said that even though my HSG test was normal that if I had endometriosis it could possibly flare up and die down. I’ve always experienced mild cramps for 1-2 days on my cycle but isn’t that normal? He said cramps could be indicative of endometriosis. I have no problems with doing a laparoscopy if it weren’t for the cost. . . $2500. I’m just wondering if with everything else positive if mild cramps being my only symptom are enough to warrant the cost of checking it out, or if it’s something that won’t affect my fertility too much. This is acceptable medical practice, however you need to ask about the payoff. If the hsg, exam and ultrasound are normal, the odds of having endometriosis are very very low. Actually the odds of finding a little endometriosis are about 10% because that’s the baseline rate in all women, but the odds of meaningful endometrioses that has grown to the point of interfering with you getting pregnant are very low. Now that’s not to say that the laparoscopy is not an option, but I would get a second opinion if you wish.
As far as my comments on the antiquated tests, again acceptable medical practice, but a little out of date. It does seem that your doctor is organized and at least has a plan.
If you are a little older and had a chromosomal miscarriage, should you be discouraged from trying again? I don’t think so. Yes the odds of miscarriage increase with increasing age. Most pregnancies, even in women in their early 40’s go to term. The miscarriage rate is high, but there are more babies than miscarriages.
Should you take any steps to shorten the follicular phase? If your cycles are far apart, it just makes it harder to conceive because you get fewer chances per year than most people. Another problem is that it’s hard to know when ovulation is taking place, so timing can be an issue. However, I am not aware that the egg quality is compromised in a long cycle. If you can time it well, the odds are the same as in a more normal cycle, and I have not heard that the miscarriage rate is any higher. So most do correct a long cycle to make it shorter, but it’s not because we are trying to control embryo quality.
How are polpys diagnosed? Ultrasound or HSG or sono-hysterogram (this last one is where the doctor uses a speculum and squirts a little water inside the uterus while doing the ultrasound. This really helps see small defects in the uterine lining, like polyps). I have found through the years, especially as the quality of the ultrasound machines have improved, that a careful vaginal ultrasound works quite well. HSG has been OK, but it misses small polyps. The sono-hysterogram is probably the best test because it finds the smaller ones, but if the uterus looks perfect on regular ultrasound there is only a small benefit to having the sono-hysterogram.
Day 7 blastocyst? If day 6 works why wouldn’t at least some day 7s?. I have not had any patients use day 7 embryos. It’s suboptimal. Maybe as we get more experienceday 7 will become useful. One problem may be that a good embryo will be hatched out of it’s shell by day 7, which may or may not be a problem. .
IVF during breastfeeding? It can work but I don’t know if the breastfeeding affects your chances of success. Yes most fertility drugs are the same hormones that are already circulating, but taking the drugs will increase their concentration in breast milk.
After chemo, if the sperm counts are ok, is the sperm ok? This is tough to answer. My feeling is that it is, but it’s just a feeling. You will certainly get different opinions from different doctors. I have not met any doctors who do not want the husband to use the sperm, but there could be some out there. The doctors may inform the husband that there may be unknown issues.
Translocations: is IVF the only way to have a healthy child? No. Pregnancy and delivery on your own is possible. The stats on this are tricky because most embryos that are created from a couple where one partner is a translocation carrier are abnormal. However, most abnormal embryos do not implant, so if there is implantation, odds are its normal (not 100% and the odds depend on if the translocation is maternal or paternal). You really need a genetic counselor to give you more specific numbers and more of an explanation. IVF with PGD will help, however, it’s expensive and tedious, and does not guarantee a pregnancy, or even a transfer. That being said, there are patients with translocations who are only interested in IVF with PGD.
If I am not crazy about PGD for genetic screening (for Down’s syndrome and the like) , how do I feel about PGD when you know when you have a specific disease (such as CF or hemophilia)? I feel much better. PGD works better in such cases.
Cervical stenosis: good idea for a blog, but yes it can be a cause of infertility.
If the semen analysis is abnormal, always repeat it. Sometimes the minor abnormalities just go away.
What if you go for the hsg and the cervix is closed? If you get a period, your cervix is not closed. There are different ways to do the hsg and one involves putting a tube through the cervix and into the uterus. This is at times difficult or impossible to do because the cervix may not be completely closed, but narrow. The better way is not to put the tube in and just squirt the fluid up the cervix. The cervical canal acts as the tube and brings the dye up into the uterus. In this case, there is a much lower chance of running into “stenosis” issues.
Thanks again and please read the disclaimer 5/17/06.
Dr. Licciardi
Posted on December 13, 2009 | Filed under Infertility News | Permalink
Hello to all,
Here is your latest entry.
What if I have had miscarriages but my HSG and clotting tests are normal? Make sure you get the karyotype test, the blood test to check your chromosomes.
What if your partner recently had a vasectomy reversal and the motility is only 20% with poor morphology. Will these numbers improve with time? Hard to say. If there is not much improvement in 6 months, there will probably not be much change after that.
Are there any tests to explain poor embryo quality? At this time there are none. We don’t know why within a batch of embryos, some look good and others do not. We don’t know why some women make nicer embryos than other women.
What about shared risk IVF programs? They have their pluses and minuses. The name is deceiving. It sounds like your doctor is somehow contributing to and sharing your financial burden, but this is not the case. Shared risk means the other patients in the program are all sharing the risk. The price of shared risk in many cases does not include all of your costs. It’s all figured out mathematically. Some patients will end up pay less, some pay more, but what the average a person pays in most shared risk programs is the same the average person would pay without the program.
Are there options other than IVF ICSI with 6% motility? Realistically; no. Miracles can happen. We don’t know why but to get pregnant on your own, your need millions of moving sperm. Even IVF without icsi requires millions, although not as many as you need for a natural pregnancy.
What if you are young and have had 4 unexplained miscarriages and your workup is normal? Facing another pregnancy and miscarriage sounds impossible to you, and your doctor says there are no other tests? The unemotional cold hard fact is that trying again is the only real option and the odds are that the next pregnancy will be successful. Your miscarriage risk is higher than others without your history. I’m not saying trying again is the best thing for you, I understand why you may not want to.
Mini IVF. It has its place. Things to watch out for are any hidden costs, which could be high. There is a higher chance that there will be no egg retrieved. You really need to know what the deliver rate is for people your age. The “pregnancy rate” is not the delivery rate. There are different versions of mini IVF. Most involve clomid, but sometimes low doses of injections are added. Also be careful about the freezing option. Many times the doctor will say the lining is not right and he wants to freeze the embryos, so they can be transferred when the lining is more favorable. This gets a mini Arghh. Mini IVF has a lower pregnancy rate and freezing embryos probably makes the rates lower still. Plus if the goal of mini IVF is to save money, it seems that the costs will add up between the cycle, the freeze and the frozen transfer.
What if you have been offered frozen donor eggs (not embryos). This could be a good option. Ask for details (not an estimate) about success at your clinic. If they do not have good results from at least 10-15 thaws, you may want to reconsider. People in the field feel all of donor egg will be using frozen eggs in the near future, although today the science is still new.
Should you consider a surrogate if you have had 2 failed fresh DE cycles, one with a proven donor? If you have no uterine issues i.e. a nice lining and no scaring/previous surgery, the added benefit from a carrier will be minimal. However, if you have access to a good carrier and are open to the idea it is not unreasonable to at least explore the option.
What if you only have access to insemination M-F? Not great. Most of the time there is room for getting inseminated a little early or late, but having weekend services available to you is much better.
Does natural cycle insemination increase your odds of twins? No. Twins come from 2 or more eggs and in the natural cycle, usually only one is produced.
What if you have pain and your doctor is not listening? Maybe your doctor does not feel that you have a pelvic problem that requires further evaluation because your exam and ultrasound are normal, and she does not feel a laparoscopy is right for you. If that’s the case your doctor needs to at least give you another complete exam and a repeat the ultrasound, and then needs to discuss your options. She needs to let you know what she is thinking and visa versa. If you can’t get this with her, try someone else.
What if you are 41, and have gotten pregnant easily twice. Is there an advantage to going to IVF? Theoretically yes because if you have more than one embryo to transfer you will increase your odds of success. The dilemma is that you are getting pregnant on your own easily, which does not necessarily mean you will get pregnant easily with IVF. If you decide to try on your own again, get help quickly if you don’t get pregnant soon.
What if you have stage 3 endometriosis and have not become pregnant with a few iuis? You should consider moving to IVF sooner than average. Pregnancy even without drugs is certainly possible, but the odds are lower because of potential tubal issues related to the endometriosis.
What about stress management programs to increase the odds of conception? I think these programs are extremely helpful. I started the NYU Fertility Center Wellness Program, which incorporates acupuncture, mind-body and yoga into our practice. I don’t like selling these things as ways to get you pregnant, because more research needs to be done. But they are very beneficial for stress management and treatment tolerance.
What’s better for low sperm counts, IVF/ICSI or donor sperm? Donor sperm is a lot easier and cheaper and may lead to a quicker pregnancy. That being said, most people prefer partner’s sperm, IVF and ICSI.
Could a hydrosalpinx prevent pregnancy? The answer is yes. A publication of the American Society of Reproductive Medicine states that a hydrosalpinx can lower pregnancy rates by as much as 50%. I think it’s closer to 30%. Many years ago I would remove a hydrosalpinx in any woman wishing to attempt IVF. More recently I let people know that a hydro will lower the odds in some women but not all, and with the hydro the odds are still good. So I let them decide if they want the surgery prior to IVF. Having a hydro will increase the chances of an ectopic pregnancy with IVF. Hydros can be a problem even if you are not yet a candidate for IVF. In other words if one tube is normal and the other a hydro, removing the hydro may help you get pregnant on your own.
What if you are 44 and were told the chances of IVF are 5%, but you make 14 eggs and have nice embryos? Are your odds higher? Yes they are. Most, but not all, women who get pregnant in their mid 40’s are lucky enough to make a high egg number. The more the better.
What if you were just diagnosed with terrible endometriosis and are offered Lupron? There are no good studies showing Lupron will take away any of the endometriosis or improve scarring. The story is different for pain; Lupron can help tremendously with that.
How to find the best IVF clinic? Start with SART.org and look up the pregnancy rates for your age group. The tables are a little hard to read, go to the line that says live births per retrieval. After that it’s about chatting it up in person and on line.
What if you are obese and the doctor is worried about doing IVF in the office safely? Different doctors will have different thresholds for maximum weight. Some are more relaxed when dealing with very obese patients. So get more opinions. Some IVF centers do their retrievals in the hospital, and they may be more eager to treat you. At 26 you do have time to lose weight before you start, which would be better for the baby. There is new data every day on the detrimental effects of obesity on the fetus. The old saying”you are what you eat” has been replaced by “you are what your mom eats.”
What if you have a 2 cm endometrioma on your ovary? As long as they are sure that’s what it is, and it’s not another type of tumor, a 2 cm endometrioma will not hurt your chances of conceiving with IVF.
What next? You are young and have had a baby then 3 miscarriages, the workup doesn’t show much. Too many women have been hit with similar issues. It’s all about the tough decision to continue. If you get pregnant again, odds are that you will have the baby. However the thought of facing another loss sometimes overwhelms us. I try to encourage more attempts, but it’s your decision in the end.
Thanks for reading and read the disclaimer 5.17.06.
Dr. Licciardi
Posted on November 17, 2009 | Filed under Infertility News | Permalink
Hello Again. I will spend the next few blogs catching up on questions. It’s been a while and I see that many were time sensitive, so I am sorry if missed your immediate problem. I’ll try to keep more up to date. One problem is that not all readers like the questions, but I like doing them, and if I make the answers relevant to a group of people, I think they work for a larger group of people. I got caught up in a bunch of topics that I wanted to cover, but for now, back to the questions.
What if you are young, make many eggs and embryos, have very nice quality, a normal uterus and are not getting pregnant? Could it be an implantation issue related to the uterus? Chances are this is not the case. Your doctor may be right, it could be bad luck. It could also be that you need to try another IVF clinic. It could also be there is some unknown genetic problem with your eggs or sperm, but the answer here is years away. Some would consider PGD in this case, but it is questionable if it would help.
If you do clomid, do you need to wait 2 weeks and provera to start? No. Your doctor wants 2 things. He wants you to bleed before the clomid, and he wants you not to be pregnant when you take the povera or clomid. There are ways around this. If you have not bled in many many months, it’s not a bad idea to get a period to start, so provera is not a bad idea. If you have had a period in the past few months, provera is probably not necessary. To be sure you are not pregnant; you can just do a progesterone blood test. You can’t be pregnant if you never ovulated, so if your progesterone is very low, it’s ok to start the clomid (if your doctor says it’s ok). If it’s high, you did ovulate, and you will need to wait less than 2 weeks for your period. If your period does not come, do a pregnancy test.
What if you were diagnosed with stage one enodmetriosis and were told to take Lupron for 3 months. Here is today’s ARGHHHHHHHHHH!!!!!
No one has ever shown that being on Lupron after surgery does anything to reduce endometriosis or improve pregnancy rates. It works like this. Endometriosis grows from estrogen; when Lupron takes away the estrogen the endometriosis stops growing. But Lupron does not kill the endo, it just suppresses it. So once the lupron is stopped, the endometriosis goes right back to where it was. Yes staying on the lupron will take away pain, but once the lupron is stopped, the pain comes right back. So the 3-6 moths of lupron will not help you become pregnant, it just makes you older and more frustrated. A new endometrioma should not appear on Lupron. If the cyst was not well removed at surgery, it can reappear, even if on lupron.
Is a large clot during the period a problem? Probably not. A very large clot is probably not coming from the uterus. It’s from fresh blood that flows from the uterus into the vagina, then sits there and clots. If you think overall the amount you are bleeding is excessive, there could be issues related to fibroids, polyps, etc.
Do we know more about Unexplained Infertility? The problem with writing about unexplained infertility (UI) is that patients are put in the category of UI only after the things we know about have been excluded. It is true that in the past many years, no new meaningful tests have been developed to get people out of the UI group and into one of the groups that are explained.
What if you have severe endometriosis and are not getting pregnant with IVF. Women with endometriosis do make few eggs than average, but 16 is plenty. Should you go to another IVF center? Look up their stats at SART.org. If the numbers look good, stay, if not, get another opinion. Genetic testing is always an option. With a mostly normal family history, the odds of a chromosomal problem are 1-3%.
What if you are 37-38 and your FSH is very normal buy you only make 4 eggs? Well FSH is not the whole story. It’s a good guide but if your number is low, it doesn’t mean you will definitely make many eggs. If you are starting on 2 Follistim and one Menopur, there is definitely room to increase your dose, which could make a difference.
What about a poor responder with normal FSH levels and antral follicle counts? Our pre cycle predictions don’t always match what we get during the cycle. Estrogen prime is probably as good as day 2 start. But if you have tried one, it makes sense to try the other next time.
What if you spot for 51 days straight? You need a pregnancy test and an ultrasound. Things may be just fine but there could be problems with ovulation (or non-ovulation) or uterine issues.
Are frozen embryos any worse because of ICSI? If they were frozen on day 3, is it ok to they and transfer day 5? Yes it is. ICSI will not negatively affect the embryo’s ability to grow from day 3 to day 5 after the thaw, depending on the labs experience with day 5 culture.
If you have regular cycles can you have mild PCO? No, because by definition, PCO women have irregular or lengthy cycles. Now this does not mean you can’t have ovaries that have a high number of eggs and follicles. So your ovaries can look like they are pco, but you don’t have a disease or syndrome. It also means that clomid could still be indicated, even if you do not have PCO.
Someone actually had a conversation with her doctor and he paid attention, and now she is pregnant. One of the most important things I learned in medical school was, “If all else fails, listen to the patient”. “When all else fails examine the patient” is another good one.
Should you have the laparoscopy or do the IVF? It would be easy to answer of either could get you pregnant right away. With a family history of endometriosis and severe cramps, and infertility, a laparoscopy is very reasonable. On the other hand, if you are a good candidate for IVF, the pregnancy will do a good job in suppressing your endometriosis, and some women have a permanent reduction in endometriosis pain after a pregnancy. If your tubes are open on HSG, and there are no endometromas of your ovary (ultrasound visible cysts of endometriosis), the odds of meaningful endometriosis (endometriosis severe enough to be preventing pregnancy) are low.
What about the third biochemical pregnancy in a row? The testing is normal so far. Here are just a couple of suggestions. If you and your husband did not have the blood karyotype test, that should be done. Even though you had a laparoscopy, consider a hysterogram.
After testicular surgery, will a sperm count of 18 million and 20% motility improve with time? It could go either way. At 31 you have few more months to see. Getting pregnant on your own with these numbers is not unheard of, but it may take longer.
I think I should have more frozen embryos. It is very disappointing to have 17 eggs, 12 embryos , 2 for transfer and none to freeze. There could be a few reasons related to the lab for this. If they transfer on day 3 and wait till day 5 or 6 to freeze, they may not have enough experience going to day 5, if they did they would do more fresh transfers on day 5. It’s also possible that the embryos look fair on day 5 and they just do not want to freeze them. There are 2 elements to this. One is a cycle using frozen embryos has a lower pregnancy rate than a cycle using fresh embryos, and that’s when using embryos that look very nice when they are frozen. So if you freeze embryos that are marginal looking, the pregnancy rates will be even lower, and many times not worth the freeze. The other element is that some programs are too restrictive on the quality of the embryos they freeze. I other words, they want their frozen rates to be high. One easy way to do this is to just freeze the really nice embryos and not the ones that look ok or worse. Lastly, it is possible you have some average or good embryos to transfer and all of the others are not really that nice. It may have nothing to do with the lab. Modifying your protocol may possible improve the quality of the lot.
We do not recommend amnio based on just ICSI. However, every case is different. For some, amnio may be indicated.
We have never dealt with a day 7 embryo.
Progesterone orally or vaginally? For IVF we use IM because we had some bad experiences with vaginal. However that was years ago, and maybe the preparations are better now (that’s what’s claimed). The oral is too unreliable to be used alone. If we use oral, it’s in combination with vaginal. Oral progesterone may make you very tired or dizzy.
What if you ovulate every month and on clomid, nothing, no ovulation? Yes indeed, this can happen. Why, we do not know, but it is pretty rare. If you are taking estrogen with the clomid, the estrogen may stop your cycle (like the birth control pill ) . But otherwise, we really don’t know why. If you take clomid another month, odds are you will ovulate. These types of problems usually do not recur.
Is it bad to switch doctors because the first doctor has your history? No not at all. We can all tell exactly what’s going on with you by listening to you in person and studying the paper work. IVF is about the stimulation and embryos, both of which should be clear in the documents.
It seems that there are doctors who tell patients that IVF is the way to go because in their case FSH iui is too risky. It is a little risky but it can be handled correctly. Start on a low dose, get monitored and stop the cycle you are on track to make too many eggs. If a low dose causes a big response, use even less drug next time. Yes, it’s easier to do IVF but if you chose to do FSH iui, talk to your doctor about trying.
If you hyperstimulated during an IVF cycle, and have frozens, generally it does not make sense to do another fresh. The point about saving young embryos for later is valid, although I do not push for that much. Saying you can get kids from a frozen cycle is not appropriate. You really don’t know if you will get pregnant from any embryos, fresh or frozen. If your plan is to have 3-4 kids, doing another fresh and saving the frozen is reasonable. Clearly you need a much lower dose of drug for the next fresh cycle.
OK that’s it for now, more to come.
Thanks and see disclaimer 5/17/06.
Dr. Licciardi
Posted on October 20, 2009 | Filed under Infertility News | Permalink
Dear All,
Congratulations to all of you who read this blog, it has been nominated for the People’s HealthBlogger Award. See the yellow blue and orange box to the right? Clicking it would be a great help. Winning would be very helpful because the blog would get more publicity, which will bring us more readers. This in turn could help us get the blog to even more health-related web sites. The voting ends December 15Th.
Thanks for everything through the years.
Dr. Licciardi
PS The company encourages you to ask your contacts to vote too. I guess they want some publicity too, which is fine with me.
Posted on October 20, 2009 | Filed under Infertility News | Permalink
The time between the hCG and retrieval
For an FSH injection cycle leading to insemination, it’s ok if the ovulation naturally occurs a little early (via a premature LH surge) because we can just do the insemination early. Rarely it’s too early, before the follicle is big enough, and we cancel the cycle. However, for an IVF cycle we have to cancel the cycle if there is an early natural LH surge, even if it’s only a little early, because the timing of the retrieval is very dependent on when the surge starts. The retrieval needs to be about 34-36 hours past the start of the surge (which would also be the time if the hCG shot).
Because we are not taking blood every hour, if the blood test shows a rise in the LH level, we don’t really know when the rise started so we don’t know the right time for retrieval. Lupron, Antagon and Cetrotide prevent the natural rise of the LH, so the premature surge usually cannot occur. However, these drugs do not interfere with the effects of an hCG injection. So there is no natural surge, but there is an artificial surge which starts the moment the hCG goes in.
Final Maturation
There is a second very important job of the LH Surge/hCG injection:
it causes the egg to mature. As the days of stimulation progress the eggs are slowly maturing, but more is needed for the final maturation. Necessary last minute changes occur inside the egg from the LH/ hCG.
Why is this important? An immature egg will not fertilize. If the retrieval is before about 33 hours after the hCG, the result will be immature eggs. Sometimes they are all immature, or just some.
If the retrieval is 38-39 hours after the hCG, the eggs will be mature but they will already have ovulated. We would retrieve none; they would be floating in the pelvis around the ovaries waiting to get picked up by the tubes. So we need to grab the eggs just after they mature but just before they ovulate, which is at about 34-37 hours after the hCG injection.
What day should you get your hCG?
hCG can only mature eggs that have been growing for enough time for the follicle to become large. The sizes of all of the follicles need to be taken into consideration before giving hCG in IVF cycle.
Not all of the follicles grow at the same rate. For example, if there are 10 follicles, and the biggest is 18mm, they will not all be 18 mm. Some will be mid-sized and some will be much smaller. Each follicle does not need to be 18 mm to produce an egg that is mature. As long as the biggest (the lead follicle) is 17-18mm, the mid-sized (13-16) should also have mature eggs. The small follicles (10-12) may or not be mature. But if the lead follicle is 14 mm, none of the eggs have yet reached maturity. Giving hCG would not be enough to achieve maturity.
How Important are Estrogen Levels?
Not very. When you are monitored for your IVF cycle, the follicle size is much more important that the estrogen (estradiol) levels. We need the estrogen to rise, but if midway through your cycle we see 10 follicles, with the biggest being 13 mm, we don’t really care if the estrogen level is 500 or 900. Estrogen is more important when we are monitoring someone who may be on track for hyperstimulation.
Therefore, we use mostly the size of the follicles, with not much emphasis on the estradiol levels, to determine when to give the hCG. At NYU we feel the best time to get the hCG is when the lead follicle reaches 18 mm. Now because there are many variations from cycle to cycle and from patient to patient, it’s not easy to say that 18 mm is the rule.
For example, let’s say there is one follicle 18 mm, three that are 15 mm and others that are smaller. Here we may worry that some of the small ones may be too immature, so we may wait another day before giving the hCG. Let’s say there are 20 follicles, with the biggest 17mm and an estrogen level of 2900. Here we are aware that the smaller follicles may be immature, but we also are concerned about the estradiol getting much higher because the woman would be increasing her risk of hyperstimulation. So we give the hCG at 17 mm, which may yield some immature eggs, but should give us enough mature eggs to work with.
And there are many more variations. Some women have gotten their hCG a little on the early side and have all mature eggs. Some women in their first cycle get the hCG at 18 mm with lots of good size follicles, and have ½ their eggs be immature. So next cycle we wait till the follicles are 20-22 mm before giving hCG. This sometimes gets more mature eggs but sometimes no matter what we do, that woman’s ovaries make more immature eggs than expected.
So why not wait and give hCG later? Because eggs can get over-mature. This over-maturity can lead to lower embryo quality and lower pregnancy rates.
When we see the records of women who have failed IVF elsewhere, many times we see that he hCG was given with large sized follicles. The first and easiest “fix” we can do is to give the hCG earlier in her next cycle, more inline with our standard procedures.
Why do some doctors wait longer to give the hCG?
Some may feel that the higher the estradiol level the better, so by waiting estrogen levels will go up. This is probably not important. Others may feel that it is necessary to wait so there will be no immature eggs. Well this sounds good, but it may not be worth sacrificing the quality of the eggs form larger follicles, which are probably the best eggs anyway.
And back to the original question.
What if instead of the average 11-12 days it takes to grow the follicles, they are of the right size after only 6 days or 8 days?
If the size is good, but it seems early, we usually go at least one more day that we normally would, maybe 2. If it’s day 9 and the follicles are 19-20 mm, it really sounds ok to give hCG. If it’s day 7 (so 5-6 days of FSH injections), and the follicles are 17-18 mm, more time would probably be a good idea.
Thanks for reading and don’t forget the disclaimer 5/17/06.
Dr. Licciardi
Posted on September 30, 2009 | Filed under Infertility News | Permalink
I was invited to the MSNBC show “Dr. Nancy”. Here’s what I had to say.
http://www.msnbc.msn.com/id/31388323/#33006217
Posted on September 30, 2009 | Filed under Infertility News | Permalink
Here is a question someone asked about the timing of hCG. It’s a good starting point for this blog.
“I am 40 and just had a failed first IVF cycle that resulted in all immature eggs (7 retrieved) after only 5 days of stims (follistim/menopur + ganirelix days 4 & 5) before the hCG shot.
The doctors were very surprised that by day 5 I had 7 follies 12 – 19 (more <10) and they said I had to trigger, my final E2 was only around 700. I had a good hCG level after the trigger.
I have never heard of anyone only stimming for 5 days. I am curious what your experience has been with people who are fast responders and what you recommend in terms of changing protocols? Do you believe that follicle size alone determines egg maturity or can a short follicular phase be a problem even with larger follicles?”
Figuring out the right time is not that difficult, but there are a few important factors that must be taken into consideration. We need to first start with a brief review of what happens in the natural menstrual cycle, then it will be easier to understand how the IVF cycle works. There are 3 important elements: the growing follicle’s schedule, estrogen levels, and the size of the follicle at ovulation.
Just a reminder: the follicle is the fluid-filled cyst that houses the egg. Each follicle has one egg. We can’t see the egg on ultrasound because it’s microscopic. But we can see the follicle.
The Growing Follicle’s Schedule: By the 2-3rd day of bleeding, the previous month’s follicle has disappeared and the new one, which has already been chosen, has not started to grow much. On ultrasound you may see it, but you may also see other small ones that look the same. It’s the FSH coming from the pituitary gland (the pituitary will be a blog to come) which causes the little follicle to start and continue to grow.
As the next week goes by, the chosen (or dominant) follicle gets bigger and bigger, until it ovulates somewhere usually between days 11 and 20, most often close to day 14. It’s pretty rare to ovulate before day 11, but not so rare to ovulate later. The day of ovulation is related when the follicle starts to grow, and the cycle length gives us a hint as to when this was. It takes about 2 weeks for the follicle to grow from tiny to big. That means for a 28 day cycle, the follicle grows till ovulation, usually day 14.
What if the cycles are, say, 35 days? Well it still takes the 2 weeks to grow, it just starts later. So for a 35 day cycle the early follicle sleeps for about a week, then wakes up and starts growing day 7 and ovulates day 21. We don’t know what causes these differences.
What if the cycle is 24 days? In this case the follicle probably takes less than 2 weeks to grow, so 2 weeks is not mandatory. Again, the reason for these differences are unknown.
Estrogen Levels: As the follicle grows, it makes more and more estrogen, so the blood levels of estrogen rise each day. The estrogen is not coming from the egg, it comes from the tons of little ovarian cells (the granulosa cells) that surround the egg. The estrogen is probably not important for the egg, but one of estrogen’s very important jobs is to thicken up the lining of the uterus.
Estrogen’s second job is to cause the ovulation. The pituitary gland is constantly monitoring the estrogen levels, and when they get high enough, the pituitary dumps out LH (this is what your home ovulation kit reads) and this is what causes the egg to pop out.
There is not an exact estrogen level that causes the ovulation. Most of the time it’s anywhere from 150 to 350. Why there is a difference we do not know, it may be that there are other unknown hormones that work with the estrogen to get the job done.
Follicle Size: The size of the follicle is important too. Most ovulations occur with a follicle that is 20-25 mm(about one inch), but 16 mm is close to the bare minimum and 30 mm is close to the top size.
Next time we will talk about the timing of ovulation in an IVF cycle.
Thanks for reading,
Dr. Licciardi
Posted on September 25, 2009 | Filed under Infertility News | Permalink
We are still working towards the timing of the hCG shot, but we first need a little more background. We need to go over difference between the natural LH surge and the hCG injection.
After LH leaves the pituitary during the surge, it causes the ovulation by landing on specialized spots on the ovarian cells, the LH receptors. All hormones act by landing on (binding to) their specific receptor, and usually one hormone does nothing if it lands on the receptor of a different hormone. There has to be a match.
This is usually dictated by shape. It’s like a lock that recognizes the shape of the key. FSH and LH are similar hormones, but their shapes are a little different. So if LH comes across a FSH receptor, it would not bind.
There is a notable exception. Because hCG and LH are chemically very similar, with very similar shapes, hCG can bind to the LH receptor, and can do it well. Since hCG can land on the LH receptor, hCG can do the same job as LH.
This is actually very important to pregnancy. Pregnancy needs progesterone, which comes from ovarian cells with LH receptors. So LH causes the ovary to make progesterone after ovulation. Good: the progesterone allows the embryo to implant. Then the embryo makes hCG. Better: this causes the ovary to make even more and more progesterone which keeps the implantation going strong. Both occur via the LH receptor.
That hCG can behave like LH is good for treating fertility patients because we can cause ovulation with an injection of hCG instead of an injection of LH. This is good because hCG is easier to get than LH.
So why not just give LH? Up until very recently, LH was not available. Years ago the only way to get FSH for our fertility drugs was to extract it from the urine of menopausal women.
(This is a whole story by itself. Initially, starting in the 1970’s, the urine was obtained from menopausal Italian nuns who would leave jugs of pee for the drug company Serono to pick up in the mornings. Menopausal women have really high amounts of FSH in their blood, and most of it comes out in the urine. The pee would be taken to a factory with a swimming pool-sized pee vat, and they would somehow get the FSH from the pee. Serono went on to be the most profitable company in the world. The Catholic Church was rewarded for its cooperation. Even today, pee swimming pools exist for companies who make fertility drugs from urine.)
Because FSH and LH are similar molecules, the methods used to pull out the FSH grabbed LH too. Once we got the FSH/LH mix, we didn’t have the science to separate the two. So we could not get enough pure LH to cause ovulation. Today we can get pure LH made in a lab, but still in small amounts, not enough to get a good ovulation going.
How do we get the hCG? That is piece of cake, we get it from placentas. There are tons hCG in placentas and it’s easy to extract. Today hCG is also made in a lab, that’s the Ovidrel. It’s pure stuff, and that’s why it can be given in the skin. The placental hCG is given IM because it’s contaminated. hCG is also a protein, and the system for extracting the hCG protein from placentas is pretty crude, so tons of other placental proteins get caught in the net too. These extra proteins can cause a local allergic reaction when given in the skin, but not when given in the muscle.
When we used to get fertility drugs from urine, same thing, they had protein contaminants and needed to be given into the muscle. Recent exceptions are Menopur and Bravelle. These are from urine but using new systems that are better at cleaning out most of the unwanted contaminating proteins. Gonal-F and Follistim are both made in the lab and do not have the contaminants. They are given into the skin.
Today there are 2 products, placental hCG given in the muscle, and the lab-made hCG given in the skin. The placental is still cheaper and words great.
In a cycle stimulated with injected FSH (for IUI or IVF), most of the time the natural LH surge does not occur at all, so we need to give the hCG. In some cases the LH surge does occur, but it happens too soon, before the eggs are mature. This is probably due to the fact that estrogen levels are higher earlier in a medicated cycle, so the LH rises earlier. We don’t know why a premature LH surge only happens in about 20% of cases.
The bottom line is that we cannot count on the natural surge to occur at all, or at the right time, when we are using FSH injections. We need to use the hCG injection for proper timing of ovulation and proper timing of the egg retrieval.
That’s it for now. Next time we finish up by talking about the right time to give the hCG shot.
Thanks for reading,
Dr. Licciardi
Posted on September 25, 2009 | Filed under Infertility News | Permalink
Spotting.
Really frustrating. Where does it come from? We first look for an anatomical reason (a problem due to some sort of growth that we can see usually with the ultrasound). The most common reason is that there is a polyp inside the uterus. A polyp is a benign growth inside the uterus, kind of like a skin tag on the inside. They are easily removed via hysteroscopy. If you have had polyps removed and still have spotting, you need to have a sono hysterogram to be sure that the polyps were completely removed. Or maybe they grew back. If the lining is pristine, you we have to look for other causes. Adenomyosis is another reason for spotting. Usually there is evidence of adenomyosis on ultrasound. If not, an MRI will make the diagnosis.
Women with endometriosis are more likely to have spotting, and this may be may be due to a few causes. With endometriosis, the glands of the uterus grow in areas they shouldn’t. The most common abnormal areas are around the ovary and tubes, but there can also be spots of endometriosis on the surface of the cervix. Because the glands don’t always behave as the normal endometrium, they can bleed anytime, causing spotting.
Another source of spotting in women with endometriosis is a hydrosalpinx. A hydroslapinx is a big scarred fallopian tube that is blocked on the part away from the uterus, near the ovary. If the hydro is caused by the chronic inflammation of endometriosis, blood can slowly built up inside the tube. This blood can sometimes back up from the tube into the uterus and then out the cervix, causing spotting. It’s usually not red, but more of a chocolate brown.
Occasionally no reason for the spotting is discovered. So we blame in on being “hormonal”, but we really don’t know what the specific hormonal abnormality is. Could spotting a few days before the period be due to a luteal phase defect and low progesterone levels? There may be one rare woman who has this issue, but for most women with pre-period spotting, their hormones are just fine. I have found that persistent spotting stops when moving to injectables, which do increase both of those hormones.
Post ovulation spotting can in many cases be controlled with progesterone and estradiol in the luteal phase. I remember one patient from years past who had the spotting mid cycle, had a negative hysteroscopy, and got pregnant on her own a few months later. So even though she had monthly spotting it had little effect on her ability to conceive. Maybe the spotting was normal for her and it stopped once she became pregnant.
If you are anovulatory due to PCO and you have frequent spotting, you may need to have a biopsy of the endometrium. PCO women who rarely get a period are at higher risk for endometrial hyperplasia or even cancer. This usually causes heavy irregular periods, but sometimes it’s just spotting. An office biopsy can usually make that diagnosis.
Other Variations in Bleeding
“I don’t bleed for a long as I used to”. I hear this a lot. Typically someone will say they used to bleed for 4-5 days and now they are finished after 3. There is no evidence that this means anything bad. Certainly after a delivery such changes are more common. But even without pregnancy, some women have changes that are hard to explain. I don’t think this means there is a change in fertility.
Heavier bleeding is more of a problem because it is more likely to signify a change that may be important. Remember that fibroid the doctor told you you had, but said it’s not a problem because it’s small? Unfortunately they can grow and become a problem with time. Increased estrogen levels associated with repeated drug cycles can accelerate their growth. Adenomyosis can also progress, leading to increased bleeding.
Consistent heavy bleeding in the setting of normal anatomy may require a consultation with a hematologist. Many of us are born with blood abnormalities that don’t’ allow for proper blood clotting. These issues are usually discovered in adolescence after the first periods are found to be abnormally heavy.
And of course, unexplained heavy bleeding may also require an office biopsy or hysteroscopy to rule out pre-cancerous or cancerous cells.
Thanks for reading and please see disclaimer 5/17/06.
Dr. Licciardi
Posted on September 25, 2009 | Filed under Infertility News | Permalink
Before getting to FAQ’s here is a little vignette.
Last week I saw a woman who has been trying for 3 years. 3 years ago she told her doctor she had an extremely heavy period, and during her other periods she was losing more blood than she did in the past. No ultrasound was performed. Well 3 years later another doctor got a scan right away and she was found to have a huge fibroid in the middle of the uterine cavity. There is no way she could have become pregnant in the past few years with this fibroid in place. She lost 3 years. Take home message: abnormal uterine bleeding requires an ultrasound. In fact all infertility patients need an ultrasound right off the bat.
Can you travel by plane after IUI and IVF? There is no evidence that plane travel hurts anything. However, you need to have a very flexible schedule. There are a few things that could force you to stay home after a cycle. One is hyperstimulation. The other is an abnormal pregnancy. If you’re pregnant, the worse time to plan travel is about 2 weeks after your transfer. This is a bad time because often enough we don’t the location of the pregnancy. So if the day 35 blood test does not show a doubling every other day, your doctor may order you to stay put. No one wants you to rupture a tubal pregnancy, especially on a plane. The condition and location of the pregnany will mostly be determined as the next 1-2 weeks progress, so after that travel becomes more of a possibility.
Prolactin: Will get its own blog
MTHFR: Methlyenetetrahydrofolate reductase (yes, I had to cut and paste): This is an enzyme (a protein that is involved in a chemical reaction in the body) that is involved with the metabolism of folic acid. Folic acid can’t be properly utilized if there are problems with this enzyme. We have 2 copies of the DNA for this enzyme. It’s more common to have on abnormal copy, but 2 abnormal copies are more rare. If there are one or 2 bad copies, the next step is to measure the homocystine level. If the homocystine is normal, this indicates that even of the copies are abnormal; folic acid is still doing its job. If the homocystine is high, there is an interference of folic acid’s function. In this case, treatment may be necessary, with folic acid and other vitamins. Some doctors will recommend Lovenox (a heparin blood thinner). Some doctors recommend these therapies when the homcystine level is normal, but this is very controversial.
Late Onset Congenital Hyperplasia(CAH). Testing is via hormone levels, however there is a DNA test. If you have CAH, you shuold have the DNA test and your partner needs to be tested too. Just like above, you have one copy. He may have one copy too. The bigger problem is that your offspring may inherit one from you and one from him, and have 2, which is a much more serious disease. As far as treatment and pregnancy attempts, if you have a mild form of CAH, DEX may be overkill. Ask your doctor about other options such as just going to clomid.
Is IVF the only option for 1% sperm morphology? No, you also have the option trying on your own or iui.
What if you did 3 FSH iui cycles and can’t afford IVF? Practicality will dictate your path. You can get pregnant with FSH iui in the 4th 5th or 6th try. The odds become lower in the later cycles, but it’s still better than on your own or with clomid.
A 29 year old who made 10 eggs and had 2 average quality embryos is being told she needs donor egg. ARRGHHHHHHHH!!!. Give me a break. Can I guarantee you will get pregnant with your own eggs? No. Keep at it. Keep tweaking it, and get to the best program you can.
One tube and Clomid. If you have one tube clomid can work, but it does help to have the follicle on the same side as the tube. You may not need IVF right away. Usually with FSH iui you can make eggs on both sides at the same time giving you a better chance each month.
What IVF protocol is best? No one knows. I prefer the day 2 start with pure FSH. Why? Because no one has ever shown that one protocol is better than another. This is especially true when comparing pure FSH with FSH combined with LH. So if they are the same, why not make it simple. With the day 2 start there are no pre-cycle medications, and with FSH only there is just one drug to worry about. If that does not work, I can use all of the other protocols out there. I do feel that day 21 lupron is not the best for women we expect to be low responders.
How long after having a baby should you try before seeing your RE? It depends on your fertility problem. Obviously there is no waiting for severe tubal or sperm issues. If ovulation was the problem, you can wait a little to see if your cycles straighten out, but if even early on you see that things are as they were, get back to the RE.
What about a short luteal phase when taking clomid or FSH? Studies have shown that the luteal phase in a clomid or FSH cycle is better than a luteal phase from a natural cycle, probably because the progesterone levels are higher. I routinely do not prescribe progesterone for clomid or FSH. However, occasionally a patient will let me know that the luteal phase after a drug cycle was unusually short, maybe 8-11 days. I don’t know why it happened but I agree it sounds too short. Now maybe it’s ok, and if there were a conception, early bleeding would not have happened, but here I make sure we give progesterone in any subsequent cycles.
What should my progesterone level be? It needs to be over 8. No one has shown that 11 is worse than 40. When using clomid we sometimes get levels to be sure ovulation took place, but I don’t worry about the level.
Female anti-sperm antibodies. I would definitely believe in them if there were quality papers showing they play a role in infertility.
What if you have a short cycle but home ovulation testing shows a color change late? Well either the kit is off or there is a short luteal phase. In this case, office monitoring is the way to go. There are a few people who do well growing the follicle, but it just sits there a few days before deciding to ovulate.
Should you take progesterone with normal levels and a normal luteal phase? Data does not support its use.
Is DE the only option if the FSH level is 16. You have to ask your doctor what the odds of having a baby are using your eggs with an FSH of 16. I am sure the odds are very very low. So you have to decide if the numbers make it worth it to you.
Should husbands with male factor get genetic testing? It depends on the counts. The lower the counts, the greater the chances of a genetic abnormality, although even in cases where the sperm counts are less than 2 million, the genetic testing usually comes back normal. So I suppose it’s up to you and the urologist. There’s always a small chance that the genetics will be abnormal.
What about clomid in the case of severe endmetriosis and and at least one blocked tube. You can try clomid, but with the enod and only 1 tube, your odds with clomid are low. Remember, for women with normal tubes and sperm and FSH levels, the odds with clomid are only 8%. So with a problem pelvis, the odds will only be lower.
What if you became pregnant naturally with a sperm count of 3.8 million, and you want to now try again? Yes miracles do happen, but not often enough. Start with repeating the semen analysis. Maybe the counts are higher now. It’s also possible that they are lower, so you should check. If they are still 3.8, you can try for a little while, but I would get help if you are not pregnant quickly.
This is for relatively young women who don’t make many eggs. Get off the lupron. Many times, but not every time, more eggs are produced without lupron. If the egg number remains the same, then you are stuck and you will have do decide if its worth going through with the retrieval.
How often do you need to monitor progesterone levels after IVF? Usually progesterone levels are very high the first week after retrieval, but after the ovaries decrease their progesterone production in the second week. If the levels are high enough 1 week after, they will probably be fine as the second week progresses. The hcg produced by the early pregnancy will increase the ovaries output of progesterone. The point is is that if the progesterone levels are low on the day of the pregnancy test, it’s probably because there is no pregnancy, not because there is not enough progesterone being given to the woman. If a person is getting more than the usual amount of progesterone(IM plus vaginal and or oral), measuring levels will be less helpful.
If you have a family history of miscarriage, genetic counseling is indicated.
That’s it for now, thanks again. Please see disclaimer 5/17/06.
Dr. Licciardi
Posted on September 25, 2009 | Filed under Infertility News | Permalink
Here’s a little vignette first.
I have a patient who was told after a hysterogram (HSG) and laparoscopy that her tubes were blocked. So she did an IVF cycle, didn’t get pregnant and came to me.
She was not told what type of blockage. I asked for her op notes and saw that her problem was that her tubes looked normal, but were blocked near the uterus (proximal tubal occlusion).
I told her that there is a way, using another hysterogram, that the tubes could be potentially opened using a wire. She went for the test and one tube did not require fixing, it was open, and the other needed the wire and was successfully opened. So her first HSG was wrong, both tubes were not blocked, and her laparoscopy, the so called gold standard, was wrong. See blog from 10/05/06, Blocked Tubes: 2 Cases of Proximal Tubal Occlusion.
None of this is uncommon. When I have a patient with proximal occlusion I send them for the recanulization hsg (the wire), and in many cases the original blocked tubes were nothing more than spasm, and the next hsg is perfectly normal. Laparoscopy isn’t always good for showing if the tubes are open. Sometimes it’s just hard to get the dye to go out the tubes at laparoscopy. If I am convinced that there is blockage at laparoscopy, I can pass the wire at that time. If this woman had her tube properly opened at laparoscopy, she maybe could have avoided IVF and seeing me.
Are low grade, slow blastocysts chromosomally abnormal? There may be a slight difference; better looking blasts may have better chromosomes than a blast that does not look as good. If there is a difference, it’s too small to make a decision related to transfer. In other words, if you best embryo is a slow blast, you should not be afraid to take it. Odds are if it sticks, it will be normal.
I made 7 eggs, why did the clinic immediately exclude me from a day 5 blastocyst transfer? Every clinic has its own criteria. Yours sounds a little strict, but check their SART stats. If their rates are good take their advice and follow their plan.
What about getting your period early in an IVF cycle? Probably if you were pregnant your period would have not come, even though you got it early. If you are taking suppositories, I would ask your doctor about taking progesterone injections for the next cycle. Sometimes I add estrogen. In general estrogen is not necessary after transfer, but in cases of early bleeding it may help.
What if there is no ovulation with clomid? If you don’t respond to clomid, you can’t keep trying forever. The injections sound intimidating, but most people get it done. If you do injections, it is very important that your doctor start you on a low dose and monitor you carefully.
What if you were planning to go to IVF if this IUI didn’t work, but you got pregnant and miscarried? Logic would say it makes sense to do 1 to 3 more IUIs, after all you proved the tubes work, fertilization can take place and implantation can happen. However, most people, but not all, stick to the original plan and go to IVF out of frustration. Plus, usually a miscarriage results in extra lost time, and this gets people to want to get to IVF.
If you are older (I’m 49, so most of you are young to me), do your eggs need ICSI? Is the shell of the egg harder and less penetrable? This is my ARGHHHHH of the day. Simply, the answer is no.
At a young age, can anorexia or exercise induced amenorrhea mess up your eggs later in life? It actually is a very interesting question; however I have not seen any studies supporting this. There is probably no effect.
Could a woman with unexplained infertility donate her eggs? This is a tough one but probably not. Only because the recipients are taking a big financial and emotional gamble on the quality of your eggs. If you have unexplained infertility then have a successful IVF and wanted to donate later, that would be great for a recipient.
What if you are young and all the tests are normal. Your day 3 FSH is normal but you estradiol on day 3 is 20. Low is usually ok. Repeat it if you want piece of mind.
Donor egg or donor sperm? If you are young and the sperm counts are very low, and the embryos don’t look good, of course it could be the eggs or sperm. It really could go either way. Which brings us to a common dilemma. Getting inseminated with donor sperm is quicker, easier and tremendously less expensive that donor egg. So for that reason, if it’s not perfectly clear where the problem lies, and you have accepted the idea of donor egg, it is reasonable to consider a few courses of donor sperm insemination. Couples do seem more reluctant to do the donor sperm than they are for donor egg.
Major League questions about blastocyst. Are cryo’d blasts as sturdy as day 3 embryos? The answer is yes. A day 5 3BB is better than a day 6 4AA, unless the day 64AA was a day 5 3BB or better. It the trick with frozens in the freeze or thaw? Most of the skill is in the freeze, not the thaw.
Sorry, I do not now how to get pregnancy rates from Canada.
Update on 0ne-embryo transfer? Yes, in the past 1-2 years, every clinic has performed more and more one embryo transfers. So ask about their latest stats. I strongly suspect that the pregnancy rates for one embryo are lower in a frozen cycle. One way to up your odds in a frozen cycle would be to thaw a few (if you have them) and transfer the best one.
What if the sperm count is 145 million, with 40% motility and 2% normal morphology? Most REs would tell you that’s normal, but you need to ask yours.
If money is not an issue and you are faced with the choice between iui and IVF, and you want to do IVF, IVF is your best option. The success rate with FSH iui when all the testing is normal depends on your age. At age 37 it’s about 15%. Could be as high as 20%. IVF will be about twice that.
Should you go to surrogate if you are 43, have failed 6 fresh and 2 frozens, your lining is 5-6 mm and have 4 frozen embryos remaining. It’s a lot to consider, but surrogacy is an option. I am sorry but I can’t make more of a recommendation without seeing everything.
Can Lupron’s effects linger after your stop taking it? Anything is possible. However I have not had a patient with that problem.
With fairly good sperm should you spend the money on 2 iui’s or save for IVF? IVF is more cost effective than FSH iui. FSH iui is cheaper but much less effective. IVF is usually 2-3 times more effective than iui. There was a recent study showing going to IVF gets a baby with less time and money compared to FSH iui and IVF later if necessary.
Post coital test? Very few RE’s do this test anymore. It is just not accurate. Even if the test is abnormal, iui bypasses the cervix so antibodies in the cervical mucus (if such a thing matters) do not come into play.
Is IVF the answer if there have been 3 miscarriages and sperm with DNA fragmentation? I can’t be too negative about DNA fragmentation because it’s a little early to really know. However there is no good evidence yet to show those test are predictive of infertility or miscarriage. If your doctor feels differently, ask him or her to show you the studies.
Can very poor sperm lead to biochemical pregnancies and miscarriage? Yes but it’s not common. We all know that ICSI is used for very low sperm counts, and leads to good embryos and excellent pregnancy rates. However occasionally we see very low sperm counts and very poor embryo quality. In these cases, some women want to repeat IVF and expose a few of their eggs to donor sperm to see if there will be an improvement in the embryo quality. In some cases the difference is dramatic, and some couples will change over to donor sperm. If you are getting pregnant on your own without IVF and are having biochemical pregnancies, I’m not so sure it’s the DNA fragmentation.
Is IVF a treatment for 3 miscarriages? There are studies showing IVF without PGD is not very helpful for the treatment of miscarriages. There are some limited studies showing PGD may reduce the odds of miscarriage, but the data is not overwhelming.
What if you have had 3 biochemical pregnancies in a row? It’s hard to put much faith in the platelets, antibody, and autoimmune issues. Early on there is no placenta to speak of. There are no significant blood vessels to clot off. I must be sensitive to those of you who have had early losses and biochemicals, and then normal pregnancies after treatment for autoimmune/clotting factors. Maybe these things helped, but it can be possible that after a number of early losses, it was time for normal pregnancy.
What if you are 36 with all tests normal and 4 months of trying with good timing? Your odds of getting pregnant on your own in the next 4 months are still very good. Clomid or FSH iui are options, but giving it at least a total of 6 months on your own is a good idea.
How’s it going with the Priming protocol? If seems to work as well as other protocols in producing eggs. However the pregnancy rates are a little lower, so far. This is explained by the fact that we save the priming protocol for the worst responders, many of who have been cancelled using other protocols. So even if it’s a good protocol, we may not be seeing it because we are giving it to the patients who have low rates to begin with. So my bottom line is it’s worth trying as alternative, but it’s not a magic potion.
I am sorry I am not aware of co-culture with green monkey cells. Such a process would not be allowed in the US.
Thanks for reading and don’t forget to see the disclaimer 5/17/06
Dr. Licciardi
Posted on September 25, 2009 | Filed under Infertility News | Permalink
Next »
Copyright @ 2001 and Beyond Fertility Portal: Fertility and Infertility Research News
Web Design By Dynamic Creator | Web Hosting by Trade Web Hosting
