The AFA Blog

Endometriosis and food

by Corey Whelan

More than five million women in America have been diagnosed with  endometriosis, a leading cause of infertility.

Endometriosis occurs when the endometrial tissue that lines the inside of the uterus finds its way outside and into other organs of the body, such as the abdomen and fallopian tubes.  When this happens, the misplaced tissue develops into lesions which respond to the woman's menstrual cycle.  Each month, the tissue builds up and then sheds.  Inside the uterus this natural shedding becomes part of the menstrual flow.  But outside of the uterus the tissue has nowhere to go and backs up, causing internal bleeding, inflammation, adhesions, pain, and eventually for many, infertility.

There are a number of medical research studies that indicate no curative effect for endometriosis through diet, although in at least one study conducted in Italy, fish oil was shown to alleviate symptoms and in another study conducted in Mexico, a diet high in antioxidants was found to be helpful..

Nutritionists, however, are convinced that diet can play a pivotal role in controlling endometriosis and the often debilitating symptoms that accompany it. 

Nutritional expert  Karen Spencer-Dees, Ph.D. states that "Nutrition is the science of food.  Being educated on proper diet and modifying your eating habits can make all the difference between  successfully having a family, or not.  Sometimes, even the simplest of changes yield the biggest results."  She should know.  Dr. Spencer-Dees is herself a longtime sufferer of endometriosis who through dietary changes, including food combining, dramatically improved her symptoms as well as her overall health.  

For those with endometriosis, there are not only specific foods that you should eat, but also specific foods that you should avoid.  Detrimental foods include those that  increase prostaglandins E2 (GE2) and prostalandin F2a (PGF2a).  These two types of prostaglandins stimulate estrogen, which is the main hormone found to increase the symptoms of endometriosis in those who suffer from it. 

Simply put, the Endometriosis Bad Foods List is as follows:

• Sugar
• Wheat
• Caffeine
• Alcohol
• Dairy
• Red Meat
• Saturated Fat and all transfats
• Refined Carbohydrates
• Additives and preservatives

What's left?  The Endometriosis Good Foods List includes (but is not limited to):

• Fruits
• Vegetables, especially cruciferous vegetables
• Whole Grain Foods
• Flaxseed and other whole seeds
• Beans such as Navy Beans, which are high in choline or choline supplements
• Chicken in moderation
• Fish
•  Fish Oil and other good unsaturated fats high in Omegas 3 and 6 

Also key when you have endometriosis is doing lots of exercise, and drinking 6-8 glasses of fresh water daily.

So does this food list leave you at a loss as to what to nibble on when the munchies hit?   Straight from the kitchen of Dr. Karen Spencer-Dees, try this truly delicious Zucchini Dip.  Healthy does not have to mean boring!

Zucchini Dip

1 1/2 cup shredded zucchini

2 tbsp. parmesan cheese

1/2 tsp. minced garlic

1/4 tsp salt

1 cup plain yogurt

1 tsp. lemon juice

1/2 tsp. crushed basil

Shred 1 1/2 cups of the zucchini.  Place in strainer and discard all moisture.  Combine remaining ingredients and add zucchini.  Cover and chill overnight.  Serve with raw veggies, and enjoy!

 

 

Why You Should Like Infertility

by Merry Armentrout

I have a confession. I don't want anyone to know what I'm about to share, but feel the need to do so to prove a very important point. Let me start from the beginning...

As Director of Communications for The American Fertility Association my job is to spread the word about our organization. This involves working with the media, including the emergence of social media. I created a Facebook Fan Page for The AFA a few months ago, and I'm proud to say it rocks. The fan page includes 15 HD videos on a variety of topics, including Endometriosis, PCOS, Recurrent Miscarriage, In Vitro Fertilization and Reproductive Options for Gay Women, to name a few. The videos featured on our fan page come from The AFA's online library which includes Video Fact Sheets, informational fact sheets featuring a top expert in the fertility field on video. The best part, the videos are only a small fraction of our fan page. You can find pictures from our outreach events across the country, information on The AFA's board and staff members and daily posts and discussions on relevant topics on family building.

I've said it once, and I'm not afraid to say it again- our fan page rocks!

You would think I would be the first person to "Like" the own fan page I created, but I wasn't- I hesitated. That one small moment of hesitation shows there's a huge problem with the negative stigma associated with infertility. I didn't want to become a "fan" of The American Fertility Association because I didn't want my 550 "friends" on Facebook to think I was infertile. It doesn't matter the people who are closest to me, about 50 or so, know my husband and I haven't tried to have a baby yet, but it was the 500 other "friends" I was concerned with. The people I haven't seen since high school graduation, the people who I haven't talked with in years, it's those people I didn't want to think I was struggling with infertility.

If I saw a "Like" button for such organizations as Livestrong, a group that fights cancer, I would have no hesitation becoming a fan. In fact, thousands of people wear a yellow bracelet showing their support for fighting cancer. Cancer does affect more people, but infertility is one the rise. The latest statistic is one in 6- that's how many couples in the United States are facing infertility.

People who are coping with infertility have enough on their plate, so the least we can do is be supportive.  How can we do that? The AFA is working tirelessly to normalize the conversation about infertility in the mainstream. Our goal is to remove the shame and embarrassment many people feel when dealing with infertility. I'm hoping my confession might help us towards that goal.

I'm urging all of you who are reading this blog to "Like" The American Fertility Association on Facebook. Become a fan. Email the link to your friends and family.  Urge them to "Like" The AFA.  The more fans we have the better. Everyone facing infertility should know they're not alone. Cheesy, but true- one in 6 remember.

Don't do what I did. Don't hesitate. Our mission is too important. Help us spread the joy of family.

Here is today's ARGHHHHH!!! Lupron and Endometriosis

by Fred Licciardi, M.D.

What if you were diagnosed with stage one enodmetriosis and were told to take Lupron for 3 months? Here is today’s ARGHHHHHHHHHH!!!!!

No research study to my knowledge has ever shown that being on Lupron after surgery does anything to reduce endometriosis or improve pregnancy rates. It works like this. Endometriosis grows from estrogen.  When Lupron takes away the estrogen the endometriosis stops growing. But, Lupron does not kill the endo, it just suppresses it. So once the Lupron is stopped, the endometriosis goes right back to where it was.

Yes, staying on Lupron will suppress the pain, which is not a small thing.  But once the Lupron is stopped, the pain will come right back.

In conclusion,  3-6 months of Lupron will not help you to become pregnant, it will just make you older and more frustrated.

A new endometrioma should not appear on Lupron. If the cyst was not well removed at surgery, it can reappear, even if on Lupron.

Here are some surgery questions.

by Fred Licciardi, M.D.

If you have severe endometriosis and pain with a history of multiple laparoscopies, and you are at the end of your rope, is a hysterectomy the answer? This is too complicated for me to give any hard advice here. The options are to get another opinion from a doctor is an established endometriosis laparoscopy doctor, who can maybe improve your pain without a hystersctomy. Maybe even someone who is not in your area. On the other hand, there are some women who say the hysterectomy was the best decision they ever made, and some who are neutral and some who are not happy with the results.

Is a laparoscopy through 3 incisions better than a laparoscopy where the doctor only used 2 incisions? Impossible to say. Some surgeons are really crafty using only 2, some need 4. Sometimes a doctor who usually uses 2, will need to use 3-4 in the really tough cases. But redoing a laparoscopy just because only 2 incisions were used does not make sense.

What if there is a hydro on hsg and at laparoscopy the tube does not fill with dye? Should the doctor assume the tube developed proximal occlusion and just leave it? I think not. For some reason, sometime tubes just to not fill with dye at the laparoscopy. Even normal tubes sometimes do not fill, but a post op hsg shows normal tubes. So if they are hydros at hsg, but closed at laparoscopy, your doctor should consider removal.

Is it normal to have a myomectomy and have some fibroids left behind at surgery? This does happen, but I do not leave any behind. I could see rare cases of fibroids left behind for a couple of reasons. Fibroids on the cervix are more dangerous to remove because the cervix is where the uterine arteries bring blood to the uterus, so around the cervix there is more blood flow and more chance for heavy bleeding during the operation. Also, if there are very thick intestinal adhesions attached to a fibroid, separating the intestine from the fibroid may cause excessive bleeding or damage to the intestines. That being said, leaving fibroids behind should be reserved for the most extreme cases. I have not left a fibroid in 15 years. The doctors I work with do not leave in fibroids. However I am aware of doctors who routinely leave in some of the smaller or difficult to reach fibroids, and I do not know if this is the best thing. A myomectomy is not minor surgery. In many cases, smaller fibroids get bigger. So if your problems are bad enough that you need the myomectomy, getting them all is the best thing. It is also true that the doctor may do a great job getting them all out, and sure enough, 3 months later a scan shows another fibroid. This is harder to explain, but probably there was a very small one that could not be seen, and it that grew after the initial surgery.

The AMH test: a good or a bad thing? One woman's take on the debate across the pond.

by Maria Portella

There has been a lot of discussion in the United Kingdom media over the last month as to the use of the AMH test. Two new uses are suggested: one is as a predictive tool for women to know when they will hit menopause and to be able to decide therefore when to try for a family; the other is for the National Health Service (NHS) to use as the deciding factor on whether the State pays for IVF treatment or not.  Currently age is one of the key criteria applied.

With respect to the latter, some of the concerns are financial and political relating to a person's view as to whether fertility treatment should be paid for by the State or not.  (It should be noted that the State discounts monies from each working person's income to contribute to the pot to pay for health coverage for all.)  People fear that this will open floodgates to more IVF being provided by the State and in many cases people don't feel that it should be covered in the first place, and that couples should pay for it themselves.  The arguments aren't dissimilar to those in the USA regarding how contributions to insurance schemes should be applied.  

The other concerns however relate to how the AMH test result will be used by women.  Will they rely too much on this result and forget the other factors which may affect their fertility?  A woman with a good AMH number may assume she can delay having children into her late thirties and forget that there are other relevant factors – e.g. as she gets older the quality of her eggs reduces, there is a greater risk of chromosomal defects, miscarriages are more of a risk.  The best age physically to have a child is between 18 and 30 apparently, and while in today's world it isn't always possible to have children in that bracket, it isn't necessarily a good idea to put off having children much past thirty or thirty five if you can help it.  The fear is that over reliance on the AMH result will exacerbate the modern problem of couples electing to delay child-birth later than they should.

 So is AMH testing a good or a bad thing?

I don't propose to try and discuss whether it should be used as criteria for determining who gets State paid IVF and who doesn't.  That is one for the politicians and medical professionals to decide.  My only observation is that fertility is a very complicated issue, and someone with a low AMH isn't always the poor responder, so it is dangerous to be overly simplistic in the evaluation criteria.

 In relation to how an AMH test can help women to understand how fertile she is, though, I do think it is a good thing. But with one huge caveat; which is this:

 It has to be relayed and given to women in the correct factual context.  You can't just say to a woman that she has a good AMH number and allow her to think that she should be fine to delay having a family if she wants to.  She needs to be given all the other relevant facts and risks and be told that this is just one indicator as to her fertility.  There are many others risks and factors which are relevant and so that she cannot rely only on a good AMH.  She has to be told to not ignore all the other risks that come with age – for example if she has fibroids or endometriosis, this could be more of a complication as the years go on.  And further, she should be reminded that even if she is absolutely fine it doesn’t rule out that her partner/husband may have issues – male fertility problems are the sole cause of at least a third of cases.

 Any initiative which enables women to be more aware of her fertility from early on, as opposed to having an unpleasant surprise when it may be too late, has to be a positive thing in my opinion.  But she needs to be made to understand her AMH number in the context of all of the other risk factors that come with age and fertility. And that she is only half of the equation, albeit an important half.  And while presently AMH testing seems to be less popular in the US than in the UK, in our modern world of internet, ideas can cross the pond pretty swiftly.  So everyone needs to be aware of this as it relates to an issue which applies to all couples, irrespective of their nation.  The goal is the same – reducing the number of infertility cases and improving education on fertility.

 Maria Portella is originally from the U.K. and now resides in the West Indies.  Her special interest is promoting better education about fertility amongst working women.  She reached out to The American Fertility Association because she wished to share her story.

Photo: Courtesy M. Portella

IVF and Stimulation Questions

by Fred Licciardi, M.D.

Should you avoid pregnancy if you are starting an IVF cycle with day 21 Lupron or Synarel or Buserelin? The stock answer is yes. However there are many women who have become pregnant while on those meds. If you do become pregnant, make sure you get luteal support with progesterone and maybe estrogen. Ask your doctor.

Does it help to take estrogen for luteal support in an IVF cycle? Probably not. There have been studies showing no improvement. There is even scientific evidence that estrogen may be unnecessary in the luteal phase. Some clinics routinely prescribe the estrogen; I tried it for a while in select cases with no improvement. I have had a little success using estrogen in women who have luteal bleeding despite progesterone. It’s used in medicated frozen cycles and DE cycles because the ovaries in those cases make no hormones (no estrogen or progesterone) so we add both hormones during their cycles.

Should you try IVF again if you are 29, have an FSH of 12 and make 8 eggs with 2 fertilized? Yes. I have been getting many comments from young women, some with high FSH levels, who are failing first cycles. Get to the best clinic possible and have your doctors come up with possible improvements for your cycle. Age is key. A high FSH in a 27 year old woman, or even a 36 year old, is not as telling as it may be with a woman in her 40’s.

What can I suggest to up your odds for the FET? Most FETs are pretty routine. Sometimes we suggest thawing more than you need and picking the best for transfer. Not everyone wants to do this. Some would rather thaw few so they can get more cycles out of what they have frozen. Either way is ok; see what your doctor says.

Hopeless after failed iuis, 2 fresh IVFs and one FET cycle? You do have to take into consideration age and FSH levels and embryo quality. It’s rarely hopeless. Maybe less hope, but not none. Know your stats, get another opinion and take it from there.

Can a para-ovarian cyst interfere with IVF or implantation? Probably not.

What if you are an established young poor responder who has had multiple failed IVFs. In addition there is a question about your uterus, meaning the was a scar but hysteroscopies and hsgs are now normal? This depends somewhat on the thickness of your lining on ultrasound. I have said before, and still believe, the lining thickness may be less important than we once thought, but of course everyone’s story and uterus are a little different. If you want to carry and our uterus is “acceptable” then donor egg without carrier is what most women would do, and probably with a very acceptable pregnancy rate. If you feel strongly that carrying is not important, just getting that baby asap, consider a carrier. However, donor egg, carrier is not guaranteed either.

I am hearing from women who have premature surges during antagonist cycles. I have not had this so I don’t know why people are having this problem. Antagonist should start at a follicle size of 13 mm (some clinics use 12 mm). Sometimes the estrogen levels do fall a little when the antagonist is started, but this fall does not mean there has been premature ovulation. So if the estrogen falls (but not by too much), but the follicles still grow, and the estrogen level goes up the next day, that’s all ok. There has not been a surge.

How long after the last depot lupron shot do you need to wait for IVF? The depot shot is supposed to stay in your body 4 weeks, but may be in a little more. Ask your doctor about this one but probably if you start 4 weeks after your last shot, but the time you are retrieved it will be 6 weeks after the shot.

What’s the doctor doing at my transfer, and why is there a delay? You can’t see what’s going on at the transfer, but any of your questions at the time should be answered. Doctors have certain catheters they like to start with. If they have trouble getting the catheter through the cervix, they may ask for another type. They should keep you informed.

Breastfeeding during IVF. FSH levels in breast milk will be higher than during a natural cycle. I really can’t comment more than that. There are some women who do IVF while breastfeeding.

Can a varicocele repair correct azospermia? I am not a urologist, but I have not had an azospermic patient develop sperm in is ejaculate after a varicocele. I’m not saying it can’t happen. It is also possible that the counts could go up without surgery.

What about a period that lasts for months with a completely negative workup? Make sure you do not have a bleeding disorder. Some women have vascular abnormalities if the uterus that cause constant bleeding. Maybe an MRI will help.

East meets west and ivf success rates benefit

by Corey Whelan

For many men and women who are struggling to conceive a child, Traditional Chinese Medicine (TCM), including the practice of acupuncture, has proven to be a successful enhancement to western reproductive protocols.  Over the past decade, the number of  infertility specialists who have begun to acknowledge the potential benefits of acupuncture for patient care has grown considerably.

A wide host of studies demonstrate that acupuncture improves reproductive outcomes for most patients undergoing assisted reproductive technology; these include fewer ectopic pregnancies, lower miscarriage rates, and less multiple births.  However, the American Society for Reproductive Medicine (ASRM) does not agree.  Published highlights from the 62nd annual meeting of ASRM included excerpts from research conducted by Lehl and co-investigators as well as contradictory research conducted by lead investigator Paul Magarelli. Magarelli's findings indicate that "the modulation of reproductive and stress hormone levels with acupuncture is a possible explanation of infertility modifying effect."  However, the ASRM's position continues to be that "although acupuncture might improve IVF outcome, convincing evidence is not yet available".  Later findings also reported upon at ASRM's 2009 meeting,  and presented by Drs. James Smith and Arate Aelon indicated that CAM (complementary alternative medicine) did not increase pregnancy rates among IVF patients.

Despite competing studies, many within the field of assisted reproductive technology have embraced this 3,000 year old practice and the trend of East Meets West IVF clinics is becoming popular nationwide.

So how does acupuncture support traditional methods?  TCM has been shown to  help women with PCOS (polycystic ovarian syndrome) ovulate without the support of drugs such as clomid.  For the endometriosis patient, acupuncture, in conjunction with herbal medicine, can often reduce the inflammatory environment, and thus the pain that earmarks this disorder.

Traditional Chinese Medicine is a holistic approach to health, meaning that the whole person, not just the reproductive organs, are taken into account.  This includes psychological issues such as depression, and also the individual's lifestyle.  A single woman who has recently been laid off from work for example, might receive different treatment than a woman in a solid, financially secure situation..

TCM is intrinsically different from reproductive technology, and points to  the kidney as the internal organ responsible for the reproductive cycle, including growth, and also the aging process.  If kidney energy becomes depleted by poor diet or stress, one of the possible outcomes, according to the principles of TCM, is infertility.  

So will it work for you?  The concept of acupuncture will not appeal to every patient.  Given the number of infertility medications that are given via injection, you may feel that there are already enough needles in your life.  But if  you are currently considering adding acupuncture to your treatment protocol, discuss the concept with a physician that you trust, weigh the pros and cons, and make the decision that feels most approprate for you.  

Sources:

Lehl K, Pitzer L, Schoolcraft WB, Stevens JM. Elective acupuncture treatment pre and post embryo transfer: comparison of clinical pregnancy and implantation rates within age groups and in recipients of donor oocytes. Program and abstracts of the American Society for Reproductive Medicine 62nd Annual Conference; October 21-25, 2006; New Orleans, Louisiana. Session P-556.

Magarelli PC, Cohen M, Cridennda DK. Proposed mechanism of action of acupuncture on IVF outcomes. Program and abstracts of the American Society for Reproductive Medicine 62nd Annual Conference; October 21-25, 2006; New Orleans, Louisiana. Session P-118.

Adapted with permission from an earlier article published at www.examiner.com

AP Photo 

PCO and other Fertility Related Topics

by Fred Licciardi, M.D.

PCOS (Polycystic Ovaries) and Ovarian Drilling.

Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Androgens, by the way, are the hormones that get changed into estrogens, so androgens are absolutely necessary for normal repoduction, but in PCO the androgens are in excess. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because they do not always work, can cause scar tissue, and there are other alternatives.

There are other ways to stimulate ovulation, including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option.

Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling.

So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin.

What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.

Other PCO Topics

Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.

When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.

Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.

Egg quality clomid vs FSH? Probably similar.

Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.


Sperm Topics:

Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.

Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.

Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.

Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.

Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.

Miscarriage

What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.

Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.

Frozen Embryos

Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.

What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.

General Topics

Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.

Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.

Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.

What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.

How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.

Infertility Question and Answer Time

by Fred Licciardi, M.D.

Hello again. Here is the latest entry.

Can a small hydrosalpinx prevent pregnancy? Yes it can and it can prevent pregnancy when trying on your own or with iui (assuming the other tube is normal) , or with IVF. Now a small one is less likely to be problematic, but the studies showing hydros are a problem do not differentiate between small and large. It is not mandatory that hydros be removed, but the pros and cons of removal should be discussed with your doctor.


Does a 44 year old woman who makes 14 eggs have a higher pregnancy rates than most women in her age bracket? Absolutely. For women in their 40’s, egg number is strongly related to odds of conception. It may be that bigger the reserve the healthier the eggs are in general, or it may be that the more you have, the high the chances of finding at least one good one. This is less important in younger women, whose odds are good even with a lower egg number.

Should you have a second laparoscopy soon after a first in order to do more fixing and cleaning up? These are options but there are others. Back in the day before IVF worked well, this scenario was common, but today if the first laparoscopy looks that bad we recommend IVF. Now this does not mean surgery should be out of the question, it’s just that odds are if the pelvis is so bad, a second surgery will not help much. You really have to try to get a sense of what the doctor feels the improvement will be after a second surgery vs. IVF. If IVF is not an option for you, then the surgery may make sense. It’s a little strange that all of the fixing up was not performed at the first surgery, but there may have been very good reasons for stopping the first time.

Why give 5,000 units of hcg instead of 10,000, and are there any problems with this? It has to do with hyperstimulation. You cannot have significant hyperstimulation without the hcg injection. The hcg stays in your system for at least 10 days, stimulating and stimulating the ovaries to make progesterone, but the stimulation keeps the ovaries big and can push them to hyperstimulate. So it makes sense to maybe give less if we are worried about hyperstimulation. If we give half the dose we may be lowering your risks. Again, makes sense, however, I have not seen much written showing that ½ the dose is any safer. It is possible that if you try to take less you will not get enough. Now if you have a good vial that really has 10,000 units, and you are a good mixer, then ½ the dose should be enough. But it may be that some vials do not contain the full 10,000 units. Sometimes the extra mixing instructions are just too confusing and for one of a number of reasons 5,000 units do not make it into the syringe and into your body. This is why we measure the hcg level the day after the hcg injection. A few times per year someone in our practice has a blood level of the zero the day after the injection. The most common reason for this is the injection of air, which occurs by not putting the needle into the liquid before withdrawing. The second most common problem is the injuction of water only, which happens if you forget to mix in the powder. Believe me, both of these happen mopre than we would like. The water only problem can't happen when using the premixed. Sometimes the there is some hcg in the blood, but the level is really low. If we get numbers under 50, we give another shot but go with the original retrieval time. If the level is zero, we give the hcg that evening and make the retrieval one day after the original day.

Can you exercise while trying to conceive? Sure. However you cannot if your ovaries are enlarged from fertility drugs. If you are unsure when the stopping time is, ask your doctor every time you have a scan.

I am posting this question because it applies to a large number of fertility patients who are starting out. My comments are in bold:
So my hubby and I have been doing infertility testing for a year. I had a miscarriage at about 7 weeks about 2.5 years ago and have been unable to get pregnant since. I did a 6 month study through the national institute of health where they gave me either a placebo or low-dose aspirin and a fertility monitor, all with no success of pregnancy. My hubby's done 3 semenalyses, (which have proved to be normal. . . he had an abnormal count of about 30% on one, but the rest were fine and the counts were fine), we both did the antisperm/antibody test most of us to not do this test, it just has not been shown to be helpful which turned out normal, he did the hamster test and got 100% penetration never done anymore, an ultrasound which proved to be normal good, as well as blood tests for both of us that have proved to be normal.
My cycle varies between 25-33 days, but always falls within that window, just varying lengths within that window no problem. I recently did an HSG test and it showed no blockages excellent.
Our next step in the process is a post coital test antiquated, a blood draw at a certain point in the cycle, and a sample of my uterine lining antiquated to see if it's thick enough at that point in the cycle to be viable for a baby.
My Dr. said that at that point, if everything's normal, we can proceed with IUI. However, he did say that we should consider doing a laparoscopy to check for possible endometriosis. He said that even though my HSG test was normal that if I had endometriosis it could possibly flare up and die down. I've always experienced mild cramps for 1-2 days on my cycle but isn't that normal? He said cramps could be indicative of endometriosis. I have no problems with doing a laparoscopy if it weren't for the cost. . . $2500. I'm just wondering if with everything else positive if mild cramps being my only symptom are enough to warrant the cost of checking it out, or if it's something that won't affect my fertility too much. This is acceptable medical practice, however you need to ask about the payoff. If the hsg, exam and ultrasound are normal, the odds of having endometriosis are very very low. Actually the odds of finding a little endometriosis are about 10% because that’s the baseline rate in all women, but the odds of meaningful endometrioses that has grown to the point of interfering with you getting pregnant are very low. Now that’s not to say that the laparoscopy is not an option, but I would get a second opinion if you wish.
As far as my comments on the antiquated tests, again acceptable medical practice, but a little out of date. It does seem that your doctor is organized and at least has a plan.

If you are a little older and had a chromosomal miscarriage, should you be discouraged from trying again? I don’t think so. Yes the odds of miscarriage increase with increasing age. Most pregnancies, even in women in their early 40’s go to term. The miscarriage rate is high, but there are more babies than miscarriages.

Should you take any steps to shorten the follicular phase? If your cycles are far apart, it just makes it harder to conceive because you get fewer chances per year than most people. Another problem is that it’s hard to know when ovulation is taking place, so timing can be an issue. However, I am not aware that the egg quality is compromised in a long cycle. If you can time it well, the odds are the same as in a more normal cycle, and I have not heard that the miscarriage rate is any higher. So most do correct a long cycle to make it shorter, but it’s not because we are trying to control embryo quality.

How are polpys diagnosed? Ultrasound or HSG or sono-hysterogram (this last one is where the doctor uses a speculum and squirts a little water inside the uterus while doing the ultrasound. This really helps see small defects in the uterine lining, like polyps). I have found through the years, especially as the quality of the ultrasound machines have improved, that a careful vaginal ultrasound works quite well. HSG has been OK, but it misses small polyps. The sono-hysterogram is probably the best test because it finds the smaller ones, but if the uterus looks perfect on regular ultrasound there is only a small benefit to having the sono-hysterogram.

Day 7 blastocyst? If day 6 works why wouldn’t at least some day 7s?. I have not had any patients use day 7 embryos. It’s suboptimal. Maybe as we get more experience day 7 will become useful. One problem may be that a good embryo will be hatched out of it’s shell by day 7, which may or may not be a problem.

IVF during breastfeeding? It can work but I don’t know if the breastfeeding affects your chances of success. Yes most fertility drugs are the same hormones that are already circulating, but taking the drugs will increase their concentration in breast milk.

After chemo, if the sperm counts are ok, is the sperm ok? This is tough to answer. My feeling is that it is, but it’s just a feeling. You will certainly get different opinions from different doctors. I have not met any doctors who do not want the husband to use the sperm, but there could be some out there. The doctors may inform the husband that there may be unknown issues.

Translocations: is IVF the only way to have a healthy child? No. Pregnancy and delivery on your own is possible. The stats on this are tricky because most embryos that are created from a couple where one partner is a translocation carrier are abnormal. However, most abnormal embryos do not implant, so if there is implantation, odds are its normal (not 100% and the odds depend on if the translocation is maternal or paternal). You really need a genetic counselor to give you more specific numbers and more of an explanation. IVF with PGD will help, however, it’s expensive and tedious, and does not guarantee a pregnancy, or even a transfer. That being said, there are patients with translocations who are only interested in IVF with PGD.

If the semen analysis is abnormal, always repeat it. Sometimes the minor abnormalities just go away.

What if you go for the hsg and the cervix is closed? If you get a period, your cervix is not closed. There are different ways to do the hsg and one involves putting a tube through the cervix and into the uterus. This is at times difficult or impossible to do because the cervix may not be completely closed, but narrow. The better way is not to put the tube in and just squirt the fluid up the cervix. The cervical canal acts as the tube and brings the dye up into the uterus. In this case, there is a much lower chance of running into "stenosis" issues.

IUI vrs. IVF – a Patient Guide

By Daniel Shapiro, M.D. 

 

When a couple present themselves for fertility care, their obvious goal is to leave the care of their physician with a healthy pregnancy. For most couples where the woman is under 40, pregnancy is the ultimate outcome, although it often comes at great expense. In many cases, the cost is not only financial but also emotional. It is quite common for reproductive endocrinologists to have patients express a desire for pregnancy as soon as possible without complete understanding on the patient’s part of what that might exactly entail.

When deciding on a particular therapy, patients and their doctors need to consider many factors including: success of therapy, cost of treatment, inconvenience, side effects, and risks of treatment.

Certain diagnoses leave little choice. For example, a patient who has had her fallopian tubes removed has no choice other than IVF if she desires pregnancy. Similarly, patients with certain anatomic abnormalities require surgery. For most patients, however, there are several options for treatment.  Lengthy discussion between the patient, her partner and their doctor is necessary to properly tailor treatment.

 After an initial work-up for infertility has been performed, one of three conditions will exist: 1) a diagnosis with a specific treatment will be evident or 2) a diagnosis with treatment choices will be found or 3) no specific diagnosis will be identified and the doctor and patient will have to decide which treatment from the appropriate list will be attempted.

 In real terms patients will be found to have tubal disease, ovulatory dysfunction, male factor, uterine abnormalities, endometriosis-associated infertility, a combination of the above or no diagnosis at all. Though other infertility diagnoses exist (such as immune dysfunction or luteal phase dysfunction), they are uncommon and poorly defined. Consequently, there is no consensus for treatment of these potential problems.

 Also in very real terms, all fertility care can be reduced to one of four categories: expectant management (which means do nothing special), surgery, ovulation induction with or without intra-uterine insemination (IUI) or lastly, In-vitro fertilization (IVF).

 For patients with early stage endometriosis, mild male factor, ovulation errors or unexplained infertility, many doctors recommend, and many patients request, therapies based on intra-uterine insemination. IUI can be timed by ovulation induction protocols where the doctor monitors the growth of a patient’s ovarian follicles (egg sacs) while the patient takes either oral or injectible medication. IUI can also be timed by ovulation predictor kits in which a patient dips her urine to detect the most fertile time in a cycle by detecting the presence of LH, the ovulation hormone, in urine

 Insemination has been around quite a long time and predates IVF treatment by 25+ years. The first recorded inseminations were performed with donor sperm in the 1950s and were surrounded by much controversy regarding the ethics of the procedure. These inseminations were of the ‘turkey baster’ variety, where donor sperm was placed in the vagina or on the cervix but not injected into the uterine cavity.

 Clomiphene Citrate (Clomid) was approved for use by the FDA for ovulation induction in anovulatory women in 1967 and within a few years, insemination was added to the protocol in many centers. Initial experience with intrauterine insemination yielded the observation that direct injection of raw semen into the uterus could cause intense cramping and pain. These symptoms are caused by the hormones in human semen called prostaglandins. By the mid-1970s methods of washing sperm out of semen and re-suspending live sperm in nutrient media became available and allowed for IUI to be performed without side effects.

 Unfortunately, reliable clinical analysis of the efficacy of IUI wasn’t available until much later. It was (understandably) assumed by many that simply increasing the number of sperm in the fallopian tube (where fertilization takes place) would increase the chance of pregnancy. At the time that ovulation induction and insemination therapy was coming into common practice, doctors performing these procedures required no special training and scientific evaluation of new therapies was often slipshod. Since there really wasn’t anybody tracking outcomes adequately in the early years of IUI, it took a long time to realize how limited the therapy really is.

 To understand the limits of IUI it helps to know the natural rate of pregnancy in couples attempting conception at different ages. The maximal chance of pregnancy per month occurs at age 27 and is about 22% per month. This means that in any given month of trying one in four or five 27 year olds will conceive.  At age 35 the month to month chance of pregnancy is 16 % and at age 40 it is 7% per month.  We now know that IUI alone DOES NOT CHANGE the month to month chance of conceiving AT ALL because the number of sperm is, sadly, irrelevant.  The limit to fertility at any given age is the egg. In cases where there is only one egg, it matters not whether there are millions of sperm around (as is the case with IUI) or tens to hundreds as seen with natural intercourse. The inherent potency of the single available egg will set the pregnancy rate.

 That being the case, several fertility centers began offering therapies to women to increase the available egg number per cycle. The rationale here was obvious: increase the number of targets for the arrows and one becomes more likely to hit a bullseye. The first reports of combining ovulation induction drugs and IUI in women who already ovulated normally began appearing in the early 1980s. This too was met with great controversy, but the combination of drugs plus IUI was more successful than IUI alone or drugs alone and IVF was still in its infancy, so the therapy stuck.

 Reports on the efficacy of drug therapy plus insemination began to pop up frequently in the literature but again, there were no truly reliable reports available to quantify outcomes.  It was not until 1991 that the first paper considering the cumulative benefit of IUI was published in Fertility and Sterility. The paper, by Linda Chaffkin, MD, showed that with injectible drugs and insemination, pregnancy rate varied by diagnosis AND very few pregnancies occurred after a 3^rd attempt for some diagnoses or a 4^th attempt for others.  As expected, patients with ovulation dysfunction had the highest cumulative pregnancy rates while patients with severe male factor did quite poorly.

 Irrespective of diagnosis though, the paper showed quite clearly that with IUI it is basically ‘three strikes and yer out!’ Plainly, and less bluntly put, this means that for ANY IUI treatment regimen in ANY patient population, it makes little or no sense to keep trying if no pregnancy occurs by the third attempt. Though similar data does not exist for Clomiphene plus IUI, other authors have considered the existing publications and derived similar conclusions. These same is also true for IUI based on LH timing alone (no drugs).

 With regard to the use of oral ovulation induction agents, clomiphene in particular, all the reliable data on cumulative pregnancy rates is derived from women with ovulation dysfunction. In work dating back to the 1960s and validated by Guzick, et al. in the 1980s, women with PCOS type ovulation dysfunction could expect 30-37% cumulative pregnancy rates over the course of 6 attempts. Most of the pregnancies occurred within the first three attempts. These studies were conducted without IUI as part of treatment but they illustrate that, generally speaking, effective therapies work early on in their course or something more potent will be needed to cause pregnancy.

 In 1998, Guzick et. al also published a comprehensive review that details what is outlined above. He examined papers on the treatment of couples with unexplained infertility and compiled the data to find average outcomes by treatment choice.  Once a patient has had a year or more of infertility, the month to month chance of pregnancy in the future is 1-4%. The table below details the expected outcomes by treatment protocol.

 Note that Clomiphene is ‘Clomid’ and Gonadotropins are injectible drugs containing FSH (follicle stimulating hormone). 

In his study, Guzick found that on average, IVF worked no better than 21% of the time. The data he examined was from the late 1980s and early 1990’s. IVF outcomes have improved markedly since then and in the most recent analysis from CDC (2007 data) the overall chance of having a baby from IVF is about 35% per try for all patients entering treatment. When broken down by age, patients under 35 have close to a 50/50 chance while 40 year olds have about an 18% chance per IVF cycle.

 Which brings us to the main the point of this article…IVF may in fact be the better first choice treatment based on outcome. Given the findings from the Chaffkin paper, patients who decline IVF as primary therapy should do no more than 3 cycles of IUI with gonadotropins before giving IVF a try.  Classically, patients would start with Clomid alone and then progress to clomid plus IUI followed by injectibles plus IUI before considering IVF. For a patient who did everything mentioned above 3 times before trying IVF, the total amount spent before IVF would be about 18,000.00. This is more than a single IVF cycle. Though I did not mention it before, the Chaffkin paper showed CUMULATIVE pregnancy rates for all diagnoses other than ovulation dysfunction to be less than 38%. This means that in 2009, using current technology, patients at any age engaging in three IUI cycles with injectible drugs will spend more for treatment than one IVF cycle and wind up with a lower overall chance of pregnancy to boot.

 Cost efficiency analyses have been performed by several authors and they all show the same thing: for advanced stages of endometriosis, male factor, severe PCOS (ovulation dysfunction) or tubal disease, IVF should be the first choice of treatment because overall, patients will spend less per live birth than if they chose IUI-based treatment.  Even for diagnoses where IUI proved (slightly) more cost effective (unexplained infertility or early stage endometriosis), other considerations should move many couples to IVF quickly.

IUI based therapies with injectibles are notorious for causing higher order multiple births because doctors have poor control of what happens once the eggs drop and the sperm flies north. Though twins are not generally considered a poor outcome, triplets and above are. Almost all of the morbidity and mortality from fertility treatment occurs as a result of higher order multiple birth. Drugs plus IUI therapies are too imprecise to prevent this. In IVF, embryo number can be controlled and the higher-order multiple birth rate kept to a minimum.

 IUI-based therapies also fail to preserve the ‘extras’.  A patient may make 3-5 ripe eggs in a typical IUI cycle. Pregnant or not, the eggs are lost once the cycle is over. In IVF, additional embryos can be cryopreserved for many years. With new freezing technology now available, eggs can be frozen too so that patients can both get the advantage of the ‘left-overs’ and avoid abandoning embryos in the future. Egg freezing allows patients with religious or ethical concerns about discarding embryos to avoid this quandary altogether.

 In sum, IUI is a reasonable therapy for some infertility patients but should be abandoned for IVF by the end of the third IUI cycle at the latest. This is clearly true where the drug therapy is injectible FSH but is also probably true for Clomiphene as well simply because the original data on clomiphene for anovulatory patients showed very few pregnancies past a third to fourth attempt. Unfortunately, reliable data for oral ovulation induction agents like clomiphene in OVULATORY women is not as clear as it is for injectible medication, though Guzick’s data shows abysmally poor pregnancy rates for clomiphene with or without IUI in ovulatory patients IUI without any medication has almost no role except in single women or couples with coital failure as IUI for proven infertile couples offers no benefit at all. For patients with concerns about multiple birth who will not accept selective reduction to avoid delivery of higher order multiples, advanced IUI treatment should be avoided altogether.

 Consequently, IVF should be considered much earlier in a treatment course than has been the case in classical management. This statement applies regardless of diagnosis or (within reason) the age of the female patient. IVF offers higher pregnancy rates per attempt that the cumulative rates for any IUI therapy. IVF allows cryopreservation of extra eggs and/or embryos and IVF allows the patient and the doctor to better control multiple birth by controlling embryo number for transfer to the host uterus.