Shedding Holiday Pounds

The Holiday Season is upon us. As many of us know all too well, Holidays and weight gain can go hand-in-hand. While exercising away those extra pounds is typically the right thing to do, for those who are conceiving, exercise habits need to be tempered a bit.

My colleague Philip Chenette, MD was kind enough to share his insights on this issue:
Before you jump on that bicycle, be aware that there is considerable debate about the impact of exercise on fertility. A sudden and extreme change in your diet or work out regimen can have hidden consequences. Too strenuous exercise can lower estrogen levels and suppress the hypothalamus and pituitary gland, leading to irregular ovulation. Some women who exercise vigorously cease menstruating and ovulating all together.

In fact, because the research on even moderate exercise has been inconclusive, some reproductive endocrinologists advise their female patients to avoid all exercise that brings the heart rate above 110 beats per minute. This pretty much rules out jogging, aerobics and biking but not necessarily yoga and weight lifting.

Both women and men need some body fat in order to reproduce. (Although overweight women experience more hormonal imbalances because excess weight can cause excessive production of estrogen.) Body Mass Index measures the ideal level. Women who have a BMI of between 20 and 25 are most fertile.

As far as the male factor, the most important thing to remember is that sperm are very sensitive to heat. Taking saunas and hot tubs are enjoyable side benefits at many exercise clubs, but these heated conditions can greatly diminish healthy sperm counts. Bicycling is the main sport that is best avoided by men who want to maintain optimal conditions for reproduction.

Permalink | 0 Comments| Email Post

Post your comment

3D Ultrasound Enhances Diagnosis

For some women, infertility is caused or exacerbated by having a uterus with congenital abnormalities that cause it to be misshapened. These uterine anomalies can lead to greater difficulty with embryo implantation and/or cause higher rates of miscarriage.

Until recently, a physician’s capacity to properly diagnose this problem has been limited to a hysterosalpingogram (x-ray with dye); a MRI (magnetic resonance image); a laparoscopy (surgery which limits the evaluation to the outer contour of the uterus); or a standard 2D ultrasound. The emerging technology of 3D ultrasound is starting to provide a highly improved, noninvasive, more cost effective option. Fortunately in the Bay Area, women can obtain a 3D ultrasound at the CPMC OB/GYN Ultrasound Suite which is directed by Dr. Lourdes Scheerer and two other physicians, Drs. Claire Serrato and Shelly Zaglin.

An ultrasound uses high-frequency sound waves (between 3.5 to 7.0 megahertz) sent through the body via a transducer or a scanner that is placed either on the lower abdomen or inside the vagina. The ultrasound beams scan specific areas of interest within the abdominal cavity and are reflected back onto the transducer to produce an “echo” image of the internal organs. This process had been shown to be both safe and effective.

There are several reasons why a physician would want a 3D image of the uterus, explains Dr. Scheerer. By using a 2D ultrasound one can assess the shape of the uterine cavity, but cannot assess as clearly the positioning relative to other pelvic organs (ovaries) nor the contour of the uterus itself. This information is important in assessing a possible abnormality of the uterus, and on deciding appropriate intervention.

There are some congenital anomalies of the uterus that can impact an embryo’s ability to implant and develop within the cavity. If a woman has an abnormally formed uterus, this can cause a higher incidence of miscarriage or be an obstacle to carrying a pregnancy to full term. In women experiencing unexplained repetitive miscarriages, it is important to rule out the possibility of uterine anomaly as the cause. Women with uterine anomalies can also experience higher rates of preterm labor, bleeding during pregnancy, diminished fetal growth, and fetal malpresentations (such as breech), which lead to a higher rate of Cesarean delivery.

A typical uterus is shaped like a small pear and the cavity within has a hollow triangular form. The uterus develops inside a female fetus by the fusion of two separate halves (Mullerian ducts) into a single organ. The uterus subsequently becomes hollow, creating a normal cavity. Abnormalities in the shape of the uterine body and/or the uterine cavity are called “fusion” defects because they arise from failure in the aforementioned unification and hollowing process. If there is failure of the uterine body to fuse completely, the uterine shape will be abnormal. Because the ovaries are derived from different fetal tissues, the development of the ovaries is not affected by Mullerian defects.

Failure of fusion and hollowing can present as a spectrum of abnormalities from a simple dimpling of the top of the uterus as seen in this arcuate shaped uterus


Arcuate Shaped Uterus

One of the most common abnormalities is a bicornuate uterus.


Bicornuate Uterus

As shown here, a bicornuate uterus has two uterine horns. Pregnancy within a bicornuate uterus typically occurs within one of the horns and pregnancy outcome is usually as normal as for a fully developed uterus. Surgery is not required for this kind of an abnormality.

The uterine abnormality most commonly associated with miscarriages is a uterine septum


Septated Uterus

This is an abnormality of the hollowing process where a residual midline septum is present. Normal uterine lining does not grow over a septum, so if the embryo implants in the septum, it will not have an adequate blood supply for growth. The traditional way to correct a septum was performing an abdominal surgery called a “metroplasty”, where the septum was removed, and the uterine walls sewn together. This surgery was not very successful, and nowadays we can remove a septum by hysteroscopy, which provides a much more successful outcome. For a uterine septum, surgery is the correction.

Understanding the type of uterine defect one has is critical, because this will determine if surgical intervention is needed to optimize one’s chances of a successful pregnancy.

A 2D ultrasound can suggest that an abnormality is present, but does not necessarily differentiate among subtle abnormalities. The advantage of 3D ultrasound is that it will better define the specific defect present. Based on this improved image, the best recommendation can be made. 3D ultrasound provides a cost-effective imaging modality, which gives good resolution when differentiating Mullerian anomalies.

Dr. Scheerer reports that 3D ultrasound can also be helpful in differentiating the location of abnormal pregnancies. For example, the improved imaging can be helpful in distinguishing a tubal ectopic pregnancy, versus a corneal pregnancy.

The technology that makes 3D ultrasound so reliable is evolving rapidly, partly due to the sudden popularity among pregnant women who want the better-defined early fetal images for their baby books. While this is currently “in vogue”, it is important to understand that there are no long-term studies looking at the effects of 3D ultrasounds in pregnancies.

While we don’t endorse the use of 3D ultrasound strictly for photo opportunities, we think it is a very valuable tool for finding and evaluating certain uterine abnormalities. This information gives us the opportunity to optimally treat each individual person and maximize the chance for a successful pregnancy.

Permalink | 1 Comments| Email Post

Post your comment

Endometrial Lining and Post-Transfer Bed Rest

I recently saw a patient in my practice, Pacific Fertility Center, who had recently undergone a retrieval and she inquired about a couple matters that I get asked about all the time. For starters, she inquired as to what is the optimal endometrial lining on the day of the HCG shot (i.e. 36 hours before egg collection); i.e. 9 mm, 10 mm, 11mm, 12 mm, or greater; additionally, she inquired about the value of bed rest following an embryo transfer.

For starters, as long as the endometrial thickness reaches 8-9 mm with a good pattern, the pregnancy rates should be fine. There isn’t any strong evidence that endometrial thickness beyond 9mm (i.e. 10, 11, 12 mm etc.) will produce higher pregnancy rates.

Furthermore, bed rest is not necessary after an embryo transfer. Gravity does not play any role in implantation success, i.e. embryos do not fall out. We recommend you try to live as relaxed and stress free a life style you can. Eat a normal balanced diet with your prenatal vitamins and avoid exercise until the pregnancy test.

If this scenario sounds familiar to you, or if you have any additional questions, drop me a line. I’d love to hear from you!

Permalink | 0 Comments| Email Post

Post your comment

Coping Through the Holidays

Following Halloween, the holiday season suddenly looms. Excited children, crowded stores, decorations, and holiday parties are all set to descend on us. Yet because the winter holidays tend to celebrate families and children, these usually joyous occasions can bring up painful feelings when you are struggling to create and celebrate with a family of your own. In order to feel as good as possible during the holidays, you will need to develop some good holiday coping skills. Coping is "developing the ability to manage in a difficult situation."

Here are a few suggestions from my colleague at Pacific Fertility Center, Peggy Orlin, MFT. Use whichever of these suggestions seems helpful to you. Do what feels right for you.

DO: Give up any and all feelings of guilt for how you are feeling. There is no right or wrong way to experience infertility. Your feelings may run the gamut from indifference to intense anger and despair and everywhere in between.

DO: Reach out to childfree friends. Their parties will be adult-focused.

DO: Choose the gatherings you attend carefully. If you are upset by being around children or babies gracefully decline invitations to events where they are likely to be present. Know your limits and stick with them.

DO: Think of non-child centered holiday rituals. Take a vacation. Eat at a fancy restaurant.

DO: Continue to get moderate amounts of exercise. Eat healthy and get plenty of rest. You will feel better if you treat your body with care.

DO: Shop for the holidays online or from catalogs. You will avoid mall madness.

DO: Attend religious services at the time when there will be the least number of children. Or attend on a university campus, as those services tend to be more adult focused.

DO: Volunteer at a nursing home or homeless shelter. It may help to help others having a difficult time at the holidays.

DO: Plan for how you will answer uninvited questions about when you're going to have children. Remember, you are not required to tell them your entire "story!"

DO: Meet and talk with others who are experiencing similar feelings. Finding that you are not alone helps.

DO: Communicate with your partner to let him/her know of your feelings. If you are single, call a friend with whom you feel safe to share your feelings.

Permalink | 0 Comments| Email Post

Post your comment

How Embryos Make the Grade

Where I practice, many patients are curious as to how we evaluate the quality of an embryo. My colleagues Carolyn Givens, MD and Joe Conaghan, PhD, HCLD, where kind enough to share their insights on this topic:

Patients are often awestruck when they see a photo of their embryos for the first time on the morning of their transfer. That morning each embryo is carefully observed under a powerful microscope and the information about the quality of the individual embryos is given to patients prior to their transfer. There are three pieces of evaluative information patients receive about each of their embryos: the number of pro-nuclei, the number of cells present and the grade of the embryo. Using this information, decisions are then made about how many embryos to transfer and how many to freeze, and importantly, what to do with embryos that are not developing very well.

For the most part, the process of gauging the quality of an embryo involves a lot more than what meets the eye. Embryo evaluation, a standard practice in fertility clinics worldwide, allows embryologists to provide you and your physician with valuable information about your embryos, and about your fertility.

When eggs are retrieved from a patient’s ovaries, they are surrounded by thousands of helper cells that prevent us from seeing eggs directly or making any comments about quality. For patients having ICSI (Intra-Cytoplasmic Sperm Injection), we strip away the helper cells, but even then, very little information on quality can be ascertained. Only when eggs are of particularly poor quality are we able to observe obvious differences from healthy eggs. The vast majority of eggs do not show any characteristics to indicate quality. Therefore, the embryologist will not typically convey any information about egg quality.

For most patients, about 70% of their eggs will fertilize, regardless of egg quality (see Fertility Flash Vol 3 Issue 3 for more details). And fertilization is not necessarily an indication of things to come. A high rate of fertilization does not suggest better embryo quality.

The first step in embryo evaluation is examining fertilized eggs for the presence of two pro-nuclei (PN) in their centers. Each of these pro-nuclei contain the DNA from one parent, and in 95% of fertilized eggs they are unremarkable. In a small number of fertilized eggs however, we do see nuclear abnormalities such as asymmetry of size, any number other than 2, or failure to align in the egg center. These unusual abnormalities do suggest abnormal embryos, and we make patients aware of these. Each embryo will be noted for its number of pro-nuclei, e.g. 2PN or 3PN.

All of the fertilized eggs or embryos are kept in the laboratory for a minimum of 48 hours prior to the embryo transfer procedure. Only eggs that are grossly abnormal, such as those fertilized by more than one sperm, are discarded. Even eggs in which we see no evidence of fertilization are kept in case they fertilize late. No further observations are made until close to the time of transfer as the embryos must be left undisturbed in the laboratory incubator.

While incubating, the fertilized egg begins to divide. This first round of cell division happens within 12 hours of fertilization and thereafter, the cells in the embryo divide in two about every 16 hours. This continuous process of cell division is a very important indicator of embryo health as the embryos have only 4 to 5 days to make enough cells for implantation in the uterus. When we look at the embryos on their third day of life, we expect to see about 8 cells. Many embryos will have close to this number, and some will even have more, but embryos that are significantly delayed with 4 cells or fewer will have very little chance of establishing a pregnancy. Counting the number of cells in an embryo is the most important part of assessing their quality. We will give patients this cell count for each of their embryos.

A much less important aspect of determining quality involves observing the integrity of the cells. Some embryos will have uneven or asymmetrical cells and some will have one or more cells that are disintegrating. Cellular fragments that result from this disintegration are only an indicator of quality when they are severe, or when most or all of the embryo has broken up. Fragmentation is a normal feature in embryos and only about 20% of embryos have no fragments at all. However, the absence of fragments does not guarantee pregnancy, as there are many other factors involved in embryo quality.

This degree of fragmentation and cell asymmetry is given as a grade, usually 1, 2 or 3. Grade 1 embryos look beautiful and normal in every way. Grade 2 embryos will have a small degree of fragmentation and or unevenness, but are still considered high quality. Only if an embryo is in real trouble and has more fragments than cells, will we assign the dreaded Grade 3. These embryos very rarely implant after transfer and are not considered viable enough to freeze regardless of how many cells they contain.

While cell number is a very important predictor of embryo quality, grade is mostly most useful in deciding which embryos to transfer or freeze. Grade allows us to rank embryos when there are several embryos with the same cell number, and grade is only loosely associated with quality. Embryos that are given a poor grade are unlikely to implant after transfer, but other factors are much more important in establishing a pregnancy. A patient’s age for example is the best predictor of pregnancy, regardless of embryo grade. Also there is no correlation between embryo grade and genetic status. Genetically abnormal embryos are just as likely to be Grade 1 as genetically normal embryos. Moreover, a pregnancy from a Grade 3 embryo has no more increased risk of birth defects than a pregnancy from a Grade 1 embryo.

Joe Conaghan, PhD, HCLD and Carolyn Givens, MD,
Fertility Flash (SM), April 2005, Vol. 3, Issue 4

Copyright © 2005 by PFC. All Rights Reserved

Permalink | 7 Comments| Email Post

Post your comment

Clomiphene Citrate Challenge Test

There are a variety of diagnostic tests for infertility. One that you might have heard of is the clomiphene citrate challenge test (CCCT), also referred to as the Clomid challenge test. It is a method of assessing the age-related decline in fertility or “decreased ovarian reserve.” As women age, so do the eggs in their ovaries, which over time leads to lower pregnancy rates and higher miscarriage rates. It is difficult to accurately predict the age-related decline in fertility for an individual patient without doing hormonal testing. The most comprehensive test for assessment of ovarian reserve is the CCCT.

The CCCT is usually recommended for patients 38 years of age or older, those with unexplained infertility, those with a prior history of ovarian surgery, those with poor responses to fertility medications, and those where other symptoms may be suggestive of decreased ovarian reserve (such as shorter menstrual cycles).

The test is performed as follows:

• On menstrual cycle Day 2 or 3 (second or third day of flow), have a blood test for FSH and Estradiol

• Take Clomiphene Citrate, 2 pills per day (100 mg total dose) from cycle Days 5-9

• On cycle Day 10, have a blood test for FSH

Your physician will interpret the tests results and provide you with an assessment.

The most common side effect of clomiphene citrate is flushing; these symptoms usually end by day 11. Other side effects include headache, breast tenderness, nausea, and vaginal dryness. Clomiphene should be discontinued if visual side effects are present (e.g. Blurry vision).

You can try to conceive during your CCCT month. There is an increase in the chance of twins to 5 – 10% chance, but multiple births greater than twins are rare.

Permalink | 0 Comments| Email Post

Post your comment

AFRAID of IVF?

You’re not alone. Many couples, when faced with the possibility of needing to undergo fertility treatments, much less in vitro fertilization, react with disbelief and fear. Most of what we know about fertility treatments are the unpleasant things we hear in the media, from well-meaning friends, family and even from the most casual of acquaintances. Yet it is possible that many women you know have safely and successfully undergone IVF without serious disruption to their lives and with a minimum of discomfort.

So what is the truth? Is the process of fertility treatment and in vitro fertilization really the house of horrors it is rumored to be? If the idea of having to undergo fertility treatment or in vitro fertilization causes you to have serious concerns, please take a moment to read this. We would like to address some of the most common fears associated with undergoing IVF treatment and demonstrate how, with modern medications and compassionate care, the process can be much less unpleasant than you might imagine.

“Aren’t the injections painful?”

Most women have heard that a series of painful injections of fertility drugs must be undertaken during the IVF process. Some of the hormones used to stimulate multiple egg development are large protein molecules and cannot be given orally. However, the new technologies for the manufacture of these medications have helped us minimize the number of injections needed and the size of the needles used to administer the medication.

One of the common medications used for IVF is a drug called Lupron. Lupron works to temporarily shut off the hormonal signals from the brain to the ovaries and thus prevents the eggs from being ovulated before they are ready to be harvested for the IVF procedure. Lupron is usually self-administered for about 21 days by injection with a small needle under the skin, similar to the way diabetics take daily insulin injections. There is an equally effective alternative to Lupron called Synarel that can be administered by nasal spray, thus avoiding the 21 days of injections. At Pacific Fertility Center, where I practice, our physicians have had over 15 years of experience using Synarel for IVF and have published journal articles demonstrating how effective Synarel is for this purpose. Another common medication now used to prevent an LH surge in an IVF cycle is Antagon or Cetrotide. These new medications are given by injection but, rather than 21 days of Lupron, Antagon and Cetrotide are usually given for 3-4 days.

Many of the older drugs, such as Pergonal, Metrodin and Humegon, used in IVF to stimulate multiple egg development had to be administered by intramuscular injection, deep into the muscle of the buttocks. This technique was used because these older medications were less pure than the medications available today and a larger volume of fluid had to be given with each dose. Thanks to recombinant DNA technology, we now have medications such as Gonal-F and Follistim that are extremely pure, can be dissolved in small amounts of liquid and injected just under the skin (subcutaneous) with a small needle. These medications are usually injected over a period of ten to eleven days plus or minus three days. The newer drugs are as effective as the older drugs, perhaps more so. There is now a pre-filled “pen” injection system much like a ball point pen which holds a cartridge of premixed medication. The only remaining medication that still must be given by intramuscular injection is hCG. HCG is a single injection given 36 hours prior to the egg retrieval procedure.

During the IVF process, it is necessary to supplement the ovary’s production of progesterone to help implantation and early pregnancy. Many clinics still use deep intramuscular injections of progesterone (which must be dissolved in an oil base). Some women are prescribed these injections for as long as 100 days in a row. At Pacific Fertility Center, where I practice, we have been offering progesterone vaginal suppositories or capsules as progesterone supplementation for many years, thus avoiding progesterone injections altogether. We know from our success rates that this treatment is as effective as injections. Unfortunately, for recipients of donor eggs whose own ovaries do not make any progesterone, injection is still considered the only form to adequately provide support.

In addition, the physicians at PFC are advocates of using natural cycles for frozen embryo transfers whenever possible. This protocol can significantly minimize both the amount of medications required and the costs of the procedures for most patients. There is no difference in the success rates of frozen embryo transfer cycles comparing a natural cycle to a programmed cycle, which uses estrogen and progesterone injections routinely.

Using our protocols at PFC, a woman who wishes to minimize the number of injections in her IVF cycle, may need only 10-11 days of subcutaneous injections and one intramuscular injection of hCG. That’s it!

“Are the procedures painful?”

The only procedure that could be considered a minor surgery in the IVF process is the retrieval or harvest of the eggs from the ovary. This is done by introducing a needle attached to a vaginal ultrasound probe through the wall of the vagina and into each ovary.

If you were to undergo this procedure without any anesthetic, it would likely be painful. We are able to take advantage of an array of excellent anesthetic medications that are administered through an intravenous line, are rapid in onset of anesthetic effect, and wear off quickly when the procedure is over. Our patients breathe completely on their own during the approximately 20 minutes of the procedure, but sleep deeply enough to be completely unaware of any discomfort. After the retrieval procedure the patient wakes up relatively quickly and, at most, may feel some minor cramping in the ovaries, which can also be treated with very safe medications.

At PFC, each patient at every egg retrieval procedure is closely monitored by a fully board certified M.D. anesthesiologist. We can safely provide as much anesthetic as may be necessary for complete pain relief during the procedure.

“Will my baby suffer birth defects?”

In 1977 the first baby was conceived through in vitro fertilization. This then radical new method of human conception raised significant concerns about whether babies born from the procedure would be “normal.” When Louise Brown was born in England nine months later, she appeared to be a perfectly normal infant girl. However, scientists and physicians knew that much more data was needed to determine whether the rate of birth defects was higher in children conceived in the in vitro laboratory.

It is important to note that the rate of birth defects in humans in the general population is about 3% of all births for major malformations and 6% if minor defects are included. Fortunately, 20-plus years following Louise Brown’s birth, we now have ample data that children conceived through IVF have no increase in these rates of birth defects, outside of the use of ICSI. Further follow-up on older children indicates that IVF children have done as well or better than their peers in academic achievement (probably a social bias) and have no higher rates of behavioral or psychological difficulties.

“Will the hormones cause long-term health risks?”

The only long-term health risk that has ever been suggested to be associated with the use of medications used for IVF is the possibility of an association between these drugs and the risk of cancer, specifically ovarian cancer.

An important facts to keep in mind is that women who suffer from infertility and have never conceived appear to have a slightly increased risk of ovarian cancer as compared to the general population (about 1.6 times the rate). As these are the women who use fertility medications, the medications themselves have been implicated in the cancer risk. However, these medications have never been proven to be a cause of cancer. Since this initial concern was raised in a 1992 study by Whittemore and colleagues, several studies have addressed the issue more directly. These studies from Australia, England and Denmark all find no association between fertility medications or IVF treatment and a higher risk of ovarian cancer.

An ongoing National Institutes of Health-funded study in California is specifically designed to address the question of whether fertility medications themselves may play a causal role in ovarian, breast or uterine cancer. While the study is still under way and needs another 5-10 years of follow-up to be conclusive, preliminary results suggest no association between fertility medications and risks for invasive cancers. At this time, we can say that there is no direct evidence that fertility drugs play a causal role in increasing a woman’s risk of invasive ovarian, breast or uterine cancer.

“Will the hormones make me a raving maniac?”

A common misconception is the notion that women become emotionally unstable and out of control while taking these hormone injections, both during the stimulation process and beyond. Why does this notion exist?

One potential reason for this misconception is that the injectable medications are perceived to be “stronger” than the other common oral fertility drug, clomiphene. While it is true that injectable hormones are more powerful in terms of recruiting more eggs, the manner in which they work is completely different from clomiphene. Clomiphene is an anti-estrogen and “tricks” the brain into thinking there is no estrogen available. The brain responds by putting out more natural FSH hormone to stimulate the ovary. Because the brain perceives there is no estrogen available, the brain reacts similarly to menopause. The symptoms of temporary hot flashes, mood changes and irritability are a result. Conversely, the injectable medications such as Gonal-f and Follistim contain pure FSH and stimulate the ovaries to make more estrogen. Estrogen is a hormone that has a positive effect on the brain, hence no hot flashes. It is uncommon to see significant mood changes or irritability on these injectable medications.

Undergoing IVF treatment can be stressful and it is possible that some of the hormones accentuate whatever a woman’s prevailing mood is at the time. Couples may often feel conflicting emotions of hopefulness, apprehension and uncertainty. We recognize these feelings are normal human responses to this type of stress. The vast majority of our IVF patients say that the process was not as emotionally difficult as they had anticipated. We strongly recommend that couples seek the information and support they need. PFC provides an on staff marriage and family therapist experienced in fertility issues. RESOLVE is a national organization that is an advocacy and support group for couples coping with infertility and can be an important resource for both emotional support and unbiased facts.

Permalink | 0 Comments| Email Post

Post your comment

Intrauterine Insemination

I’ve spent a significant amount of time discussing the infertility treatment in-vitro fertilization (IVF). While IVF is an outstanding treatment for many patients, there are instances when the treatment intrauterine insemination (IUI) is a viable option. Most fertility clinics, including where I practice—Pacific Fertility Center, perform IUI. Intrauterine insemination (IUI) is the process of preparing and concentrating a sperm specimen for the most active motile sperm and placing the washed sperm into the uterine cavity. Intrauterine insemination is often recommended because studies have shown that pregnancy is more likely to occur if timing of exposure to sperm is controlled, and if sperm is placed in higher numbers in the uterus.

IUI is often recommended for women or couples who:

- have ovulatory dysfunction and are undergoing ovulation induction;
- are unable to have normal intercourse with ejaculation into the vagina at
appropriate times;
- have mild male factor infertility;
- have unexplained infertility;
- are using donor sperm;
- have failed other treatments, such as Clomiphene alone.

In some cases, IUI is performed in natural cycles without the use of any fertility medications. However, studies in the fertility literature have demonstrated that, especially in combination with clomiphene citrate (Clomid or Serophene) or gonadotropin (Gonal-f, Repronex or Follistim) administration, IUI significantly increases chances of conception.

The Intrauterine Insemination Process

There are many techniques available for preparing the sperm, most of which are derived from in-vitro fertilization laboratory techniques, or from study of sperm behavior in the laboratory. The goal in sperm processing is to separate the sperm cells from the seminal fluid, fluid that can be irritating to the uterine lining. In the process, the most active, motile sperm are concentrated and separated from dead sperm, cellular debris and bacteria.

The sperm can be collected at home and brought to our office within 1.5 hours or can be produced in our clinic’s sperm collection room. The laboratory will then perform a sperm count and motility evaluation and prepare the sperm. The usual preparation procedure takes about two hours. After preparation, the sperm concentrate is placed into the uterus, through the cervix, using a small catheter. Some of the sperm will also be placed directly into the cervix. The actual insemination process takes approximately 5 to 10 minutes.

In the vast majority of cases, IUI is a completely painless process. Some inseminations are accompanied by cramping, but this is usually very mild and transient. It is not necessary to remain lying down after the procedure and you may immediately resume your usual activities.

Preparing for an IUI Cycle

During your consultation with your physician, you will create a treatment plan. Some couples need testing done to determine the best treatment option. These tests vary, depending on the evaluation already completed and the reason for considering IUI. Will the test help to diagnose your infertility? Will it change your individual treatment plan? Is the information worth the expense of the test? In most cases, the status of the fallopian tubes needs to be determined and ovulation needs to be verified. In addition, the quality of the sperm needs to be assessed. All women who have regular menstrual cycles should have a cycle day 2 or 3 FSH and estradiol blood level test.

In California, where I practice, every husband/partner/donor giving a semen specimen for IUI must be tested for infectious diseases. This testing is required by California State law and must be complete, with results in our office, before an IUI can be done. There are no exceptions to this policy. The specific tests required are HIV, HTLV I, RPR/VDRL, Hepatitis B Surface Antigen, and Hepatitis C Antibody. Depending on the lab used and/or the doctor ordering the testing, the test results can take 7 days to 2 weeks to arrive in the fertility clinic. We advise all those considering IUI to have these tests done as soon as possible to avoid added stress at treatment time. Patients are responsible for ensuring that these lab tests are their medical records. Once testing is complete, a woman can waive repeat testing for subsequent treatment cycles by signing a waiver.

Permalink | 0 Comments| Email Post

Post your comment

Hydrosalpinx

A hydrosalpinx is a fallopian tube that is filled with fluid. Injury to the end of the fallopian tube, the ampulla, and its delicate fingers, the fimbria, causes the end of the tube to close. Glands within the tube produce a watery fluid that collects within the tube, producing a sausage shaped swelling that is characteristic of hydrosalpinx.

Causes

The tubes are prone to injury. The fimbria are the delicate fingers that extend from the funnel-shaped end of the fallopian tube to the ovary. The fimbria actively search out the egg after it is released, or ovulated, and carry the egg to the waiting sperm within the fallopian tube. The fimbria are lined with delicate cells that contain the actively moving hair-like cilia, which move the eggs and sperm together. With injury, not only are the fimbria themselves injured and fused together, but also the delicate lining cells are lost. Fluid collects within the closed tube. A normally rich and supportive tubal environment becomes the dead sea of the hydrosalpinx.

Hydrosalpinx is a result of injury to the tube, usually from an infection. The classic causes of hydrosalpinx are chlamydia and gonorrhea, which can run undetected for years, slowly injuring and destroying the delicate fimbria. IUDs, endometriosis, and abdominal surgery sometimes are associated with the problem. As a reaction to injury, the body rushes inflammatory cells into the area, and inflammation and later healing result in loss of the fimbria and closure of the tube. These infections usually affect both fallopian tubes, and although a hydrosalpinx can be one-sided, the other tube on the opposite side is often abnormal. By the time it is detected, the tubal fluid usually is sterile, and does not contain an active infection.

Not only does a hydrosalpinx cause infertility, it can also reduce the success rate of fertility treatment, even those treatments that bypass the fallopian tubes. The blocked tube can communicate with the uterus, and the fluid in the tube can be expressed out of the tube into the uterus. This fluid is probably somewhat toxic to early embryo development, and certainly provides an unfavorable environment. The large volume of the fluid flow back into the uterus and can produce enough flow that embryos find it difficult to attach, since they have no ability to move against the tide. Fertility drugs may cause the fluid to build up in the tube, since the tubes are responsive to the ovarian hormones produced during fertility drug therapy.

Complications

Hydrosalpinx can be hazardous during fertility evaluation and treatment, since it is prone to re-infection. Hysterosalpingogram is a particular problem, since the dye can inadvertently introduce bacteria into the tubes, and a serious infection can result. Fertility procedures like insemination and embryo transfer can cause similar problems. Infection in a hydrosalpinx, salpingitis, can be a serious surgical emergency and result in hospitalization.

Evaluation

Hydrosalpinx can be evaluated with several maneuvers:

The hysterosalpingogram (HSG) is a procedure in which dye is placed through the cervix and into the uterus and fallopian tubes. An X-ray picture then reveals the outline of the uterus and tubes. A hydrosalpinx appears as a large-sausage-shaped dilation of the tubes. The folds that are present inside the tube disappear and a flat bulbous shape is seen. Dye does not spill out of the tube.

Ultrasound uses sound waves to image the tubes, and is somewhat safer than HSG and more comfortable. The best view, most of the time, is obtained with a vaginal ultrasound probe. A normal fallopian tube is usually not visible; a hydrosalpinx appears as a characteristic sausage-shaped fluid collection between the ovary and fallopian tube. The wall of the hydrosalpinx is often thick and flat. Ultrasound provides a quick and painless screen of the pelvic organs and is an excellent first assessment of the tubes.

Laparoscopy is another means of assessing the tubes, but is generally used only for treatment and not for assessment. In laparoscopy, a small television camera is introduced through the belly button. The pelvic organs can be visualized on a television screen. It has been said that physicians with expertise at video games excel at the hand-eye coordination required to perform these procedures! Laparoscopy is the gold standard test for evaluation, since looking at the fallopian tubes will usually provide the best view of their anatomy.

Diagnostic tests such as ultrasound and HSG are not 100% accurate, and can be misleading, sometimes missing significant tubal disease, and sometimes showing abnormal results when the tubes are actually quite normal. Laparoscopy usually will confirm the diagnostic tests, but can show that tubes that were thought to be normal actually have significant disease, and vice versa. The risks of anesthesia and surgery dictate that laparoscopy is used for definitive therapy, rather than as a diagnostic test.

Treatment

In vitro fertilization is the ultimate fertility therapy. The ability to optimize fertilization rates, place embryos into their correct location, and provide excellent hormonal support to the early developing embryo have vastly improved success rates over the last few years. In patients with hydrosalpinx, the fallopian tubes can be bypassed, since eggs are taken out of the ovary, fertilized in the lab, and transferred back into the uterus. A hydrosalpinx can be repaired, but with improving success rates from in vitro fertilization, should it be?

Hydrosalpinx can be repaired in carefully selected cases, but pregnancy rates remain rather low. Hydrosalpinx can be treated laparoscopically, a procedure known as neosalpingostomy. In neosalpingostomy, an incision is made in the end of the hydrosalpinx and the edges of the incision are folded or flowered back, leaving an open tube. Unfortunately, the tube often closes back up, and the hydrosalpinx has a high recurrence rate.

A small hydrosalpinx is the most successfully repaired. Since pregnancy requires six months to a year after surgery, younger women with relatively healthy ovaries and eggs, and lots of time, tend to have the best success rates. Women with a large hydrosalpinx and those in older age groups do not benefit from surgical repair.

A hydrosalpinx can have adverse effects on pregnancy rates with in vitro fertilization. As success rates with in vitro fertilization have improved dramatically over the past few years, surgical repair of the fallopian tubes holds less appeal. Indeed, the concerns over re-infection of a hydrosalpinx and problems with fluid build-up with fertility drug therapy have raised the stakes for a hydrosalpinx. Removal of a damaged tube reduces the risk of complications of therapy and improves success rates with in vitro fertilization techniques.

Today, most patients with a hydrosalpinx do not try to repair it. Repair can be done in carefully selected young patients with minimal damage to their tubes, but should not be attempted with a large hydrosalpinx in an older woman. In these patients, the tube should be removed, via laparoscopic salpingectomy. Salpingectomy is an easy procedure that takes less than an hour. The risks with an experienced surgeon are low, and the benefits substantial. It is important to choose an experienced surgeon, since considerations of safety and preservation of the ovarian blood supply with improvement to later pregnancy rates require judgment and experience.

Hydrosalpinx is a classic fertility problem that prevents embryos from reaching the uterus and limits pregnancy rates. It can interfere with fertility therapy and cause problems for in vitro fertilization. Fortunately, excellent methods are available to manage the hydrosalpinx. With the proper expertise, such as that provided by a board-certified reproductive endocrinologist, success rates are excellent.

Permalink | 6 Comments| Email Post

Post your comment

Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS), also called Stein-Leventhal Syndrome, is the most common endocrinologic disorder in women of reproductive age. Approximately 5-10% of reproductive age women have PCOS. This syndrome can have many symptoms. However, the two key components defining this disorder must include chronic anovulation (inability to ovulate an egg) and clinical hyperandrogenism (elevated male type hormones).

The various symptoms of PCOS can be irregular or absent menstrual cycles, infrequent or absent ovulation, excess facial and body hair, male pattern balding, acne of face/back/chest, and infertility. Other findings can include an elevated FSH to LH hormone ratio, elevated levels of male hormones, multiple small cysts of the ovaries and elevated cholesterol.

Some women with PCOS also suffer from other subtle endocrine abnormalities. One is insulin resistance, which affects sugar and fat metabolism, and may increase the long-term risks of heart disease, diabetes and high cholesterol. Insulin resistance (IR), the precursor state to diabetes, is present in 35-40% of women with PCOS, even if they are not overweight. Insulin resistance is diagnosed by blood testing, either as fasting glucose to insulin ratio, or as a complete glucose tolerance test (GTT). Long term follow up of women with PCOS reveals that up to 40% develop impaired glucose processing or diabetes by age 40. The prevalence of diabetes in women with PCOS is seven times higher than for the non-PCOS population. Excessive insulin production is thought to promote excess male hormone production, though the actual mechanism explaining this observation is still unclear.

The causes of PCOS are unknown. We do know that the imbalance of the ovarian hormones exists, which prevents the eggs from growing and ovulating every month. Additionally, this imbalance contributes to an excess of male hormone production by the ovaries, which can be worsened by insulin resistance. There is no cure for PCOS, though the various symptoms can be addressed and managed, and therefore help reduce the risk of long-term health consequences.

Numerous strategies are available for women with PCOS wishing to achieve pregnancy.

For overweight women, simply loosing 10-15% of total weight may be enough to allow spontaneous ovulation to occur. If so, then fertility medications would not be needed.

If fertility medications are required, the first and simplest step is to use the fertility pill Clomid (Clomiphene Citrate). We typically start treatment with the lowest dose (50 mg/day), and once a dose which achieves ovulation is determined, we remain on this dose for future cycles.

If ovulation is not achieved using a dose of 200 mg/day, then other strategies have to be investigated. These strategies include using injectable medications (gonadotropins), which are administered using a "low-slow" protocol. When using injectable medications we must be careful to use enough mediation to have one or two eggs grow, but not so much medication that too many eggs grow. This strategy of using low doses of medications, with slow increments in dosage increase, describe the "low-slow" protocol.

If this strategy proves ineffective, then pursuing in vitro fertilization (IVF) is the next treatment option.

In 1935, Stein and Leventhal originally described the syndrome we now call PCOS. Their strategy for treatment was to surgically reduce the size of the ovaries by performing a "wedge resection" (removing a wedge of ovarian tissue). This procedure would result in a decrease in male hormone production by the ovaries, and would allow approximately 80% of the patients to ovulate. Today, we can surgically perform a similar operation called "ovarian cautery or drilling", which is performed by laparoscopy. This procedure is a treatment option for women who fail medications (Clomid or gonadotropins), and who may not want to pursue other available options. Ovarian cautery provides approximately an 80% chance of spontaneous ovulation. Patients who are not spontaneously ovulatory may be more Clomid "sensitive". Therefore, resuming Clomid therapy may now provide ovulatory cycles.

For patients diagnosed with insulin resistance, there is another treatment strategy. Insulin-sensitizing medications can be used to decrease insulin levels, which may help restore the normal ovarian hormone profile (i.e. reduce male hormone), thus allowing for spontaneous ovulation to occur in about 75% of patients. The most commonly used medication is Metformin (Glucophage). There are newer insulin-sensitizing medications available, though these have not been studied extensively in PCOS patients (rosiglitazone maleate (Avantia), pioglitazone hydrochloride (Actos)). Studies with Metformin indicate that most women with PCOS and IR will spontaneous ovulate after 3 months of treatment, or if not ovulatory, will become Clomid "sensitive". One must be carefully screened prior to a course of Metformin, and must be monitored during treatment. Side effects are mostly gastrointestinal (nausea, vomiting, diarrhea).

As with any endocrinologic disorder, patients need a full and complete workup with a physician experienced in that particular disorder. Your reproductive endocrinologist will review old medical records and may ask you to have additional testing. Once all of this information is available, and once a full infertility evaluation is completed (eg. semen analysis, hysterosalpingogram as needed), then treatment options can be reviewed. When you and your partner have decided on the best initial plan, a fertility specialist can proceed with treatment.

Permalink | 15 Comments| Email Post

Post your comment

Unexplained Infertility

People often approach infertility testing with some trepidation, as they may be concerned about discovering abnormalities, and undergoing treatment. However, it is even more frustrating to have completed a fertility evaluation and be told at the end of the process that there is "nothing wrong".

About 85-90% of patients will have at least an educated guess about what is keeping them from conceiving by the end of the evaluation process. For the remaining 10-15% there may be no clear answer. There are causes of infertility that are beyond either our current level of understanding or the present level of sophistication of our testing procedures.

"Unexplained infertility" does not mean "undiagnosed infertility".

"Unexplained infertility" means that all other known diagnoses have been eliminated.

When an individual is diagnosed with "unexplained infertility", a careful review is conducted of their entire infertility evaluation.
• Each test is examined to ensure it was performed correctly and is technically sound.
• The interpretation and/or conclusion drawn from the results is also examined.
• Tests with questionable results may be repeated.
• Further investigation of one or more questionable factors may be conducted.
• If a thorough review still provides no clues or leads, the next treatment strategy is empirical therapy.

Empirical therapy is treatment based on observation or experience with other infertile couples, rather than on conclusive evidence of what is wrong. The justification for empirical therapy is that it frequently works. Through the use of "Assisted Reproductive Technology" or ART, we join hormonal therapy with a form of artificial insemination (i.e. intrauterine insemination, or IVF).

The purpose of ART is to enhance or bypass as many fertility factors as possible. Sometimes these ART techniques are used to overcome known deficiencies, such as using IVF to circumvent damaged fallopian tubes. Because these techniques are based upon enhancement and/or substitution, they can be applied to unexplained infertility patients with the hope that what is being enhanced or substituted is the element responsible for the infertility.

• The following three levels of empirical therapy treatments are presented in the order of increasing success rates, time commitment and cost.
• All steps do not need to be tried before proceeding to the last level.
• Each level involves treatments, which enhance certain factors while bypassing other factors.

The Three Levels of Empirical Therapy Treatments:

Level 1 includes up to three cycles of clomiphene combined with intrauterine insemination, using 100mg/day for 5 days starting on cycle day 3, 4, or 5. Transvaginal ultrasound monitoring will be performed. Half the time there will be two or three mature follicles seen. Once the largest follicle is = 17 mm, hCG is given as a single injection and intrauterine insemination with washed and separated sperm performed 24 to 36 hours later. It is also possible to determine the timing of the IUI based on urinary ovulation predictor kits.

• Using this treatment modality, the ovulatory and male factors are being enhanced while the cervical factor is being bypassed.

Level 2 includes up to three cycles of gonadotropins combined with intrauterine insemination. Gonadotropins (Gonal-F, Follistim, Fertinex, Pergonal or Humagon) are started on cycle day 3 and administered daily as an intramuscular or subcutaneous injection. Transvaginal ultrasound monitoring is begun after four days of treatment and repeated every 1-2 days until 3-6 follicles reach a size of = 17 mm. To induce ovulation, hCG is given as an injection and then intrauterine insemination with washed and separated sperm is performed 24 to 36 hours later. It is also possible to determine the timing of the IUI based on urinary ovulation predictor kits.

• Using this treatment modality, the ovulatory and male factors are being enhanced while the cervical factor is being bypassed.

Level 3 includes up to three cycles of IVF. Gonadotropins are administered as in level 2, but with the addition of Lupron injections or Synarel nasal spray starting either at the same time or one week before the HMG. Transvaginal ultrasound and blood estradiol measurements are done per routine, with hCG administered when at least three mature follicles are detected. Transvaginal ultrasound-guided follicle aspiration is performed 36 hours later, and embryos are transferred into the uterus 3-5 days later. With IVF, further diagnostic information will be obtained, as we are able to observe the fertilization efficiency of the sperm, and the embryo development prior to transfer. This information may provide clues to a prior undiagnosed infertility factor.

• With IVF, the ovulation and male factors are being enhanced and the cervical and tubal factors are being bypassed.

Permalink | 0 Comments| Email Post

Post your comment

Approaching IVF Treatment Options

There are only a few causes of infertility for which In Vitro Fertilization is the only treatment option. These causes are the following: blockage of, or severely damaged fallopian tubes and extremely low sperm count or no sperm in the ejaculate.

For most all other causes of infertility, it is possible that a patient or couple may be able to conceive without assistance or with a less aggressive approach such as intrauterine insemination (IUI).

In developing a treatment plan, the difficulty often lies in estimating the odds of conceiving with any one treatment method, considering the patient's age and diagnosis. We do know that IVF is probably one of the most efficient forms of fertility treatment, in that it usually provides for the highest rates of successful conception for any one treatment cycle. But for some people with less severe causes for their infertility, non-IVF approaches may prove successful and for others, IVF is realistically the best way to achieve pregnancy within a reasonable period of time.

If the female partner is young (for instance, less than 38 years of age), and if the infertility has not been too significantly long-standing, a fertility specialist working with the patient may propose a treatment plan that consists of using fertility medications along with intercourse or intrauterine insemination in order to improve the chances of conception over the chances with natural conception without medical intervention. Whether or not to move directly to in vitro fertilization or to consider other approaches first will depend on a patient's (the female partner) age, diagnosis, and how long she has been trying to conceive.

If a treatment plan is devised including non-IVF treatments, it is usually a good idea to decide at the outset how many cycles of intrauterine insemination with clomiphene, for example, or how many cycles of intrauterine insemination with injectable medications will be undertaken and what to do if the treatments do not work.

In general, as the age of the female partner increases, less aggressive approaches should probably be eliminated and/or the amount of time spent on non-IVF attempts should be limited. Many women will conceive with these non-IVF methods and they should at least be considered and discussed with your reproductive endocrinologist during consultation.

Permalink | 0 Comments| Email Post

Post your comment

Embryo, day three transfer versus Blastocyst, day five transfer

Transferring embryos at the blastocyst stage may be an option for patients in an IVF cycle. As background, a blastocyst is an embryo that has undergone multiple cellular divisions with the formation of a cavity within it. A fertilized egg reaches the blastocyst stage usually 4 to 5 days after fertilization. We encourage the majority of patients in my clinic to have their transfer earlier, on day 3, when the embryos have approximately 8 cells. For most patients, the best embryos are identifiable at this time and we like to transfer them into the uterus (their natural environment) as soon as possible. Embryos that are not transferred can be frozen for later use. However, if a patient has a large number of embryos and/or the best embryos are not clearly identifiable on day 3, we may suggest waiting 2 more days and doing a blastocyst stage transfer. Waiting gives us more information on how well the embryos are developing and may allow us to make a better choice for transfer. The downside of allowing embryos to grow to day 5 is that not all will develop to the blastocyst stage and therefore there may be fewer or no embryos to freeze after the transfer. In addition, blastocysts do not tolerate the freezing procedure as well as embryos frozen at earlier stages, so your chance of pregnancy with frozen embryos may be lower.

There are advantages and disadvantages to transferring embryos or blastocysts. You may discuss the options which best suit your case with your physician or the embryologist. Issues for you to consider are listed below.


If you have any questions about the Day 3 vs. Day 5 transfer, I’d love to hear from you.

Permalink | 11 Comments| Email Post

Post your comment

Sperm Donation

Some patients in our clinic require the use of a sperm donor. There are a variety of scenarios when a sperm donor is used (i.e., heterosexual couples, lesbian couples and single women). However, for this post, I’m going to keep the focus centered around the use of a sperm donor for a heterosexual couple.

As background, sperm donation is the use of sperm from a sperm bank or a known donor.

Men who might or will need sperm donation include men who:

• do not make any sperm (can be determined by testicular biopsy)
• have had chemotherapy and/or radiation and now do not make sperm
• have had surgical removal of their testicles
• are carriers of serious transmittable genetic traits or diseases
• have low sperm counts or motility and do not want to pursue IVF

At our clinic, if a patient will be using sperm from a sperm bank, we can assist them in getting information about sperm banks that are available to the patient. Once the patient has chosen a donor, the patient will then arrange for sperm to be shipped to our clinic and we can store it until the patient’s treatment cycle.
If the patient will be using a known donor, the donor must undergo routine evaluation and screening including:

• Semen analysis
• Blood draw for infectious disease screening (HIV, etc.)
• Urine or urethral cultures for gonorrhea and chlamydia
• Psychological counseling with our in-house therapist
• The recipient parents also will undergo a psychological evaluation with our
therapist, if using a known sperm donor.

If you have any questions about the sperm donation process, I’d love to hear from you.

Permalink | 0 Comments| Email Post

Post your comment

Assisted Hatching

A human blastocyst (left side of picture) hatching from its shell (right side)

The human egg is surrounded by a protein shell called the "zona pellucida". This shell has several important functions. Most importantly, it allows only one sperm through to fertilize the egg. After fertilization, the egg divides into 2 cells and this surrounding shell prevents these 2 cells from becoming separated. Each of the 2 cells divide again, giving the embryo a total 4 cells approximately 48 hours after the egg retrieval. By 72 hours, the embryo can have 8 cells. As the embryo continues to through these rounds of cell division, the zona keeps the cells together. Embryos are usually transferred to the uterus when they have between 4 and 8 cells (2-3 days after retrieval).



After the embryo has been transferred, around Day 5, it has grown to the Blastocyst stage of development. At this stage the embryo must hatch out from its shell in order to implant in the uterus. If the embryo fails to hatch, it cannot implant.

Assisted hatching is a technique developed to encourage the embryo to hatch from its shell. It has been in use for about 15 years.

Assisted hatching is performed in the laboratory just prior to embryo transfer. It is a simple and precautionary procedure where the Embryologist makes a small hole in the outside shell (the zona) of each embryo to be transferred. Because the zona is not a living part of the embryo, making this hole does not harm the embryo. In fact, this facilitates the embryo in hatching from the zona once transferred into the uterus. A more advanced, less invasive process using laser technology makes the hole. Prior to laser technology this opening was made with an Acidified Solution, which slowly dissolved away part of the shell until a small opening was achieved. Now with the laser, a beam of light creates a much more precise opening in the shell. This procedure can be performed much more quickly; therefore reducing the amount of time an embryo is being handled. Traditionally, Assisted Hatching took about 5 minutes, with the laser this time is reduced to less than 1 minute.

Permalink | 0 Comments| Email Post

Post your comment

Infertility FAQs

Quite often discussions surrounding infertility can get a little complicated. Therefore, I decided to shift gears with this post and keep things simple by discussing some of the frequently asked questions that my colleagues and I receive at Pacific Fertility Center. I suspect most people who are dealing with infertility have wanted to ask (if they haven’t done so already) many of these questions.

What is Infertility?

Infertility is the inability to conceive, or to carry a pregnancy to term. For women under 35, infertility is diagnosed after a year of unprotected intercourse. For women 35 years of age or older, this time length is shortened to 6 months. My practice prefers the opportunity to be proactive in light of the natural decline in pregnancy rates with the aging egg. Couples or individuals who have known fertility issues, such as anovulation/irregular periods, PCOS, male factor, endometriosis, should seek a fertility consultation at the time that they are planning to start a family.

My doctor says I am not ovulating regularly. How could I get my period if I do not ovulate?

Most patients who have regular cycles (26-35 days) are ovulating every month. In order to have a regular cycle, the hormones that grow and then shed the lining of the uterus are synchronized to a mid-cycle ovulation event.
For patients who have long and/or irregular cycles (30-90 days), the body is making the hormones to grow a uterine lining. If ovulation does not occur the lining sheds spontaneously. This process results in long and irregular cycles, but does not indicate that ovulation occurred.

I am concerned that I may have poor egg quality. How can I determine my egg quality?

The most important determining factor of egg quality is AGE. As women age, so do their eggs. The consequences of this aging process are lower pregnancy rates and higher miscarriage rates. Poor response to injectable fertility medications, failure of prior fertility treatment, prior surgery to the ovaries and shortening menstrual cycles can be other signs of egg quality issues.
Blood tests including FSH and Estradiol (on the 2nd or 3rd day of the menstrual cycle) and the Clomid Challenge Test (CCCT) can indicate if egg quality issues are present. Sometimes we do not have confirmation of an egg quality issue until we do an IVF cycle and see how the eggs behave and embryos develop (abnormal fertilization, poor embryo development).

I have been diagnosed with Decreased Ovarian Reserve, what does it mean?

Decreased or diminished ovarian reserve (DOR) has very significant implications for fertility treatment. It does not, however, say you cannot successfully conceive. The patient's age is of some importance, as women <38 with DOR are more likely to be successful than those who are older. However, age-for-age, patients with DOR have lower pregnancy rates and higher miscarriage rates. If all conventional treatment options have been exhausted, usually the most successful option for pregnancy is to pursue egg donation. Pregnancy rates using a donor egg are very high.

How do I interpret my FSH/E2 results?

Both of these hormone tests should be performed on the 2nd or 3rd day of the menstrual cycle (first day of FLOW is cycle day 1). Every laboratory has to determine its own FSH cutoff. However, using the more sensitive chemiluminescent assays, most clinics use an FSH level around ³ 10 IU/ml as indicating diminished ovarian reserve (diminished egg quality). The Estradiol should be less than 70 pg/ml. If the Estradiol is higher, this can also predict for diminished ovarian reserve.

It has been recommended I do a CCCT, what does it mean?

For some patients, we may recommend a CCCT for assessment of egg quality. This test is a more sensitive test than the day 3 FSH/Estradiol test. For patients who respond poorly to fertility medications, have unexplained infertility, have symptoms of decreased fertility (shortened cycles), have had ovarian surgery or are older than 37 years old we may recommend a CCCT.

The CCCT involves doing a blood test for the hormones FSH and Estradiol on cycle day 2 or 3. Then, 100 mg of Clomiphene Citrate is taken from cycle day 5-9, and the FSH blood test is repeated on cycle day 10.

Permalink | 0 Comments| Email Post

Post your comment

Halloween Grand Rounds

I want to thank Dr. Hebert for including my post on embryo adoption in his Halloween Grand Rounds. It takes creative genius to integrate so many different topics with such wit. Keep it up Dr. Hebert!

Permalink | 0 Comments| Email Post

Post your comment