The AFA Blog

Can You be a Poor Responder and Get Pregnant on Your Own?

by Fred Licciardi, M.D.

So a little story about a couple I saw recently. She was a poor responder with borderline FSH levels, normal tubes and a favorable age. He had low sperm counts. They had been through IVF. I suggested that he see a urologist because maybe there was something that could be done to improve his counts. She still ovulates every month, so by upping the odds on the sperm side, maybe they could get lucky and get pregnant on their own.

My statements were very surprising to them. They had been told that because of her “fertility status”, meaning her FSH was a little high, pregnancy could not occur naturally, so why bother with the sperm.

This may be close to accurate but it is not completely true. Unfortunately, many couples with significant fertility problems never get pregnant, but for some, the pregnancy rate per month is not zero. Even if it is ½ percent per month, after a year, a few women with normal tubes, borderline FSH levels and good sperm will get pregnant (age helps).

Can you count on it?  No, but if there is something fixable, you might as well explore the options.

This is also the reason that some doctors suggest a laparoscopy after many failed IVF cycles. Even if the odds of tubal disease are low, correcting a small problem may improve the odds of a spontaneous pregnancy down the road.

Immature eggs and infertility treatment

by Fred Licciardi, M.D.

Say you are undergoing IUI or IVF and your doctor has told you that you have a high percentage of immature eggs.

Remember, having a rate of 10-20% of immature eggs is normal.

However, having a high percentage of immature eggs can be a function of a few things. Firstly, maybe you received the hCG too early, and waiting 1-2 more days may have increased the percentage of mature eggs. Most people on average do not have an excess of immature eggs when receiving their hCG shot, once their biggest follicles reach about 18 mm. Some women however, need their biggest follicles to be 20 or 22 mm before most of their eggs are mature.

There is no way to know this in advance of the first cycle. But, if this is the case, changes should be made for subsequent cycles and you should discuss this with your doctor.

There are some women who, no matter how long we wait to give the hCG shot, will still have a large number of immature eggs. We can’t explain why this is so.  It is simply a case of dealing with what you have.

In general, we don’t want to wait too long before giving the hCG shot because eggs can become over-mature and this could show up later as poor quality embryos.

The dreaded biochemical pregnancy

by Fred Licciardi, M.D.

Here I will tell of a typical story about a woman who has been suffering from infertility, and finally becomes pregnant. After the relief of a positive pregnancy test her doctor repeats the test and says, “Well Lisa, it looks like your pregnancy is biochemical”.
Now I can’t completely describe what Lisa is saying to herself, but it’s probably something like this.
“What is he talking about? A biochemical pregnancy? Did I get pregnant? Am I pregnant? Biochemical? It's bad enough I have felt like a science experiment, now I’m biochemical?”
Let me try to straighten this out. The definition of a biochemical pregnancy is a pregnancy that stops growing before it is large enough to be seen on ultrasound. It’s a very early miscarriage. The causes are the same as for any miscarriage. By far, the most common reason is that the embryo is genetically abnormal, that is it doesn’t have the right number of chromosomes. And although it has the tools to grow for a while, as the embryo grows and needs to become more complex, the tools run out and the embryo can grow no more. There are other causes of miscarriage and that will be topic of a later blog.
The word “biochemical pregnancy” is a terrible term. It’s very cold and scientific and inhumane. I try not to use it, I just say it’s a very early loss. I thing the fertility community should throw out the word. I’m going to ask them if they will.

 

It's a Boy!

by Ken Mosesian

Congratulations to Rachel Zoe and husband Rodger Berman on the birth of their first child, Skyler Morrison. Zoe, a celebrity stylist, is the star of the Rachel Zoe Project. Last year, at the close of the season, she was discussing her desire to start a family with her physician. He told her that at her age it may be too late. She was clearly shocked.

Her response reminded me of the responses we had gotten from the hundreds of women that we have spoken with across the country about the reality of the biological clock. Well educated, professional women, who don't realize that fertility begins its first decline at age 27, and then takes a significant dip around age 35.

In a truly poignant scene, she spoke directly to the camera, saying that she had worked so hard and so long to make sure she had a thriving business, presumably to be able to provide for the child and to be able to take time off, only to find out that it may be too late.

Sometimes infertility can't be prevented, but there are many things that can be done to help one conceive. Awareness of how age factors in is absolutely key. Check out our Infertility Prevention Handbook for more information. 

And to Rachel and Rodger, our best wishes to you and your family. Here's to health, happiness, and joy for you all. 

 

 

 

 

 

The Clomid Death Sentence

by Fred Licciardi, M.D.

A few years ago I was visiting another hospital. When touring the OBGYN department, I ran across a very busy obstetrician in the middle of office hours. He was running form room to room and had a pile of charts in his hands. After her appointment, one of his patients cornered him in the waiting area and softly said, “by the way, I have not been able to get pregnant again.” Automatically, he pulled out his prescription pad scribbled a years supply of Clomid, saying, “Let me know if nothing happens in a year.” Seeing me at the last second, he said, “Actually, make it 6 months”

Needless to say I was not happy with either of his recommendations.
Giving a patient a prescription for 6 months of Clomid may be giving that woman’s fertility a death sentence.
If a woman is 39 and not getting pregnant, and she takes 6 months of Clomid, she will probably turn 40 before she starts her work-up. By the time she makes her appointment, sees the doctor, and gets her workup, it’s 6 months, maybe longer, and now it’s all too late.
It’s ok to use Clomid. I limit it to about 3 months, and there should be some workup first. I occasionally use 6 months of Clomid, but only in the case where the woman doesn’t ovulate without it. I skip Clomid in older women.

How late is late? You only know what you know

by Maria Portella

In the last month there has been some excellent articles in the UK press which really deserve to be shared. The links to the articles are below and the headline points are right on the money:

• The best age to have a baby is between 20 and 35
• Don't wait too long for a baby: Women are SIX times more likely to suffer from fertility problems when 35 than at 25
• Doctors have issued the stark warning to couples as more and more women pursue careers and leave parenthood until their late thirties.

Now, of course, not all women leave or wait JUST because of their careers. Many don't meet their other halves until in their thirties so what do you do - we all love the idea of you meet and are married and get pregnant within six months of meeting but even at age 30 plus it doesn't work like that - life isn't the fairytale for all of us and it can take 2 or 3 years before you are settled enough to get married and start to have kids by which point you are out of the optimum period.

 To me it highlights the massive challenge that comes with being a woman in the 21st century. They tell you to be financial independent and not to rely on men for financial security (well my dad certainly drummed that one into me and for good reason when he saw the amount of divorces around him and women left struggling to raise children with little money and relying on maintenance - he didn't want that to be me); but the flip side is you get an education and a career first in your twenties when historically and traditional women were having babies.

 You'll read commentaries about how women just want to 'have it all' but that is just nonsense [my opinion]. My dad died many years ago but I am sure that he no more wished for me to have to have struggled with infertility as he did not wish for me to struggle financially because I was financial dependent on a man and left divorced. And that is a man's perspective for his daughter! Not a feminist view.

 So what we need to do is make sure we educate women (and men) so that they can try and organise their lives (as best they can) to strive to achieve the two. It is harder for women possibly on this count than for men, I don't think we can argue against that. Women have more of a finite time-line to contend with than our male counterparts. But as women we have two options: to complain it isn't fair, and suffer the consequences; or do something and make sure we keep all young men and women better informed than we were by our predecessors.

 I know which one I am picking and I hope you will too - share and educate our young men and women on the challenges of fertility. Awareness is key.

 The Links:

http://www.dailymail.co.uk/health/article-1351237/Women-6-times-likely-suffer-fertility-problems-35-25.htmlhttp://www.telegraph.co.uk/health/healthnews/8287719

http://www.telegraph.co.uk/health/healthnews/8287719/Doctors-warn-couples-not-to-leave-it-too-late-to-have-a-baby.html?sms_ss=email&at_xt=4d4ade58d7be4928%2C0

http://www.guardian.co.uk/society/2010/dec/31/pregnancy-mothers-fertility-children

 

Improving Endometrial Thickness

by Fred Licciardi, M.D.

Today’s case: I have a patient who is doing a frozen embryo cycle, so we are preparing her uterus by giving her estrogen pills. She completed 2 weeks of estrogen therapy and her uterine lining was 6 mm, a ring pattern (also called a triple pattern). We decided the 6 mm was a little thin, so we kept her on the estrogen for 1 more week. I scanned her this morning and her lining was 8 mm. As this was a more acceptable thickness, we didn't need to wait any longer and we have now scheduled her transfer.

Is this a typical response? Did waiting help her cause? Let’s go over a few things.

Can your doctor do anything to improve the thickness of the lining? First let’s start with things I try. And here I am talking about a “medicated cycle”, one in which a woman is asked to take estrogen to prepare the lining for a frozen cycle or maybe in preparation for a donor egg cycle. These are cases where the ovaries are not stimulated by fertility drugs, there is no egg production and therefore the ovaries do not make estrogen. All the estrogen comes from medications.

One way to try to improve a lining is to just take more estrogen. There are different ways to get estrogen into your body: pills, patches, vaginal pills or suppositories and injections. All work well and none have been shown to be superior. When you are talking purely about estrogen levels, usually the shots and the vaginal pills lead to the highest blood levels. Levels with the oral pills and patches give levels that are a lower, but usually these methods supply more than enough.

What is the minimal acceptable level? I shoot for at least 200 pg/ml, but probably a little lower is just fine. No one has ever shown that 400 is better than 200, or 1000 is better than 400. Therefore, most of us are not overly concerned with the levels as long as the minimum is reached.

So in the case above, we didn’t even add any more, we just gave the uterus more time, and it seemed to work.

I start with estrogen pills, because I think it’s easier for the patients. Some women get bad rashes from the patches, and we all try to avoid injections. The other thing I don’t like about the injections is that the estrogen stays in your system a long time. So if you are not pregnant you need to wait longer to start again. But if you doctor has another preference, fine with me, they all work.

Some women do not absorb the pill well, and other women get low levels with all of the estrogen methods. We don’t know why. Maybe they metabolize the estrogen quickly (their lever breaks it down quickly).

If the pills are not working well, we can add a patch, so the patient is taking both. Or we can add the vaginal pills, injections or all of the above.

Case 2. I had a patient years ago who did one IVF cycle with a lining of 8 mm. She got pregnant and had an uncomplicated vaginal delivery. Nothing unusual happened at all. Then she came back for her frozen embryos and her lining would not go above 4 mm. We added everything, still 4 mm, despite very high blood levels. We cancelled the cycle, and tried another fresh IVF cycle, thinking maybe her uterus would respond better to the ovaries making estrogen, and still 4 mm. We do not know what led to the change.

The point here is that only some women respond to extra estrogen and or time. Most of the time, if you have been on some form of estrogen for 10-14 days, that’s it. What you have you have, there is no improvement later. Or maybe there is a minimal increase the lining thickness.

In many many cases, the “feel sorry” factor comes into play. This is when the doctor does the scan, finds a thin lining, and then looks and looks and looks trying to find you an area that is a little thicker, and usually finds a better spot, even if it’s 1-2 mm extra. When the lining is obviously thick, it should take the doctor about 2 seconds to measure the lining. If it’s thin, but it’s a little early, and we know you will be coming back, same thing. But if you now have had extra time or been on extra estrogen, there is nothing else to offer, and we look and look.

The point here is I don’t know if the lining actually improved. It may just be that the doctor took much more time and found a little area that looks a little thicker and everyone leaves the scan feeling a little bit better.

Off Camera

  By Jamie Schenk DeWitt

 In today’s world of 24/7 media coverage, and people’s obsession with anyone famous, celebrities are using their influence to change the social and political landscape.  They have moved beyond their traditional movie screen roles to the world stage to express their views on poverty, social injustice and man's inhumanity to man.  I applaud these efforts and the change that has occurred because of their actions. 

One area where celebrities are not consistently honest is in the realm of infertility.  Before I went through infertility treatments, I never questioned the pregnancy of a celebrity in her late thirties or early forties.   There was always a wonderful picture of her pregnant belly and a warm fuzzy story in People Magazine announcing the birth of her baby or babies. Yet after having experienced IUI (Intrauterine insemination) and IVF (In vitro fertilization) I now have to wonder if that same starlet spent months staring at a negative sign on a pregnancy stick or had to hear a nurse repeatedly telling her that unfortunately she was not pregnant, but to try again.  

Don’t get me wrong.  I am not saying that every celebrity who gets pregnant has to announce whether or not she conceived naturally or through artificial insemination.  People are entitled to their privacy.  I only wish that women who were in the spotlight struggling with infertility issues would raise their voices and share their fertility journey to motherhood in order to educate other women about the realities of infertility. 

More and more young women are graduating from college and entering the work force focusing on their careers and personal lives.  They put off marriage and children waiting until their late thirties.  It is important that we arm them with the facts about their biological clocks, so they can make educated decisions about how to be in charge of their fertility. 

When I was thirty-five years old, I received a phone call from my OBGYN informing me that my FSH levels (follicle stimulating hormone) were extremely elevated for someone my age.  My OBGYN was basically telling me that I had “old eggs that were of poor quality.”  I feel that education and awareness can prevent other females from receiving this call.

There are some celebrities who are willing to use their status to educate people about infertility issues. I want to take this opportunity to thank them. Giuliana and Bill Rancic are two such people.  They have openly shared their infertility struggles with their TV audience on their reality series, Giuliana and Bill.   In addition, they have spoken about this issue on The View, in US Magazine and wrote about it in their new book, I Do, Now What?  After having spent a year trying to get pregnant naturally, Giuliana underwent fertility treatments.  She got pregnant via IVF but unfortunately, eight weeks later, she had a miscarriage.  Throughout the couple’s attempts to have a baby, they honestly shared their feelings about the experience, how it affected them and what they learned.  

In an exclusive interview with AOL Health Giuliana states, “It’s just that for some reason, through the years, infertility has been a very taboo subject. These women in Hollywood … I think they just like people thinking they’re perfect. They don’t want to admit they have flaws. They feel like it’s going to somehow hurt their careers. They don’t want to show that they need medical help; they keep it very hush-hush. I felt like I had been duped, in a way, by a lot of these women. I’ve been interviewing actresses for the last 10 years, so I would see them and I’d go, “They’re so fabulous. I want to live like that! I’m going to focus on my career, and then at 40, I’m going to have twins!” I would talk to these women and be like, “So, ‘blank actress,’ you’re 41, and you just had twins and that is so amazing.” And they would say, ‘Well, twins run in my family!’ I remember, someone told me that as you get older, your chances of twins are more likely. Well, now I know that’s because at 40, you’re doing IVF. So that’s why this is important to me. Regular women need to see women in the spotlight having problems.” 

Rancic continues, “My thing was, I knew nothing about any of this. I thought I was still so young. We did IUI and that didn’t work. We did more tests, and [the doctors] said, “You’re 35, and your eggs are old.” And I’m like, what? I was so shocked, and I said to myself, had I known it was going to be so hard to get pregnant maybe I would have frozen my eggs at like 30 or 28."

Thank you again Giuliana and Bill for openly sharing your experience and being pioneers willing to step out from behind the camera to honestly share your fertility journey to parenthood.

For a more detailed list of starlets and celebrity couples that have been openly discussing their struggles with infertility please check out: http://abcnews.go.com/Entertainment/slideshow/celebrity-infertility-battles-10542271

Photo: Celebrity Baby Scoop

The Amazing Story of the Birth of the “Twiblings”

by Iris Waichler, MSW, LCSW

           For those of you who haven’t read it I strongly encourage you to read Melanie Thernstrom’s New York Times Magazine article called “Meet the Twiblings” at http://www.nytimes.com/2011/01/02/magazine/02babymaking-t.html.

Ms. Therstrom and her husband use an egg donor and 2 different gestational carriers that end up giving birth to twins that are born 5 days apart. I loved this article for many reasons.  She candidly discusses a multitude of issues that will be familiar to many who experience infertility.  Examples include:

1.      Beginning infertility treatment later in life.

2.      Finding a doctor that will show empathy but be honest about your best chance for success in having a healthy baby.

3.      Unscrupulous surrogacy and egg donation agencies.

4.      Legal challenges of surrogacy.

5.      Societal judgements about infertility treatment, surrogacy, and egg donation.

6.      What role do you want your egg donor and surrogate to play in your new family’s life?

We learn about Ms. Thernstrom starting out at age 41 meeting her eventual husband.  She undergoes 6 treatment failures in her attempt to have a baby. Her doctor poses a critical question that changed her life.  He asked “Is your goal to have the experience of being pregnant or is your goal to have the best chance of having a healthy baby?”  I believe that question is not asked often enough by physicians.  It is the primary question those who have had repeated fertility treatment failures need to ask themselves.

This article is filled with valuable information those in the midst of infertility treatment can apply. There is a wonderful description of meeting the 2 women who eventually become her surrogates. Fie, one of the surrogates, goes over the surrogacy agreement line by line and she and Ms. Thernstrom carefully discuss scenarios so they have a clear agreement about how to proceed. They talk about whether the surrogates will provide breast milk after the baby is born? Consider questions you must ask like who pays living costs if your surrogate is unable to work due to the pregnancy?

The surrogate’s husbands were involved and met with the Thernstroms. The role of the surrogate husband is important and is rarely considered.  Their support is invaluable during their wives pregnancy.  Ms. Thernstrom observed her surrogates in their roles as parents and that was a major consideration for her in choosing them.

We learn about Ms. Thernstrom meeting her egg donor.  It was important for her to meet the donor.  Some choose to use an anonymous donor.  She describes looking at the woman who became her egg donor and thinking “When she flashed a smile, I wondered if I had caught my first hint of my child’s grin.”  There is that natural inclination for the perspective mother to make comparisons between herself and her egg donor.  Consider your feelings about that and what role if any you want your egg donor to play in your future child’s life.

The Thernstrom’s speak with the director of their egg donor agency about disclosure. She recommends “tell everyone or tell no one.”  Disclosure is one of the more challenging aspects of infertility.  You need to decide if you want your child to hear directly from you in your own words about their birth.  You may risk your child possibly learning from someone else. How  will that impact your child and your relationship with him/her?

Using a surrogate or an egg donor requires a huge leap of faith. You have to trust that the donor is honest about their medical history.  You want to believe your surrogate will take all the necessary steps you would to be as healthy as possible during the pregnancy.

Ms. Thernstrom coins the phrase “twiblings” to describe her children.  The same egg donor was used and the embryos were transferred the same day. The kids were born 5 days apart from two different gestational carriers. She also uses the word “Fairy Goddonor” to describe her egg donor.  Much like Sarah Palin’s word “refudiate” I hope these words should become an accepted part of English language.

            I thought a lot about this remarkable story. This particular case involved a small “village” of people united together to create a family. I applaud the courage of Ms. Thernstrom for telling her story in such a public forum.  She has gotten both praise and unwelcome comments from friends, professionals and strangers.  I realized that all of us have a unique story to tell about how we become a family. It is our choice how and whether to tell it or not

Miscarriage and the Sense of Personal Failure

by Kim Kluger-Bell, MA, LMFT

Lisa Ling, the former View host, revealed this week that following a miscarriage at 7 weeks into her first pregnancy she felt like a failure, and that she also felt very isolated and alone because no one talked about it. For this reason, she is speaking out and has created a website where women can anonymously share their experiences with miscarriage called Secret Society of Women.

 Ten years ago, when I wrote “Unspeakable Losses: Healing from Miscarriage,Abortion and Other Preganancy Losses” I felt exactly the same way. The silence surrounding miscarriage only makes you feel more freakish and alone. Here is what you need to know about miscarriages:

 Miscarriages are Common

 Approximately one in 5 pregnancies in the US end in miscarriage every year. That means hundreds of thousands of women experience miscarriages every year. And most of those miscarriages occur in the first 12 weeks of pregnancy. In fact, your chance of miscarrying after that time is only 3%.

 Having One Miscarriage Doesn’t Mean You’ll have another

 Most miscarriages, however, are usually random and isolated events. Having one miscarriage only slightly increases your odds of having another one.

 The Emotional Impact can be Devastating

 For many women, the attachment to the child she is carrying begins at the moment she knows she is pregnant. That is when we begin dreaming about the baby we are carrying and imagining how our lives will change in only nine short months. Few of us hold back our excitement due to fears of a first trimester miscarriage. Instead, we start taking extraordinarily good care of ourselves—eating right, getting plenty of rest and avoiding alcohol, caffeine and tobacco products. When a loss takes place despite all of these preparations, you can feel like you did something wrong. Even the word—miscarriage—seems to imply that you did not carry your baby properly.

 It is Not Your Fault

 In many, if not most cases, the cause of your miscarriage will never be known. Again, most miscarrages are random and isolated events. Doctors now believe that at least 60% of miscarriages are caused by chromosomal abnormalities in the developing embryo or fetus, and that another 10% are caused by various uterine abnormalties (most of which can be corrected with surgery). The remaining 30% of miscarriages may be cause by immunological factors, infections or environmental factors (including smoking and heavy alcohol use).

 Recovering from Miscarriage Takes Time

 It is often more difficult to recover emotionally from a miscarriage than it is to recover physically from one. Even if you had to have a D & C, the emotional fallout from a miscarriage can stay with you for months afterward. Guilt, shame, sadness, anger, and a feeling of powerlessness are very common emotions. So is a sense of generalized anxiety and the fear of another loss. It is not uncommon, especially if you are not able to become pregnant again quickly, to have an ongoing awareness of  how far along in the pregnancy you would have been if the loss had not occurred. Many women feel particularly grief-stricken around the time of the due date of that pregnancy. Miscarriage is a traumatic experience—it takes time to heal from a trauma of any kind.

 It is important to be gentle with your self and find people to talk to who are compassionate and will not judge you for the intensity of your feelings. It is also important not to blame yourself, or to isolate yourself too much. It may be impossible to spend much time around pregnant friends or those with babies or young children, but if you don’t have people in your life who are willing to share their own experiences of pregnancy loss with you, there is a large group of people out there who have been through a miscarriage, and there are many on-line resources and books available to you that can help you feel less alone.

 Websites:

• Facebook page, “Whisperers”
• www.nationalshare.org
• www.missfoundation.org

 Books:

• Empty Arms by Pam Vredevelt
• Empty Cradle, Broken Heart by Deborah L. Davis
• Unspeakable Losses by Kim Kluger-Bell
• Miscarriage: Women Sharing from the Heart by Marie Allen, Shelly Marks

Kim Kluger-Bell is a psychotherapist and marriage and family therapist in private practice in Berkeley, California. She specializes in helping individuals and couples heal from such reproductive crises as infertility, pregnancy loss, and abortion. She lives in Albany, California, with her husband and son.