How Often Should I Have Intercourse?

(Contribution from Carolyn Givens, M.D.)

One of the common questions that fertility patients ask is: “How often should they have intercourse?” Some patients intuitively take a “more is more” point of view and want to have intercourse daily. But that isn’t necessarily the case. My colleague at Pacific Fertility Center - San Francisco, Carolyn Givens, M.D., was kind enough to share her insight on this topic:

There may be no exact right answer for everyone. Indeed, there might be a slight decrease in sperm concentration on the second or third straight day of ejaculation. However, for most men, there are still millions of active sperm present on the second or third day. As such, it may be better to have more sperm available in the reproductive tract during the window of fertilization for the egg.
My bias is to have intercourse as frequently as possible when you know you are soon to be, or in the process of, ovulating. The best method to detect when this is occurring is to use an ovulation predictor kit such as Ovu-Quick or Clear Blue Easy. When the kit detects the surge, have intercourse on that day and the next day. Beyond that, it is probably too late. If you don’t want to get that technical, subtract 16 days from your usual cycle length and start having intercourse daily from that day of the cycle for the next 3-4 days. For example, if your usual cycle length is 30 days, begin having intercourse on about day 14 and continue to day 16 or 17.

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Improving Your Fertility: Dos and Don'ts

Overcoming infertility through reproductive medicine is a team effort. Certainly patients should seek out the very best fertility medicine. Additionally, patients need to make sure they are doing their part to ensure that their lifestyle gives them the best chance of conceiving. I've taken the liberty of jotting down a list of several "Dos" and "Don'ts" which I hope will be helpful. This list doesn't cover everything by any stretch--if you are wondering about your particular lifestyle habits and how they influence your fertility, leave a comment.

Smoking -- Avoid it completely. If you are a smoker, quit immediately. This applies to both men and women.

Alcohol & Caffeine -- In moderation, having a glass or two of wine per week or a cup of coffee for a morning "pick-me-up" will not have notable adverse effects on fertility if you are trying to conceive. This applies to both men and women. If you are pregnant, then you should avoid both alcohol and caffeine completely.

Stress -- Minimizing stress is always a good thing but I understand that it is easier said than done. Without question, infertility can bring on extreme stress and feelings of isolation. Studies have shown that some patients increase their chances to conceive by practicing relaxation techniques and stress reduction lifestyle changes. Women who join support groups also respond more favorably to infertility treatments. Where I practice, we offer Mind/Body Weekend workshops that offer stress reduction workshops.

Exercise -- For women, moderate exercise is fine but do avoid rigorous activities. Excessive exercise will send blood flow preferentially to your striated muscles and potentially decrease the flow to the ovaries and uterus. If you are a marathon runner, you'll need to stop. Exercise and fertility is less of an issue for men although sperm counts can be adversely affected by excessive efforts such as long distance biking and running marathons.

Acupuncture -- It doesn't hurt. We do know that acupuncture improves blood flow, and, for the woman, increased blood flow to the reproductive system is ideal. There is at least one published study demonstrating improvement in IVF success during cycles in which acupuncture was used as an adjunct.

Hot Tubs/Laptops -- For the male partner, avoiding extreme heat helps optimize living conditions for sperm. As such, men trying to conceive should avoid hottubs. If you can't stay out of the tub, turn the temperature down to 99 degrees.Also, don't take the term "laptop" computer so literally. Laptop computers emit heat and should not be placed directly on the lap for extended periods of time.

Boxers vs. Briefs -- This is the age old question. Are boxers better than briefs for improving fertility? Frankly, it doesn't make much of a difference.

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Evaluating an IVF Clinic's Pregnancy Rates

Patients in my practice often inquire about their chances conceiving through reproductive medicine. The answer to this question depends on a variety of factors such as the patient's age and diagnosis. Thankfully, most fertility clinics nowadays post their pregnancy rates on their website. This is a valuable tool for those dealing with infertility as they can evaluate their chances of conceiving. As one can imagine, patients often rely on these pregnancy rates in order to determine which clinic to pursue care. However, I always urge patients to proceed carefully when evaluating the pregnancy rates posted on a fertility clinic's website.

Below is a list of a couple important items that people should keep in mind when they evaluate an IVF clinic's pregnancy rates:

Patient diagnosis - If a fertility clinic treats a large number of patients with a difficult-to-treat diagnosis such as decreased ovarian reserve, their pregnancy rates will not be as high. These lower pregnancy rates aren't necessarily a negative reflection on the IVF clinic. Conversely, if a clinic routinely turns away patients with decreased ovarian reserve, their pregnancy rates will, in turn, be higher.

Physician and Laboratory Credentials - It is always valuable to evaluate the credentials of the IVF laboratory as well as that of the physician. For instance, ideally the physician should be a member of reputable organizations such as the Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM). It is also preferable that the fertility physicians be Board Certified by the American Board of Obstetrics and Gynecology (ABOG) as Reproductive Endocrinology and Infertility Specialists. This is the highest level of certification in the fertility field. Lastly, it is important that the IVF laboratory be certified by reputable bodies such as the College of American Pathologists - American Society for Reproductive Medicine (CAP-ASRM).

Above are just a couple of the important considerations but there are many other factors that come into play with regard to evaluating an IVF clinic's pregnancy rates. I'm sure some of you have questions about your individual diagnosis, how to evaluate pregnancy rates, and more. If so, I'd love to hear from you!

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When to Consider Egg Donation

In my recent post, “The Biological Clock Keeps Ticking”
I suggested that as a female patient gets older, she needs to be more aggressive in seeking help from a fertility specialist. However, there becomes a point where the chances of a female conceiving using her own eggs — even with help of reproductive medicine — becomes extremely difficult.

In the clinic where I practice, we recommend that after the female patient’s 46th birthday, that she use an egg donor to conceive. This policy is set because of the limited success women in their 40's have in achieving a successful pregnancy, even with IVF.

Being told that the chances of conceiving using one’s own eggs can be an emotional blow. Nevertheless, this doesn’t rule out parenthood by any means. Egg donation has shown to be a worthwhile parenting option. (For more specifics on egg donation, visit this link.) Although the intended mother (also known as recipient) will not have biological linking to the child, she is indeed the mother. She carries the baby to term, breastfeeds the baby, and raises the baby. Another positive of egg donation is that, in general, it provides high pregnancy rates. I do realize that egg donation is not for everyone and adoption is a wonderful parenting option as well.

I receive numerous questions from patients about both the medical and emotional issues surrounding egg donation as well as the question “When is it too late to use my own eggs?” If you have any questions or comments about these issues, drop me a line.

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Metformin & PCOS Treatment

Occasionally, my patients express some confusion over the drug Metformin (brand name: Glucophage). They've heard it is a fertility drug but are thrown off by the fact that it is an FDA-approved drug for type 2 diabetes. Indeed, metformin is used as a fertility medication as it is a promising treatment in the portfolio of ovulation induction medications for women with polycystic ovary syndrome (PCOS).

Many women with PCOS suffer from insulin resistance (high blood insulin levels), a problem that is thought to possibly impede ovulation and elevate male hormone levels.

By way of background, PCOS is experienced by as many as 10 percent of women of reproductive age. An inability to ovulate normally and problems associated with an overproduction of male type hormone are typical findings in women diagnosed with PCOS. The “polycystic” aspect can be seen in the ovaries via ultrasound, which reveals a large multitude of tiny follicular cysts instead of a smaller group of well-defined emerging follicles preparing for ovulation.

Many women with PCOS respond well to clomiphene citrate (brand name: Clomid), which stimulates increased blood levels of FSH (follicle stimulating hormone) and LH (luteinizing hormone) to induce the growth of a follicle and eventual ovulation. Approximately 70% of patients treated with clomiphene citrate will ovulate and 40% will conceive, the majority within three to six ovulatory cycles.

A small fraction of patients who see no improvement from clomiphene treatment alone are good candidates for metformin, or a combination of clomiphene and metformin. Offering metformin provides such women with an alternative oral medication before being directed to the injectable stimulation medications. As an insulin-sensitizing medication, metformin decreases insulin levels, which is thought to help restore the normal ovarian hormone profile (reduces male hormone), thus allowing for spontaneous growth of a follicle and ovulation to occur. Alternatively, metformin enables the patient to become more sensitive to clomiphene. It is important to note that of those patients who do not ovulate on clomiphene alone, most benefit by the combination of metformin with clomiphene.

Metformin and other insulin-sensitizing medications may offer other benefits for women with PCOS, who are reported to be three times more prone to early pregnancy loss compared to ovulatory women. In several reports involving as yet small populations of PCOS patients, the use of these drugs appears to significantly reduce the rate of early miscarriage. One must approach this news with caution, however, until prospective controlled trials on this topic are conducted.

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President's Council Takes on the Ethics of ART

Many physicians working in the field of Assisted Reproductive Technologies (ART) braced for the release of the latest and fifth report by the President's Council on Bioethics, which takes an in-depth look at the practices and results of ART in the US. Now that the document has been finalized, we are instead pleasantly surprised.

A bevy of questions, recommendations and opinions emerge out of Reproduction and Responsibility: The Regulation of New Biotechnologies, leaving readers potentially baffled about what steps might be taken from its analysis. (See www.bioethics.gov) Yet the report stops short of recommending drastic or unreasonable changes, and instead calls for limitations to about a half-dozen of the most questionable practices (see below). In a reasoned and logical fashion, the report turns out to be a compendium of suggestions for federal monitoring, tracking and long-term research into the health implications of IVF babies and mothers.

The legislative limitations focus on those areas of research that are potentially driven by the promise of embryonic stem cell therapy, and/or cloning. Even in this politically charged area, the Council's recommendations mainly address the kind of obscure research that tinkers with, or attempts to defy the basic building blocks of procreation involving egg and sperm, such as:

- No transfer of human embryos into animals
- No hybrid human-animal embryos
- No human embryos into women without live-born child intent
- No conception other than by means of uniting egg and sperm
- No conception from gametes obtained from fetus or stem cells
- No conception by fusing the blastomeres from 2 or more embryos
- No human embryos for research beyond 10-14 day stage

Given that these suggested prohibitions in the draft report evoked little outcry, the scientific and medical community appear to be palliated by this report. The last item in particular suggests a maximum 10-14 day development stage for leftover embryos donated to research. By making sure that the embryos are donated for research early in their development, this notion gently disarms the politically prevailing view that no new embryos should be used by federal-funded research to develop new lines of embryonic stem cells.

It is well known that bioethics investigations around the world are driven out of concern that human cloning research is galloping ahead, outpacing the public's capacity to understand, let alone react to this brave new world. Media headlines announcing rat and cat cloning, and the creation of embryos from materials other than eggs and sperm seem to appear regularly in the news.

At the same time, public support for therapeutic research involving stem cells is spreading like wild-fire, prompting a majority of senators, as well as more than 200 members of Congress, including some with anti abortion views, to petition President Bush to lift the ban on new embryonic stem cell lines for federally-funded research. This should come as no surprise; 100 million Americans have various diseases that could eventually be benefited by the regenerative capacities of stem cells (i.e. therapeutic cloning), even though sound science to this effect remains elusive.

The Council's report also devotes considerable space describing the need for monitoring, testing and oversight. But again, it stops short of recommending strict new operational standards for ART practitioners, admitting that the current regulations work, notwithstanding the need for a little improvement.

Indeed, infertility practitioners are proud of the high standards they've established through peer-participating professional associations including the Association of Reproductive Medicine (ASRM) and the Society of Reproductive Technologies (SORT).

At the same time, the report's recommendation for a massive and ambitious long-term monitoring project of IVF patients' health is well founded. A 20-40 year federally funded study, following both mothers and their ART assisted children into later years, could reveal new insights into all infertility procedures and outcomes, especially if the research compliments what is already considered science.

The only caveat is additional costs of government monitoring, research and/or regulations have historically fallen back onto the consumer.

To conclude, the majority of ART physicians are in support of reining in the few rogue infertility researchers who have crossed an ethical line attempting to recreate and manipulate some of the core ingredients of procreation (i.e. reproductive cloning) with dangerous and unproven techniques. Reproduction and Responsibility is not expected to cause enormous ripples of change in the ART community. It does an excellent job of presenting the wide breadth of views on the topic, not squelching contrary opinions, but rather maintaining a healthy dialogue. We do not expect to see significant governmental controls emerge for the vast majority of couples who simply want our help in making a baby.

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The "Biological Clock" Keeps Ticking

Everyone knows the quip about the three most important things in real estate: Location, Location, Location. In reproductive medicine, it’s: Timing, Timing, Timing. By timing, I’m really referring to the age of the female patient. The older the female patient, the harder it is for her to conceive. It’s a fact. This is NOT to suggest that a woman in her late 30s or early 40s should not pursue assisted reproductive technology (ART). Quite the contrary. What I’m suggesting is that as the female patient gets older, she should seek fertility treatment as quickly as possible.

It’s too bad biological factors and social factors aren’t always in synch. For many women, having a child in her late 30s or early 40s is ideal. She may be more established in her career, finally paid off graduate school loans, bought a new house, etc. While more women are having their first child after the age of 35, this time also coincides with the biological decline in fertility potential. One of the most challenging clinical scenarios is the impact of the aging egg on pregnancy chances. This decline in fertility potential, or "ovarian reserve", is the natural consequence of the aging process on human eggs. The clinical diagnosis is called “DOR” an acronym for Diminished Ovarian Reserve.

As background, each woman is born with a set number of eggs, predetermined before birth. This pool of eggs is never replenished. A female fetus will have the greatest number of eggs around 16-20 weeks of pregnancy (6-7 million); at birth this number decreases to about 2 million, and by puberty to about 300,000. This constant and dynamic process of decline continues until menopause, and is not interrupted by birth control pills, pregnancy, or ovulation. From this reservoir of eggs, fewer than 500 eggs will ovulate during a woman's reproductive years.

Lower pregnancy rates and higher miscarriage rates are both the consequences of the aging process, and reflective of a decline in egg quality. Women ovulate their healthiest eggs during their 20s and early 30s. By the mid 30s the remaining eggs are of lower quality, and by the early 40s only eggs with very low fertility potential are available for ovulation or ovulation induction. This phenomenon is a normal biological process, which neither fertility medications nor lifestyle changes can halt.

Although there are no clinically proven treatments for improving egg quality, fertility specialists can improve the chances of having a DOR patient conceive by being more aggressive with treatment. For instance, the clinic where I practice usually will jump straight to in-vitro fertilization (IVF) as opposed to the less invasive intrauterine insemination (known as “Artificial Insemination”) for many DOR patients. However, fertility specialists can’t be aggressive with treatment until they have patients to treat.

Here is a link that provides guidelines for when a female patient should seek help from a fertility specialist. It is categorized by age and easy to understand. I can’t emphasize enough the importance of following these guidelines.

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Getting Started with a Fertility Specialist

When a patient receives an infertility diagnosis – and requires the care of an infertility specialist – acting quickly is important. However, one shouldn’t move so fast that they overlook the basic essentials of:

1) Undergoing an initial workup

2) Verifying the extent of infertility insurance benefits (if any)

This shouldn’t be a big revelation. In fact, at some point a fertility specialist will go over these items with patients. Nevertheless, addressing these two items in advance of an initial appointment with a fertility specialist can go along way toward streamlining the intake process and helping minimize financial stress.

Initial Work-Up
Having results from the initial infertility workup gives the fertility physician information needed to facilitate proper diagnosis and determine appropriate treatment protocols. I can’t speak for every fertility clinic in the U.S., but at our center we always recommend a patient get their FSH (follicle stimulating hormone) and estradiol tested. This is a blood draw on the 2nd or 3rd day of your period.

As background, in the beginning of the menstrual cycle (cycle days 1-5), the pituitary gland in the brain secretes Follicle Stimulating Hormone (FSH) to stimulate the ovaries to select and grow an egg for the cycle. Measuring the levels of FSH and Estradiol (estrogen) on cycle day 2 or 3 (first day of FLOW is cycle day 1) provide us with an assessment of the quality of the eggs.
A semen analysis for the male partner should also be performed. The semen analysis is the measurement of 4 different properties of a single ejaculate:

1. Volume – the amount of the ejaculate measured in cubic centimeters (cc’s).

2. Count – the concentration of sperm, measured in million of sperm/cc.

3. Motility – the percentage of sperm that are moving, i.e. living.

4. Morphology – the percentage of sperm that are normal in shape.

FSH, estradiol, and semen analysis testing can be ordered by a gynecologist and give the fertility physician an idea of how well the female patient is ovulating and the quality of semen the male partner is producing. These tests are what I would describe as the “bare minimum” and a physician might order additional tests after evaluating the patient’s individual case.

Insurance Coverage
Infertility insurance coverage is a complex issue and a detailed discussion is beyond the scope of this post. (For more info, read my recent post, “A Guide to Infertility Insurance”.) However, I did want to remind patients of the importance of researching their insurance company and/or employer as to the extent of fertility coverage, if any. The outcome might be good (patient has infertility benefits) or bad (patient does not have infertility benefits). Either way, one will know what to expect when the bill arrives, which can help financial planning. The way I see it, outside of winning the lottery, most “surprises” involving money are not welcome.

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When to See a Fertility Specialist

Patients are often confused about when the appropriate time is to see a specialist. There are many factors to consider before making the decision to see a specialist. Some factors to consider are age, tubal disease, a very low sperm count, and obtaining a proper diagnosis:

Age is the most common cause of infertility. Many people get pregnant in the first 3 to 6 months after stopping contraception. If your cycles are regular and you are under 35, seek help from your OB/GYN or reproductive endocrinologist and infertility specialist after 12 months of trying. If you are over the age of 35, begin fertility testing after trying to conceive for 6 months. If you are over 39, testing should begin within 3 months. If your cycles are not regular, seek help immediately.

Tubal disease If the fallopian tubes are blocked, a specialist should be consulted before proceeding with treatment such as surgery. The surgery for damaged tubes is often not successful and can increase the chance of tubal pregnancy. IVF can be a much more successful treatment and no surgery is necessary. If the fallopian tubes are blocked at the end and filled with fluid, hydrosalpinx, surgery is appropriate prior to IVF. Consultation with the specialist can determine the appropriate procedure. Their expert assessment can help prevent unnecessary second surgeries to perform the appropriate procedure.

Very low sperm count Patients should seek a specialist as soon as possible if the sperm count is very low or zero. Inseminations, fertility pills, and surgeries are usually ineffective with this diagnosis. These unnecessary medications and procedures can waste your time and money.

Proper identification of the cause of infertility is crucial to the most cost effective, and timely treatment. An infertility specialist can help you avoid unnecessary procedures, such as the advisability of laparoscopy when no symptoms of endometriosis or no history of infections are present and avoid tests of limited usefulness.

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Ovarian Reserve and FSH

FSH Levels One of the most important indicators of a women's ovarian reserve (egg quality/quantity) or reproductive potential is the follicle stimulating hormone (FSH). It is not, however, a perfect screening for egg quality and/or quantity.

FSH, a hormone produced by the pituitary gland in the brain, is released into the bloodstream and travels to the ovary where it stimulates immature follicles containing microscopic oocytes to eventually develop a mature oocyte (egg). Early in the menstrual cycle, if the blood level of FSH is high, it indicates that the pituitary is working hard to stimulate the ovaries, therefore, the number and perhaps quality of the remaining eggs is decreased. FSH is tested on day 2 or 3 of your cycle to provide a baseline measurement. An elevated FSH level above 8 might suggest that a woman is starting to experience the loss of her ovarian reserve. Menopausal women show FSH levels that are above 40. However, there are several variables, and as with many issues surrounding infertility, it has much to do with age.

Proper interpretation of FSH levels requires a simultaneous measurement of blood estrogen (estradiol) levels. Estradiol is made by the ovary, enters the blood stream and travels back to the brain (pituitary) to help regulate FSH release. Early in the cycle, day 2 or 3, it should be less than 60. A high level of estradiol, above 80, indicates that estradiol is suppressing the pituitary and providing an inaccurate FSH reading.

Several studies have set out to determine whether women with elevated basal FSH levels should be excluded from fertility treatment. A comprehensive study in the United Kingdom analyzed over 2000 patients for four years undergoing IVF treatment. Although it found no significant correlation between FSH levels and fertilization rates or miscarriage rates, the pregnancy rates and live birth rates were lower among women with higher FSH levels. Elevated FSH levels were also associated with more frequent cycle cancellation, need for larger amounts of stimulation medication, and lower numbers of eggs and embryos with fewer embryos transferred. However younger women, even with high FSH levels, had significantly greater live birth rates compared to older women with normal FSH levels. Again, age matters, despite a normal FSH value.

A normal FSH reading, although reassuring, may be indicative of egg quantity but not necessarily quality. The follicles may be producing mature eggs, however, the quality of those eggs may not be adequate. This is especially true for women over 40 years old. Another caveat is that most women have variable FSH readings from one cycle to another. The best indicator of treatment response, however, is typically the highest FSH reading. There is no benefit, therefore, in repeated testing of FSH over several cycles and choosing to undergo an IVF cycle when the FSH is normal.

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A Guide to Infertility Insurance

I am often asked which insurance company has the most favorable coverage for infertility treatment. Unfortunately, the answer is not that simple. The package of insurance coverage for infertility treatment is not up to the insurance company, per se. It is typically up to an employer to determine the scope of coverage that is offered by its insurance company, and whether that package includes compensation simply for diagnosis of infertility, or whether it also covers treatment.

Moreover, one cannot assume that coverage will be the same from one employer to another even if that company uses the same insurer. For instance, an employee of Bank of America with Kaiser coverage might have a completely different insurance package for infertility as compared to an employee of Wells Fargo who also has Kaiser insurance. Through negotiation, an employer may choose an insurance plan with more or less infertility coverage than the average plan.

Another caveat has to do with state regulations. A total of 12 states in the United States have passed laws mandating infertility insurance coverage. However much of this regulation is considered a "soft mandate" meaning the insurers only have to offer it to employers who can choose to take it or leave it. California (where I practice) has a soft mandate so companies here are not legally obligated to purchase coverage for its employees. A more forceful "hard mandate" requires a company to actually provide it, not just offer it. Massachusetts and Illinois are two states that have this hard mandate. An exception to this is when a company is self-insured and is not legally required to follow state mandates. Because the majority of people with employer-sponsored health insurance policies are "self-insured", the mandates do not apply to the majority of people, even in states with mandates.

Obviously, people who are self-employed and therefore pay for their own insurance might have a greater motivation to research those insurance companies that might have more comprehensive infertility coverage.

As you can tell, the nature of infertility treatment and insurance coverage is a complicated issue. We encourage patients to research infertility coverage with their insurance company and employer.

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