Fertility Doctor

Saying Goodbye

2011-07-07T15:56:00.000-07:00

One of the hardest things I do is say goodbye to patients. Even when they are pregnant and heading off to their obstetricians because we have been successful, it's still hard. So here are some the things I wish I could say and do:

I am not just acting thrilled that you are pregnant, I AM thrilled that you are pregnant. I am honored that you asked me to help, and I am so excited for you that we were successful.

I will think of you for at least a year after you are gone. I know that's odd, but I've spent a lot of time with you. I've been there for the ups and downs, and I've really gotten to know and like you. If you are pregnant, I will wonder whether the baby has been born yet. I will wonder who he or she looks like, you or your partner.

Please always feel free to call or visit me. If you have a question, I am still your doctor too and would be happy to try to help. If you want to come show me your big pregnant belly, you will make my day! Bring the baby in too, my whole staff will want to see him or her!

If you did not conceive, I take it personally. Even if the odds were against us, I really wanted you to be the one to beat the odds. I wish I could get everyone pregnant.

I wish I could give you a hug goodbye, but I don't know how you will take it.

Send me a baby picture--don't forget. I know that life with a newborn is all encompasing, but even if he or she is now 2 years old and you haven't had time until now, send me a picture. I love babies!

If you thought we gave you good care, tell your gynecologist and your friends. If you didn't, tell me--I absolutely want to know!

If you want to give me a hug, it's OK to do it.

If you see me in public, I will not acknowledge you until you acknowledge me. This is for your privacy. I don't know if you want to admit knowing me, especially if I have family or friends around who know what I do for a living, but I will be happy to admit knowing you. So feel free to talk to me, and please don't feel slighted if I don't approach you.

If there were times during this process where you weren't at your best, I understand. I have gone through this too, and I know how stressful and emotional it is. I have already forgotten what you did or said, and you should too. This office is like Las Vegas: what ever happens here, stays here.

Most of all know that I am terrible at saying goodbye. So if I don't convey all these things to you, it's because I don't know how to put into words how wonderful it is to have been a part of this process. I wish you all the best and hope that we meet again somewhere down the road. Even if it's just in the supermarket, where you are pushing your little one around in a cart, I will be happy to see you.

Sincerely,
Susan Trout, MD

Surrogates and Gestational Carriers

2011-07-01T15:38:00.000-07:00

"Doctor, do you think I need a surrogate?" I get this question a lot, and the answer is almost always "No, a surrogate is not necessary".

Let's start with a few definitions: a traditional surrogate is a woman who provides the eggs and carries the baby. In other words, sperm is deposited into her uterus on the day of her ovulation and hopefully she conceives and then carries the baby to term. The most famous, or infamous, surrogate was Mary Beth Whitehead. She gave birth to a little girl, who was called Baby M in the court proceedings. She refused to give up custody of the baby, claiming that the baby was her biologic child and so she had a right to keep her. After a huge, very public court battle; custody was awarded to the intended parents with Mary Beth retaining visitation rights. Because of this very ugly incident, many states (such as New Jersey where the court battle took place) have laws banning traditional surrogacy. Even in states where it is not specifically banned, many fertility centers will not provide services for traditional surrogacy because of the risk of the surrogate becoming too attached to the child and the murky legal status of the baby, even when there are contracts in place ahead of time (there was a surrogacy contract in the Baby M case).

A gestational carrier is a woman who carries a baby to term, but does not provide the eggs. She is just the "incubator". In this case, eggs from another woman (often the intended parent) and sperm are mixed in the lab to create embryos. These embryos are then placed into the gestational carrier's uterus to hopefully implant and grow. Because the carrier has no genetic relationship to the child, it is believed that the carrier will have an easier time handing over the child and less legal standing in custody battles. The courts, as long as there is a good legal contract, have mainly agreed. Difficulties have arisen when the eggs come from an anonymous donor, as then the intended parent is not the biological mother. When there has been a well written contract, custody usually goes to the intended parent anyway.

So as you can see, this is not something to take lightly. There are definitely very good reasons to use a gestational carrier, but, for most women, it is not the best option. Carriers or surrogates are obviously necessary when the intended female parent does not have a uterus or has a uterus that cannot carry a baby. This does not usually include, however, multiple miscarriages. Please see my previous blog on the subject, but the vast majority of cases of multiple miscarriages have nothing to do with the uterus. Another reason for using a carrier might be a medical condition that would make pregnancy unsafe for mom or baby. Severe lupus with kidney involvement would be an example of a condition that could cause major complications (even death) during a pregnancy. This is something that needs to be decided between you and your doctors. Older age is not a good reason, although it's the one I get asked about the most. Fertility declines and miscarriage and chromosome abnormality rates climb as women get older. This is due to the age of the egg, however, and not the age of the uterus. Therefore putting the same eggs in a younger uterus, will not chance the outcome. Putting younger eggs into the older uterus will, however, improve all of the above (see blog on age and donor eggs). This is why you sometimes hear about mothers carrying babies for their grown daughters. It's the daughter's eggs, which are young, that makes these cycles successful. The age of the mom's uterus really doesn't matter. Carriers or surrogates are also used when there is no female intended parent, such as single men or same sex male couples.

If you do need a gestational carrier or a surrogate, there are some things to consider in picking one. First, has she ever carried a baby before? If not, she may not be the best choice. She has no idea how attached you can get to an unborn child that you carry around for 9 months. It may be very difficult for her to let go once the baby is born. If she has had children, how did the pregnancies go? Were there any complications? How is her health? Does she have any habits or conditions that put her at risk for infectious diseases? (e.g., gets tattoos, needs blood transfusions or blood products, has a partner who uses drugs, etc.) Has she had all of her vaccinations (many disease we vaccinate against, like German Measles, can cause birth defects when contracted during pregnancy, and many American and even more foreign-born woman have not had their full compliment of vaccinations.) What is her nutrition like? (vegitarians and vegans, for instance, often have a very hard time getting enough protein and calcium in their diets to support a pregnancy well.) Does she take any medications? Use drugs? Smoke? Drink alcohol? Is she willing to give up caffeine? What is her mental status like? Did she have any problems with postpartum depression with her previous pregnancies? Why is she doing this? Is she reliable? Does she have any religous beliefs that are going to be a problem with any part of the process? Your fertility center will help you with these questions. The fertility center will usually get and review her previous medical records, go through her medical history with her, and order a psychological screening. They will do a physical exam and test for infectious diseases. They will also do special studies to look at the uterus and make sure it's normal. If there is any question as to her vaccination status, they may order test to make sure that she is immune to things like German Measles.

If you find someone whom you like, the next step is to talk to them about some "what ifs"'. The first one is "what if it turns out she has twins or triplets?" Would she be willing to carry more than one baby, even if it means being put on bedrest? If she is put on bedrest, will she want more compensation for lost wages? If she ends up with quadruplets or more (which really should be a very remote possibility in this day and age, if the guidelines for how many embryos are transferred are followed), will she be willing to reduce the pregnancy to twins? Will she demand it be reduced to twins, even if you do not want it? Next, what happens if the baby is abnormal in some way? You need to be very frank about whether you would want her to have an abortion or not. There are some abnormalities that are lethal at birth. Would you want her to carry the baby to term anyway? Would she be willing to do that? Another discussion point will be your involvement in her pregnancy. Will you want to go to all her doctor's visits? Will you and your partner want to be at the birth? Will that be OK with her? Then, of course, there is the money. You need to find out what compensation she wants, who will pay for maternity clothes, and whether her health insurance will cover the pregnancy and delivery (many insurances now specifically exclude maternity care when the insured is a surrogate or gestational carrier).

Once you get through that discussion, it's time to get a lawyer involved. You will need someone to write up a contract between you and your carrier. She should have her own lawyer review it (someone who is looking out for her interests). The laws vary state to state, so you need someone familiar with your state. There is an association called the American Academy of Assisted Reproduction Technology Lawyers, who can help you find a lawyer familar with these situations. Do not try to get around this part. It needs to be done right. There was a case of a couple who downloaded a contract off the internet instead of paying a lawyer, and it turned out that the contract gave custody to the gestational carrier. Not good!

After that, you should be good to go. Your fertility center will tell you more about the "getting pregnant" part. They can also help you find a gestational carrier, if you do not have anyone that you feel comfortable asking to do it.

IUI (Intrauterine inseminations)

2011-05-23T15:29:00.000-07:00

Intra-uterine inseminations may sound like a scary and invasive procedure, when you doctor first mentions it, but it really isn't. It is a procedure to put sperm into the uterus and maximize the amount of sperm that gets to the egg, and it is very similar to a PAP smear in procedure and discomfort levels. IUI is often one of the first-line fertility treatment options. With intercourse, 99.9% of the sperm never makes it into the uterus; it gets stuck in the mucus in the cervix or dies in the vagina before even entering the cervix. By bypassing the vagina and cervical mucus, millions more sperm can be delivered to the egg. Even when the male partner has normal sperm counts, this can help with achieving a pregnancy. Medications like Clomid can make the cervical mucus even more impenetrable than usual, and so IUI is often used when Clomid is prescribed as well.

An IUI consists of two steps. The first step is "washing" the sperm. This is necessary because the fluid around the sperm contains substances called prostaglandins that will make the uterus cramp, if you put the fluid directly inside the uterus. Washing the sperm can be done several different ways. Basically, though, the sperm are spun in a centrifuge to bring them to the bottom. The sperm are then removed and put in fluid designed to help them survive (media), or the fluid is removed and replaced with the media and the sperm are allowed to swim back up into the media. No matter how it is done, the sperm are only put in a small amount of fluid (0.5 ml or so). The helps keep the fluid and sperm from running back out the cervix after the insemination.

After the sperm are washed, they are placed into the uterus: A speculum is placed into the vagina, and the cervix (opening to the uterus) is located. A small flexible tube (only a millimeter or two in width) is threaded through the canal in the cervix and up to the top of the uterus. The sperm is then deposited at the top, and the tube is withdrawn. This feels similar to a PAP smear, and so should not cause much discomfort. The speculum is removed, and the procedure is done at this point. Many doctors will ask you to stay lying down for a few minutes afterwards, and, at our clinic, we actually prop your bottom up in the air a little to let gravity help. Studies show that the sperm gets into the fallopian tube, which is where it meets and fertilizes the egg, within seconds to a minute. So you do not need to stay lying down for very long. After you leave the doctor's office, you may resume your normal activities. It won't fall out!

The risks to an IUI are pretty minimal. It can cause a little spotting or light bleeding, just like a PAP smear can, but this should only last a day or so. There is a theoretical risk of bacteria from the vagina getting pushed up into the uterus with the catheter and causing an infection. In practice, however, this is extremely rare. If your cervix is very curvy or scarred from procedures like D&C's, then it can be a little more uncomfortable too. To have a reasonable chance of success with IUI, you need 10 million moving sperm, so severe sperm problems may not be amenable to IUI. In those cases, IVF may be a better option (see previous blogs on IVF and on male factor infertility). Many couples worry that IUI will cause triplets or quadruplets and such. This is not the case. It is the number of eggs ovulating, rather than the number of sperm, that determines the risks of a multiple pregnancy. So if your doctor is recommending IUI, it is something to seriously consider. It will increase the amount of sperm getting to the eggs and improve your chances of pregnancy!

Smoking and Fertility

2011-04-22T09:31:00.000-07:00

We all know that smoking can cause lung cancer, heart disease, and strokes; but many of us still smoke. "You have to die of something" is what I hear a lot from my patients. I am not going to debate the wisdom of that statement here, but let me explain smoking's impact on both male and female fertility.

Female smokers take longer to conceive and have a higher chance of not being able to have children than non-smokers. The toxins in cigarettes can be found in the fluid filled sacs containing the eggs (follicles) in a smokers' ovaries. The eggs are bathed in these toxins, and they literally kill a woman's eggs. One study looking at ovaries of smokers and non-smokers under a microscope found that smokers had about half the number of eggs as non-smokers. The toxins may cause the eggs to be more prone to genetic abnormalities as well. This can also lead to a higher rate of miscarriages. Pregnant smokers are more likely to have low birth weight babies and premature births. Babies who have a parent that smokes are more likely to die of SIDS (sudden infant death syndrome), develop asthma, or be hospitalized for respiratory illness too. Male offspring of mothers that smoked have poorer sperm and more infertility themselves. When going through IVF (in vitro fertilization or the test tube baby procedure), smokers have about half the chance of success as non-smokers. They require more medication and produce fewer eggs with more cancelled cycles. Female smokers go through menopause earlier too.

Men who smoke are not immune either. They have lower sperm counts and the sperm do not move as well. There are more abnormally-shaped sperm too. The DNA inside the sperm of a smoker has more abnormalities. All of this can affect fertility. Male smokers have more erectile dysfunction too, especially as they get older. Their passive smoke affects their female partner's fertility too, even when she doesn't smoke.

So now you have even more reasons to quit. I know it's hard, but this is very important. It's not just for you, but for your whole family. And yes, even though you have to die of something, it doesn't have to be from a stroke at age 50. You want to be around long enough to see your kids graduate from college and get married and to enjoy your grandkids, don't you? So how do you quit? There are many different ways. Many states, such as Colorado, have programs set up with the money won from the tobacco company to help you quit. In Colorado, it's called the Colorado QuitLine. You can call 1-800-Quit Now (1-800-784-8669) or go to http://www.coquitline.org/ for help. They have resources to give you free nicotine replacement gum or patches, coaching, etc. You may want to talk to your doctor about Chantix and whether it is right for you. Pick a partner and quit together, or you may want to try the carrot and stick method. Make a bet with a friend or family member--you will quit smoking by a certain date or _____ will happen. Pick something you really don't want to happen (e.g. you will have to clean out the garage and the basement, you will have to donate $100 to a political candidate you don't like, you will give up TV for 3 months, etc--make it as horrible as you can). If you do quit, the carrot happens--you will give yourself a get away weekend, your friend will buy you a steak dinner, your spouse will allow you to pick the TV shows for a month, or something like that. If you ask for help and try hard, you can quit. As Nike says, just do it!

Trying to conceive when sex isn't safe

2011-04-21T14:53:00.000-07:00

There are many couples in the U.S. who can't conceive the old fashion way. It isn't safe. This is because one or the other of them has an infectious disease like Hepatitis or HIV that could be transmitted to their partner. For these couples, having a child of their own seems completely out of reach. They would love to have a family but do not want to risk infecting their partner. That's where we come in. We can help.

If it is the female who has the infectious disease, then she first needs treatment to bring down the level of virus in her system to an undetectable level. This will help prevent transmission to the child. In the case of HIV, for instance, a c-section is also usually recommended to help prevent transmission to the baby. She will undergo counseling with an infectious disease expert so she understands exactly what the risks are to her and her child. We can then put sperm directly into her uterus on the day she is ovulating (intra-uterine insemination). This is a simple, quick procedure that feels a lot like a PAP smear. It will prevent her partner from being infected through intercourse.

Things get a little more complicated when it is the male who has the infectious disease. HIV and Hepatitis B & C can be found in the semen, even when the blood tests show no virus in the bloodstream. The female can be vaccinated against Hepatitis B, but there is no vaccine for Hepatitis C or HIV. Therefore the patient's partner is at risk. In these cases, we get the male on the best treatment available for his disease. We can then wash the sperm multiple times with a special protocol developed in Europe to remove the virus. A small sample of the sperm is then tested in the lab to make sure there is no detectable virus, and an insemination is done with the rest of the sample. About 4,000 inseminations using this method for HIV have been reported in the literature, and there are no reported infections of the female from it. We have had similar success and have several babies born now to couples who used this method to conceive.

Medications have made it possible to live a long and productive life with HIV. It is no longer the death sentence that it used to be. Couples living with this disease are now looking to the future. They want a family, just like other couples. These procedures allow them to have that family without putting their partners and children at undo risk.

I don't want to be an Octomom!

2011-04-18T16:09:00.000-07:00

Having more than one baby at a time (multiple gestations--twins, triplets, etc) is the fear and desire of many couple struggling with infertility. When scientist look at why couple don't pursue fertility treatments, fear of multiple gestations is one of the leading reasons (the other is fear of the cost--see my previous blog on the cost of fertility treatments). However, I get asked on a daily basis whether it is possible to use a treatment or dosage that will give a patient twins rather than just one baby. "If we could have twins, then we would be done!" is what I hear a lot.

We have all heard about the Octomom, but just how likely is a multiple birth with fertility treatment? Well, it depends on the treatment. Clomid or clomiphene citrate (see previous blog on Clomid) is a mild fertility treatment that is often the first treatment recommended for couples struggling with infertility. It has about an 8-10% chance of causing twins and a less than 1% chance of higher-order multiples (triplets, quadruplets, etc). Many facilities, such as ours, will monitor Clomid cycles with an ultrasound done a day or two before ovulation. By measuring the follicles (the sacs containing the eggs that are developing that cycle), we can predict how many eggs are likely to ovulate. The goal is usually 1 to 3 eggs ovulating, depending on the woman's age. If a woman looks like she is going to have five eggs ovulating instead, let's say, we would recommend canceling the cycle and starting over at a lower dose. This practice has really all but eliminated higher order multiple pregnancies from Clomid in our office.

The Octomom did IVF, but that isn't usually associated with a high risk of a multiple pregnancy, especially a high-order multiple pregnancy like octuplets. This is because the doctor and patient control how many embryos are placed into the uterus at one time. The American Society for Reproductive Medicine (ASRM) guidelines say that a woman who is 37 years old or less should have no more than 2 embryos transferred, a 38-40 year old should have no more than 3 embryos transferred, and a 41-42 year old should have no more than 5 embryos transferred (these are guidelines for good quality embryos and may be modified if the embryo quality is poorer). If these guidelines are followed, the chance of triplets or more should be less than 1%. Obviously, these guidelines were not followed with the Octomom. However, most doctors do follow the guidelines. You should definitely have a discussion with your doctor as to how many embryos they recommend transferring and what their clinic's multiple rates are, if you are considering IVF.

The treatment regimen with the highest multiple rate is using injectable medication (gonadotropins, see previous blog on the subject) with insemination. This will often get 3-5 eggs ovulating, which can sometimes be the goal. Every once in a while, though, 4 eggs ovulate, all 4 take, and you end up with quadruplets. Therefore, this treatment regimen should be treated with caution and respect. Very careful monitoring is necessary to avoid having too many eggs ovulate. Cycles should be cancelled, if it looks like the risk of triplets or more is too high. Younger women, especially those with PCOS (polycystic ovarian syndrome, see my previous blog on this topic), should be started on very low doses and watched carefully. Even given careful cautious monitoring, it is still possible to end up with a multiple gestation. Younger women may therefore want to avoid this regimen and go right to IVF. The risk, in our hands, is less than 1%. So even here you are not at tremendous risk for triplets or more.

What happens if you do end up with twins or triplets? What exactly are the risks? Well, let's start with twins. The most common type of twin pregnancy produced by fertility medication is fraternal or non-identical twins. This is a twin pregnancy from 2 separate eggs. Identical twins are not more likely to happen with fertility medication. The risk of miscarriage of twins in the first trimester is similar to single babies and depends more on the mother's age and therefore quality of eggs. However, twins usually deliver before their due date. The average delivery date for fraternal twins is 5 weeks before they are due. This can lead to premature babies with medical complications. Overall, however, most twins do well.

Triplet pregnancies are significantly more risky than twins. 90% of triplets are born prematurely. This makes them much more likely to suffer problems like cerebral palsy (a condition with the inability to coordinate movements, learning problems, speech problems, etc), blindness, breathing problems, and problems with their intestines. One study looking at triplet and higher order pregnancies found a 32% rate of minor neurologic problems and a 6% rate of major neurological problems. The risks of death in the first month of life for triplets is ten to twenty times higher than with one baby. All of these statistics get even worse for quadruplets or more, with the risk of losing all the babies before they are mature enough to survive becoming a major factor. There are risks to you in a multiple pregnancy as well. The chances of ending up with high blood pressure, diabetes, and anemia of pregnancy are higher. Morning sickness tends to be even worse. Bedrest for months is often needed, especially with triplets or more. You are more likely to need a c-section and more likely to hemorrhage at delivery with multiples too.

As you can see, multiple gestations are not with risk. The risks increase substantially as you go from twins to triplets, and beyond. Most fertility centers, however, have worked very hard at reducing their rates of multiples as much as possible. Not that you understand the risks, hopefully your desire for more than one baby at a time has also diminished. If reducing the chance of multiples does not seem to be a goal of your fertility center, you may want to seek a second opinion. With careful monitoring and by following the ASRM guidelines for the number of embryos transferred, your risk of being an octomom should almost non-existent!

What is the cost of infertility treatment?

2011-04-12T10:44:00.000-07:00

When researchers study why couple don't seek help for their infertility, they find that fear of the cost is one of the top 2 reasons (the other reason is fear of having multiple babies at once) for not going to see a reproduction specialist. Many couples believe it will take tens of thousands of dollars to get them pregnant. They have heard horror stories of friends of friends who spent $50,000 on fertility treatments. While infertility treatment can get expensive, it doesn't always have to do so. I am going to try to give you a realistic idea of what you may be in for, if you do decide to seek help.

If you are considering going to see a fertility specialist (Reproductive Endocrinologist), one of the first things you should do is check with your insurance company. You may be surprised to find out that you do have coverage. Several states, for instance, have laws that mandate insurance coverage for infertility diagnosis and treatment for all but the smallest of companies. These states include: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas, and West Virginia. Ask your insurance company whether infertility diagnosis testing and/or treatment is covered. If you do have coverage for treatment, find out the details. Many plans will cover some treatments, but not others. They may have requirements before you can start a specific treatment, or you may need to sign up for a special program within your insurance company (Aetna often makes you do this). Do you have a deductible or maximum amount they will pay out? Ask if the doctor you are planning on seeing is in their network or not. Be an advocate for yourself and learn as much as you can about your coverage. Your doctor's office may be able to help, but you are ultimately responsible for knowing your insurance coverage.

There is one more question you should ask, but this one is of your doctor. Even if your doctor is in your insurance network, sometimes they have a lab or IVF center that is not. This is unusual, but it does happen. This could mean that your insurance pays for you to see the doctor, but not your testing and treatment. Ask your doctor's office whether they will send your lab tests to a lab that your insurance covers and whether procedures such as IVF will be done through a center that is covered by your insurance. This will help you avoid unpleasant surprises when you open up your bills. If you are wondering, the answer to both questions for our office is yes.

Usually the first step a Reproductive Endocrinologist will want to take is to do some testing to see why you are not conceiving. This is often covered by insurance. Even if you do not have coverage for fertility testing, some of the tests may get billed out with another diagnosis such as ovulation dysfunction, pelvic pain, etc. This may increase the chance that insurance covers it. Many fertility centers, such as ours, also have special deals with laboratories such as Quest or LabCorp to get very good pricing on the common fertility blood tests for couples who do end up having to pay out of pocket. For instance, the common blood tests we do will only cost $50-$60, if you have no insurance coverage. A semen analysis to look at the sperm may also be needed. If your partner has different insurance, don't forget to check and see what his will cover. A semen analysis, if it is not covered, is usually about $75-$100.

There is one test that usually does get billed out as fertility testing and therefore may be denied by your insurance company, if you don't have coverage for fertility testing. That is the hysterosalpinogram or HSG. This is a test to see whether the fallopian tubes are blocked (see previous blog on blocked fallopian tubes for more on the subject). Not all women will need this test; so if your insurance does not cover fertility testing, ask your doctor whether you need the test done or not. If you have no risk factors for blocked tubes like pelvic surgeries or infections, then he or she may be willing to forego the HSG or order a blood test for Chlamydia antibodies instead. Chlamydia is a silent cause of blocked tubes, and a negative test lessens the chances that you have blocked tubes. You may also want to ask about a FemVue procedure (see same blog as above) instead, which may be less expensive. Many hospitals, such as our hospital, also have special deals for couples who pay up front rather than wait to be billed. At Rose Medical Center, an HSG ends up being about $800, though. So even with the discount, it is on the expensive side.
Fertility treatment varies tremendously in cost. The simplest treatment is Clomid or clomiphene citrate (see previous blog on Clomid for more about this medication). Clomid is one of Walmart, Sam's Club, Target, and Kings Sooper's $9 per month prescriptions. If you don't have one of those stores near your, call around. Your local grocery store or pharmacy may have a similar deal. Clomid is sometimes combined with intra-uterine inseminations (IUI). This is a procedure that deposits sperm at the top of the uterus to get get it closer to the egg. An IUI usually costs about $400, depending on the center. An ultrasound may also be used to monitor the ovaries response to the Clomid, and that will probably cost about $200. Oftentimes insurance will pay for the ultrasound. We get about a third of our patients pregnant with Clomid, so many patients never need to go on to more expensive treatments.

Beyond Clomid, things get more expensive. Injectable medication (see blog on injectables) can be as little as $600 a cycle and as much as $4,000 a cycle depending on the dose and how long you end up having to take it. When using injectable medication with IUI, a typical cycle would run about $1,000 - $1,500 in medication. Several of the manufacturers of injectable medications have samples or programs for couples struggling with the cost of medication. Therefore you may be able to get free or at least reduced price medication for a cycle or two. There are ultrasounds and blood tests needed, and the cost will vary depending on how many are necessary. Again, insurance will often cover these as testing. A good estimate would be $1,000 in blood tests and ultrasounds, if insurace does not pay a thing. When using injectables with IVF, the costs are going to be more in the $3,000 to $4,000 range. An entire IVF cycle will typically cost about $14,000 - $16,000 with the medication. The most expensive options involve egg donors or gestational carriers. If another woman's eggs or uterus is needed, then the costs are probably more in the $30,000 (for egg donors) to $100,000 (to hire someone to carry the baby for nine months) range.

So, again, infertility treatment can range from $9 for Clomid to $100,000 for an IVF cycle with a gestational carrier. Many more couples will end up in the few hundred dollar range than in the hundred thousand dollar range, so don't panic. Do a little homework first to see what insurance coverage you have, but then at least go talk to a specialist. You may find that you have a condition that's easy and inexpensive to treat, and, in any case, you will at least get some answers. Don't be afraid to talk to you doctor about any concerns about costs. We understand how expensive certain treatments can be. We will work with you to try to keep the costs down. If your doctor is not receptive to these discussions or seems to be trying to "sell" you an expensive treatment, you may want a second opinion. There are lots of great doctors out there, and we would love a chance to help you get pregnant!

Cervical Factors to Infertility

2011-03-21T14:19:00.000-07:00

The cervix is the opening at the bottom of the uterus. It sits at the top of the vagina, and it has a small canal that allow the menstrual blood out of the uterus during a period and allows the sperm into the uterus during intercourse. The canal is filled with mucus, which is made by the cells that line the canal. This mucus is important for conception. It acts as both a reservoir and barrier to sperm. During intercourse, sperm is deposited into the vagina. The pH of the vagina is too low for sperm to survive long, so they must make it into the mucus in the cervix fairly quickly (within 30 minutes or so) or they will perish. Within the mucus of the cervix, however, they can last for several days.

The mucus in the cervix varies during the menstrual cycle. During ovulation, it is thin, watery and stretchy, but at other times it can be thick and hard for sperm to get through. Even at ovulation when the mucus is stretchy, 99.9% of the sperm will not be able to travel from the vagina, through the mucus, and into the uterus. Some women have conditions that make the cervix even harder to penetrate.

The most common cause of cervical infertility is a previous surgery on the cervix. If a woman has an abnormal PAP smear (a test that looks at the cells of the cervix for cancer), then sometimes surgical treatment is necessary. Cryosurgery (freezing the cells of the cervix), a cone biopsy (removing a cone-shaped piece of the cervical canal), or a LEEP procedure (using an electrofied loop to remove abnormal parts of the cervix) can all affect the canal of the cervix and its ability to make good mucus. Severe infections can also damage the mucus producing cells. Some procedures can even block the canal or turn it into just a pinpoint opening. The most common of these would be a D&C (opening up the cervix and scraping out the contents of the uterus). This is done for miscarriages, terminations of pregnancy, and abnormal bleeding. All of these may keep the sperm from being able to get through the cervix and to the egg.

There are birth defects that can also affect the cervix. Some women will be born with an abnormal cervix or canal. This is common in women whose mothers took a medication called DES to try to prevent miscarriages. Women with cystic fibrosis will also not be able to produce the watery, stretchy mucus needed for optimal fertility. Sometimes we never find the reason why the cervix does not make the right kind of mucus, and sometimes it is a side-effect of the fertility medication they are given (Clomid is the most common culprit).

Even when the mucus appears thin and stretchy, it can still be toxic to sperm. High levels of nicotine can be found in the cervical mucus of women who smoke. A blood pressure medication called Propanolol can also be found in the mucus at four times the blood concentrations and will affect sperm's motility. Lubricants used for intercourse can also be toxic to sperm. I would recommend using no lubricants, if possible. If you do need a lubricant, there are ones designed to be "sperm-friendly" like Preseed and ConceiveEase.

Unfortunately, there isn't a good test for looking at the interaction of sperm in the cervical mucus. The Post-Coital Test (PCT) was used for many years. For this test, a couple was asked to have intercourse at a specific time on the day of ovulation. Later, the doctor or nurse removes some of the mucus from the cervix and looks at it under the microscope. If there are lots of live sperm moving around, that was thought to be a good sign. If all of the sperm were dead, that was not good. However, it turned out that this was not true. Lots of live sperm did not always predict pregnancy and vice versa. I have personally seen lots of cases were all of the sperm were dead, but the patient still conceived that cycle. So the PCT is not done much anymore.

Many different treatment have been tried with varying success as well. Cough medications containing guaifenesin are often recommended. The theory is that they loosen up respiratory secretions and they may do the same thing in the cervix. This has never really been proven, though, and my experience with them has been disappointing. It is the estrogen that is made near ovulation that causes the cervix to make that thin, stretchy mucus; so sometimes estrogen is tried. Giving estrogen before and around ovulation can affect ovulation, however, so it is not usually done unless in combination with fertility medication. Estrogen in combination with the fertility medication Clomid (which thickens cervical mucus), for instance, has not really been shown to improve mucus either. This may be because Clomid blocks estrogen receptors so that the estrogen cannot work. The failure of these medications can also be a result of the original cause of the mucus problem. If most of the cells that make the cervical mucus have been removed or destroyed with surgery, for instance, then medication is not likely to be successful.

For most cervical factors, bypassing the mucus and getting the sperm into the uterus is the treatment of choice. This is called intra-uterine insemination (IUI). Basically this is a procedure done on the day of ovulation. Sperm is washed and concentrated down into just a small amount (about 0.5 ml) of fluid. A speculum is then placed into the vagina, and the cervix is cleaned off with swabs. A small tube containing the sperm is threaded through the cervical canal and into the uterus. The sperm is deposited at the top of the uterus and the tube and speculum are removed. It feels a lot like a PAP smear and only takes a few minutes to do unless your cervical canal is very twisty. Most fertility centers are open 365 days a year, so that it can be done even if you are ovulating on a weekend or holiday. IUI gets millions more sperm to the egg, even when there isn't a cervical issue.

If you haven't been able to conceive and you have had a procedure on your cervix, then it may be helpful to go see a fertility specialist called a Reproductive Endocrinologist (R.E.). In places where there are no R.E.'s, there are oftentimes OB/GYN's who know how to wash sperm and perform IUI's. That simple little procedure may be all it takes to get you pregnant!

Surgery with a Robot?!

2011-03-16T10:01:00.000-07:00

The first time I heard the term robotic surgery, I pictured a surgeon lounging in a chair telling a robot what to do as it operated on a patient. When I tell my patient that I want to do robotic surgery, I can see on their faces that they are picturing a similar scenario. Well, the truth is far from that.

Robotic surgery is a form of minimally invasive surgery called laparoscopy. In standard laparoscopy, a scope is placed through a small incision (usually 5 -12 mm) in the belly button.   The view the surgeon gets from the scope is a 2-D view like on your TV. Other instruments are placed through small incisions near the pubic bone or out near the hip bones. The instruments can open and close, and sometimes they can be turned to point a different direction, but that's usually it. This can make surgery more challenging than traditional open surgery where a surgeons hands can move in many different directions and angles rather than just opening and closing (think of a adult learning to eat with chopsticks). Robotic surgery is done through through the same small incisions, but the instruments can move like a surgeon's hands. The view is also 3-D because there are 2 small scopes rather than just one. All of this has made it possible to do surgery that would otherwise require a large incision with the minimally invasive laparoscopic technique.

In the US, the da Vinci Surgical System (www.davincisurgery.com) is the "robot" that is used. The scope and instruments are hooked up to robotic arms that the surgeon controls. The surgeon sits at a console and looks through eyepieces that give him or her a 3-D view of the surgical site. His or her fingers are in little sleeves so that when he or she moves his or her hands or even just fingers, the robot does the same thing with the instruments at the surgical site. He or she can zoom in and out and move the scope around as well. Movements can be scaled down so that the surgeon, when doing very fine work, can make normal-sized movements, and the robot makes tiny little movements. I use this when putting fallopian tubes back together after a tubal ligation. It is much easier than trying to make tiny little movements yourself. Someday it may even become common to do remote surgery this way with the surgeon in a hospital and the patient on the battlefield, let's say.

The advantages to robotic surgery over traditional open surgery are obvious. Because the incisions are much smaller, the patient gets out of the hospital faster (the same day or the next day rather than 2-3 days later) and recovers faster (3-5 days rather than 4-6 weeks). Because the patient is up walking around faster, there is less risk of developing blood clots in the legs or lungs. The patient goes back to work much faster, and so the economic impact to the patient is usually lessened. The advantages over standard laparoscopic surgery are more tricky. With the extra mobility of the instruments, difficult laparoscopic cases can be made easier and finer work can be done. Simple laparoscopic cases may be better off with standard laparoscopy, though. With simple laparoscopic cases, the surgeon often needs only 2 incisions. The robot requires 4 incisions, and so the patient is better served by doing plain-old laparoscopy. For me, the greatest advantage is being able to take a case where I would have had to make a large incision and turn it into a minimally invasive case by using the robot.

If your surgeon has recommended that you have robotic surgery, this is what you can expect. The night before, you will be told not to eat or drink anything (and they do mean anything--no gum, no mints, nothing unless you are told otherwise!). If you have medication you take in the morning, ask you doctor whether you should take it or not. You will usually be asked to arrive at the hospital about 2 hours before the surgery. Wear comfortable, loose-fitting clothes and slip-on shoes. You won't really feel like bending over to tie shoes after the surgery. Don't bother with lots of make-up, it's just going to get smeared while you are asleep. Your doctor may ask you to take some medications and/or a special diet the day before to empty out your bowels. This is helpful when working in the pelvis or belly, because the intestines are all around the organs. By emptying them, and so making them smaller, it is easier to see.

When you arrive at the hospital, there will be paperwork to fill out and sign. You will probably be asked for your insurance card and a picture ID, so don't forget to bring those along. Bring a book or something too, as there may be some waiting too. The pre-op (before surgery) nurse will then call you back to the pre-op area. He or she will get your height and weight, blood pressure, pulse, and temperature. You will be given one of those lovely hospital gowns to change into (yes, it's true, you have to take your underwear off too). Most hospitals will also give you socks with treads or slippers to keep you feet warm too. The nurse will insert an IV into a vein in you arm and start giving you fluids. He or she will confirm your identity and review your medical history with you. You will probably be asked what type of surgery you are going to have. This is not because the nurse wants to know (she already knows), but because she wants to make sure you understand what type of surgery is going to be done. The nurse may also wrap you legs in these devices that squeeze your legs and keep the blood moving around while you are asleep to help prevent blood clots. The anesthesiologist will come and visit you as well. He or she will explain how the anesthesia is administered. If you have problems with motion sickness or you have gotten nauseous from anesthesia in the past, tell the anesthesiologist. There are lots of way to prevent nausea, if we know that it is an issue. Your surgeon will also come and see you before the surgery. If there is one side that is to be operated on (for instance you have a cyst on the left ovary), then the surgeon may make an X on that side of your belly with a marker. If you have any last minute questions, write them down so you don't forget to ask your surgeon. You will also meet his or her assistant. Often times this is a resident, and it is the person who will stay by your side and help while the surgeon is at the console. The final person you will meet will be the "circulating nurse". This is the nurse who will be in the operating room with you. She is likely to ask you the same questions everyone else has. This is just to double check everything. She will be the one to wheel or walk you back into surgery. If you have friends and family members with you, they will usually be able to stay with you until that time.

As you go back into the operating room, you will notice that it gets colder and colder. We keep the OR rooms on the cold side, because the surgical team has on gowns and gloves and masks and are under large OR lights. All of this makes them very warm. Since you want the people operating on you to be comfortable so that they can concentrate on you, it's going to be cold in the room. The circulating nurse will have lots blankets that have been warmed up to put on you, so don't be afraid to tell him or her that you are cold and need more. You may be asked to give them your name and birth date one final time. At this point, you may have been given some relaxing medicine, but you will still be awake. Once you are moved onto the operating table, they will start putting all kinds of monitors on you and the anesthesiologist will start giving you medication through your IV to put you to sleep. He or she may also ask you to breath oxygen through a mask as you are going off to sleep. The masks are plastic and smell like a beach ball. If you makes you feel claustrophobic, just let them know. They can hold it away from you face a bit.

The next thing you know, you will be waking up. It feels like time literally stopped, and it will be hard to believe that the operation is over. Most people don't have any dreams under anesthesia. You will think that you just went to sleep, when it really has been hours since you dozed off. You will be taken the the post-op area (after surgery). You will be asked to rate you pain on a scale of 1 to 10. The nurses will give you pain medication or anti-nausea medication, if you need it.  Then you will probably snooze for a while. Once you are awake and staying awake, they may allow one or two of your friends and family to come sit with you. For a while, your short term memory will be a little fuzzy. You may ask the same question several times, not remembering that it has been asked and answered. The nurses will give you something to drink and some crackers or something to eat. Don't ask for water; it tends to make you nauseous, even if you aren't to start with. I recommend ginger ale; it seems to combat nausea. After a while, the post-op nurse will get you up to the bathroom and let you get changed back into your clothes. You will notice that your belly is kind of sore. That's why loose clothing is a good idea. Take it slowly, and ask for help if you need it. When you look in the mirror, your face make look a little swollen. This is normal. During the surgery, they tilt the bed so that your feet are up in the air and your head is pointed toward the ground. This will help shift all the intestines up towards your chest to expose the area the surgeon will be working on. Being tilted on your head like that for an hour or more will cause fluids to pool in the top of your body, making your face kind of puffy. It will go away in a few hours or so. Before you go home, the nurses will give you a written set of instructions to follow for the next few days and prescriptions for medications, if you doctor has not already given them to you.

When you go home, you will likely still have some effects from the anesthesia, so you may want to take another nap. Don't be afraid to tell friends and family that you need some quiet time. They will understand.  Plan on taking it easy for a few days afterwards, so stock up on good books and movies for your recovery. It's OK to go up and down stairs and walk around, you are just going to want to do it slower and less often than usual. Usually by the fourth day, you are pretty much back to normal. The incisions aren't hurting anymore, unless something is pushing on them. Tight jeans or your dog jumping on your belly are still not a good idea. Other than that, your life should be back to normal. The only things your doctor is likely to ask you not to do until he or she sees you back in the office to check the incisions will be baths or putting anything into the vagina (like tampons, douches, or intercourse), if you have pelvic surgery. Once your doctor sees you back in the office and checks that your incisions are healing well, he or she will probably lift those restrictions. Write down and bring any questions you still have to this visit. You will probably not have a lot of time with the doctor, and you don't want to forget anything!

Overtime, the incisions will lose their redness and become small lines. Sometimes there is also some bruising around the incision, and that will go away over a week or two as well. If you have any numbness around the incisions, this will often resolve over several months. Soon the surgery will be a distant memory as, hopefully, will the problem that caused you to need the surgery in the first place!

Too Much Patience Is Not a Virtue

2011-03-09T17:26:00.000-08:00

"Patience is a virtue,
  Possess if you can,
  Found rarely in a woman,
  And never in a man."

My Grandmother used to tell me that as a child. But every once in a while, I see a patient with too much patience.

One of the first questions I ask my patients is "how long have you been trying?" Usually I get answers in the 6 months to 1 1/2 year range. The other day I got the answer "six years". She was 43. My heart just sank. It is rare for 43 years olds who have been unsuccessful for that long to be able to conceive with anything less than donated eggs. She told me that she just thought she need to be patient; that it would happen. We are going to do some testing, I told her, but it may be too late.

Most fertile couple are pregnant within a year of trying. So if it has been longer than a year, there is probably a problem. It may be very simple to fix, but you need to see a doctor for testing to see what is going on. If you are over 35, you should see a doctor after 6 months of trying to conceive without success. This is because there really is such a thing as a biological clock, and it starts ticking loudly in your late 30's. Because you have less fertile time left to conceive, it is recommended that you see a doctor sooner rather than later.

In talking to my patient more, I found out that she actually had tried to see a fertility specialist a few years ago. She didn't like the doctor, though, and he recommended a lot of expensive tests and treatments. She never went back after the initial consultation. I hear that a lot too. I told her that we would take it step by step, that I feel no need to order lots and lots of tests, and that I would give her all the treatment options available and their costs and she could decide.

Not all personalities mesh. I have one "no-nonsense" nurse and one "touchy/feely" nurse, and we definitely see patients who can relate to one and not the other nurse. The same is true for doctors. Your doctor may be an excellent clinician, but if you don't like him or her, then it may not matter. Especially when it comes to fertility treatment, where you are likely to be spending a lot of time with your doctor. If you have a teribble experience with a doctor, don't let it turn you off all doctors. If there are other doctors in your area, try a different one. If he or she is the only specialist in the area, talk to your primary care doctor. Perhaps he or she can act as a go-between. Many infertility centers offer a free 15 minute phone consultation for new patients, and that can be very helpful in figuring out whether a doctor is right for you. It also will give you an idea of what you are getting yourself into. If you like your doctor, but you have concerns, talk to him or her. You may be surprised how receptive they are. I always tell my patients that I want to hear about ANY concerns.

Sometimes, I have to give patients bad news. When I do that, I tell them that they are likely to think of more questions as the news sinks in, so they should pick up the phone and call me. So please don't feel bad, if you walk out of the doctor's office and think of questions on the drive home. Call him or her or set up a follow-up consultation, if you think it's going to take more than a few minutes to ask them all. You need to be an advocate for yourself. You should understand what's going on with your body and what options you have for treatment. It's your doctor's job to educate you, and we enjoy doing it. If you don't like what your doctor is telling you, that may just be because it's bad news. But it never hurts to get a second opinion. 80% of the second opinions I give agree with the original doctor, but that means that 20% of them don't. Even when I agree with the first doctor, patients feel better because their doubts have been put to rest. Now they can move on and deal with the problem. Don't feel like you need to stay with the second doctor, it is perfectly reasonable to see them for a second opinion and then go back to your original doctor. If you like the second doctor more, you can certainly stick with him or her. Being comfortable with and confident in your doctor is important.

So remember, patience is a virtue up to a point. Waiting too long can be the difference between conceiving and not conceiving. In this case, not making the decision to seek help can be making a decision not to have children.

Need sperm?

2011-03-08T13:22:00.000-08:00

Sometimes life throws you curve balls. You desperately want a baby, and there is no man in your life or the man you are madly in love with has had a vasectomy. Whatever reason there is for not having a sperm source, you can still conceive with donated sperm. There are two types of sperm donors: anonymous and known donors. As tempting as it may be to ask your friend or a relative of your partner for his sperm, you need to think carefully about that decision as it can lead to some unintended consequences. As the baby's biological father, the person you ask will have certain parental rights whether you put his name on the birth certificate or not. You may not think he will ever want to have anything to do with the child, but remember that life throws you curve balls. Several years from now, his situation may change and he may want more involvement in the child's life. If the donor is a relative, will it be awkward at family gatherings? What if he disagrees with the way you are raising the child? There is also the issue of infectious diseases. He is not likely to admit to you his entire sexual, surgical, and drug history. You are taking a risk of being infected, even if you use the "turkey-baster" method. Studies show, for instance, that blood that's donated by friends and family of a patient is more likely to contain infectious diseases than blood donated anonymously by the general public. It's counterintuitive, but your friends and family want to help you and therefore may not be as forthcoming about a risk factor they have. These are all things you need to think about and discuss before you make a decision.

Using anonymous donated sperm in this country is very safe. The FDA has stringent rules and regulations about the testing of sperm donors. They inspect all FDA-registered sperm banks on a routine basis to make sure they are following the rules. They require that the sperm donor be tested for infectious diseases like hepatitis, AIDS, syphillis, gonorrhea, etc. The sperm is then frozen and quarantined for 6 months. The donor must come back 6 months later and be retested for all those infectious diseases to make sure that he was not in the window period where he had contracted the disease, but the test had not yet turned positive. This works extremely well at protecting you from infectious diseases. Most sperm banks will also do genetic and psychological screening on their sperm donors too. The FDA does allow more leeway when it comes to donors who are known to the recipients (e.g. friends, family, etc). Although the original testing must still be done, the clinic can decide wether to follow the quarantine policy. They cannot decide on an individual basis. They must make one policy for everyone and then follow it. Most clinics, because it is safer, have decided to follow the quarantine policy. Which leads to one more disadvantage of using your friend as the donor. You may have to wait 6 months before you can have any of his sperm. There are, of course, times when all of these disadvantages may be worth it. You will have to decide that for yourself.

There are many excellent sperm banks in this country, if you decide to go with an anonymous sperm donor. California cryobank (http://www.cryobank.com/), Cryogam Colorado (http://www.cryogam.com/), Fairfax Cryobank (http://www.fairfaxcryobank.com/), and Xytex (http://www.xytex.com/) are the 4 main ones we use. When you are looking for a sperm bank, the first thing you should check is that they are an FDA-registered bank. Most will have a certificates page where you can actually check their FDA registration. This ensures that your sperm donor will be tested in the appropriate manner. Next you can look and see if they do any other testing on their donors, beyond what the FDA requires. Some banks will test their donors for genetic diseases for which their ethnicity puts them at risk, like cystic fibrosis or sickle cell disease. This can give you peace of mind. Some banks will also allow you to see baby photos and even current photos of the donor. You may or may not find that helpful. Finally, look at the costs. They are going to vary bank to bank. Even within a bank, they may have different costs for donors with a college degree or proven fertility. So shop around. This may not work on the first try, so you may end up having to buy multiple samples. That can start to add up.

Now that you have the bank you want, it's time to start looking at donors. You will find that they give you all kinds of information on the donor. One of the pieces of info that you will see is their CMV status. CMV is a virus that children usually get. It is not a particularly dangerous virus unless you contract it while you are pregnant. If you do get CMV in a pregnancy, it can lead to birth defects. Because there is a possibility of CMV being transmitted through the sperm sample, the donor is tested. Our policy is to test you as well. If you have had CMV already, then the chance of reinfection and subsequent birth defects is very low. In that case, you may use CMV positive or negative sperm donor. If you have not had CMV in the past, then you need to use CMV negative sperm donor. The test on you is a simple blood test that looks for the antibodies to CMV. If you don't know your CMV status, ask your doctor to test you or pick a donor that is CMV negative.

You will also see the donor's blood type as well. This is less important, unless you are trying to match your partner's blood type. There is no medical reason to do that, but some couples don't want to tell their offspring that they were conceived from donor sperm. Matching the male partner's blood type will make it less likely the child accidentally figures it out when he learns about the genetics of blood types in his high school science class. This happens a lot in soap operas, but may or may not be an issue in real life. If the recipient female is Rh negative (i.e. her blood type is O, A, B, or AB negative), then she will need an injection of something called Rhogam at 28 weeks of pregnancy and again at delivery, if the baby is Rh positive. Rhogam protects the baby's blood from being attacked by the mother's blood. If she picks an Rh negative sperm donor, then she will avoid the Rhogam shot at delivery. The injection is not a terrible one though, so this is probably not worth the hassle of finding someone you like who is also Rh negative.

The majority of the information given is going to be on physical characteristics and personality traits. You are on your own with picking out which of those are important to you. You may also have information on whether they have helped conceive a pregnancy or not. Proven fertility is obviously nice to see, but these guys are going to have a full analysis of their sperm before they are allowed to be donors. So the vast majority of them are going to be fertile, proven or not.

Once you find the donor you like, you need to figure out what type of specimens and how many you need to order. You will see that most donors will have ICI, IUI, and sometimes ART-type specimens. This relates to how the sperm is going to be used. ICI (Intra-Cervical Insemination) specimens are meant to be placed in the vagina or mucus of the cervix. They are samples of semen with about 10 million sperm. That may sound like a lot, but it actually is not. The mucus in the cervix acts as a barrier to most sperm. 99.9% of that 10 million sperm will never make it to the egg. Therefore the pregnancy rates with intra-vaginal or intra-cervical inseminations are fairly low. Although these techniques are still used for home inseminations, most physicians prefer to do intra-uterine inseminations (IUI) instead. IUI's bypass that mucus in the cervix and get all 10 million sperm into the uterus. These specimens are washed to removed the seminal fluid. The semen contains substances called prostaglandins. When put in direct contact with the inside of the uterus, they can cause fairly painful contractions of the uterus. So the specimen is washed to remove the fluid with the prostaglandins. To put the sperm into the uterus, your doctor or nurse will insert a speculum (the device used to do a PAP smear) into the vagina. A small tube with the sperm is then thread through the canal in the cervix and into the uterus. The sperm is deposited at the top of the uterus and the tube and speculum are removed. The entire procedure usually takes just a few minutes. It is no more uncomfortable than a PAP smear, either. If your cervix is very curvy, then it can take a little longer to get the tube through and may be more uncomfortable. This is unusual, though. Most fertility centers are open 365 days a year, so that inseminations can be done even if you are ovulating on a weekend or holiday. The final type of sperm specimen is ART (assisted reproductive technology) specimens. These are meant to be used with IVF (in vitro fertilization or the test-tube baby procedure). They contain significantly less sperm and shouldn't be used for vaginal, cervical, or uterine inseminations.

Ask your doctor's office whether they can store sperm for you. If they can, you may want to order 2 specimens to start. That way, if one specimen has a problem, you have a back-up specimen. Your doctor's office will look at the specimen after it thaws it to make sure it has enough sperm. If it does not, then they can use the second specimen. Your doctors office can then contact the sperm bank and ask them to refund your money for the poor specimen. Some sperm banks will also give you a discount if you order multiple specimens at one time. This may save you some money. Also, remember that if you want more than one child, you should order extra specimens when you conceive. The donor may stop donating and not be available, if you wait until you are ready to try again for a second baby. The sperm bank itself will usually store these specimens for you until you are ready to try again.

Beware of any internet sites that deviate from the above description of how donor sperm is handled in this country. If they are offering you fresh sperm, they don't seem to have done any testing on the sperm, or it hasn't been quarantined for 6 months; it could be very dangerous. I have seen men offering their sperm via the internet to women they want to "help". You have no idea what you are going to be sent. He could have multiple infectious diseases or it may not even be sperm that is sent to you. Please, please, please stick to FDA-approved sperm banks. You do not want to put your own health at risk just to save money. It is not worth it! If you have more questions about donor sperm or you are ready to get going, see if there is a reproductive endocrinologist in your area. They are the most likely to have the facilities to store and use donor sperm. If not, your local OB/GYN may be able to help. Good luck!!

Happy Socks And The Mind-Body Connection

2011-03-01T15:03:00.000-08:00

I had a patient come in the other day for the procedure to transfer her embryos back into her uterus as part of her IVF cycle. She had on these brightly-colored socks with smiley faces all over them. I told her that I liked her socks. She told me they make her happy, and so she thought they would be good for this occasion. I thought they were perfect!

There is definitely a connection between your mind and your body. Both men and women's bodies are designed to decrease their fertility with increasing stress. An extreme example of this would be women sentenced to death awaiting execution. That type of stress is often enough to stop menstrual cycles altogether. Lesser amounts of stress can be harmful too. If you think of it from your body's point of view, why would it think it is a good idea to have another mouth to feed when things are already stressful?

Unfortunately, infertility itself is stressful. Women with infertility are two to three times more likely to suffer from depression than other women. Unlike women with other medical illnesses, women with infertility are less likely to talk to friends and family about what is happening. When they do, they may not get all the sympathy they expect either. All of this leads to more stress.

So what can be done? Studies have shown that stress relievers like meditation, yoga, group therapy, acupuncture, etc can be helpful. Sit down and evaluate your lifestyle. Does it have "me" time in it? If not, find some. Find a yoga class or join a gym. There are wonderful therapists that specialize in relaxation techniques. Set time aside to take long walks, whatever works for you. Find your "happy socks". It may be time to eliminate other stressors as well. That committee that you volunteered for that is eating up all of your free time has got to go!

Do not let the destressing process become stressful either, though. You do not have to be in a perfect Zen state to conceive. Do not worry if you have a bad day, it's going to happen. If one bad day kept everyone from conceiving, there would be a lot less babies in the world! Fertility medications will also overcome a lot of the negative effects of stress too. So your goal should be to get the chronic high levels of stress under control. Doing that will allow you to better tolerate the unexpected stress like the idiot in the other lane who just cut you off. It will help you with the stress of infertility treatments as well.

If you do have any of the symptoms of depression (sadness that feels overwhelming or lasts for long periods of time; difficulty concentrating or making decisions; exremem fatigue and decreased energy; feelings of guilt, helplessness, hopelessness or worthlessness; insomnia or excessive sleeping; irritability or restlessness; loss of interest in activities that used to be pleasurable; extreme hunger or lack of interest in food; persistent aches and pains that don't go away with treatment; persistent sad, anxious or empty feelings; or thoughts of suicide) please go see your doctor. There are wonderful treatments out there for depression and there is no need to suffer in silence.

Fibroids

2011-02-28T16:05:00.000-08:00

Today seems to be fibroid day. It's funny how it goes like that sometimes. I don't have any discussions about fibroids for days, and then it's all I do for a day. A fibroid, or uterine leiomyoma, is a growth in the uterus. The walls of the uterus are mainly made up of smooth muscle cells. For some reason, one of these cells starts multiplying and growing into little balls. Nobody know exactly why this happens. These balls of cells can grow very big sometimes. They can occur anywhere in the uterus, and they are very common. African-American women tend to have more fibroids than Caucasians, but they can occur in any race. There are almost universally benign with a 0.1% chance of being cancerous. They can definitely cause problems, however.

Fibroids will often cause heavy, crampy periods. Sometimes, especially if there is one inside the cavity of the uterus, they can cause spotting or bleeding in between periods too. As they grow, they can cause pain, bloating, and even expand your belly like a pregnancy. Fibroids have been linked to infertility, but the data are still a little unclear. Fibroids inside the cavity of the uterus can definitely impair fertility and lead to miscarriages. Fibroids that touch the uterine cavity also appear to be a problem. They are very greedy and need a large blood supply. They will take it away from the rest of the tissues around them. There was a very nice study that showed that the lining inside the cavity (where the baby grows) is very thin and abnormal looking next to a fibroid, and it is normal in other places in the same cavity. So if an embryo tries to implant near a fibroid, it may not be able to get enough blood supply to keep growing. The fibroids that do not touch the cavity or are on the outside of the uterus are where the data get murky. Most of the studies say that these should not be a problem, but there are some studies that say that taking them out will improve fertility. For now, we weigh the risks of taking such fibroids out against the possible benefit and make decisions on an individual patient basis.

Fibroids are usually diagnosed by ultrasound. A pelvic ultrasound will show round structures in the walls of the uterus. CT scans and MRI's are sometimes needed, if the uterus is so full of fibroids that they cannot all be seen on ultrasound. Rarely, another uterine mass called an adenomyoma can be mistaken for a fibroid. These are also benign and are made up of cells like the ones in the lining of the uterine cavity. MRI may be helpful in differentiating the two.

Many fibroids do not need to be removed, if they are not causing any symptoms. If they do have to be removed, surgery will obviously be necessary. If the fibroid is inside the cavity of the uterus, a scope can be placed through the cervical canal and into the uterus. The fibroid is then removed from inside the uterus. Because there are no incisions, the patient is usually back to normal by the next day. If the fibroid is in the wall of the uterus, then it must be removed from inside the belly. Sometimes this can be done through a scope in the bellybutton, and sometimes a larger, c-section-type incision is needed. If the fibroids are extremely large, sometimes an incision from the belly button down to the pubic bone is necessary to remove them. The DaVinci robot has made it possible to remove much larger fibroids through a scope than was previously possible, however sometimes a larger incision is still necessary. Recovery time for removing fibroids through a scope is usually 3-5 days, for the larger incision it will usually take about 6 weeks to recover. If fertility afterwards is not desired, there are two other treatments too. A radiologist can thread a small catheter (tube) through the blood vessels in the groin up to the arteries that supply the uterus. These arteries are then blocked off with small inert spheres. This will then cause the fibroids to shrink. The recovery time is 1-2 weeks. There is also a procedure where concentrated ultrasound beams are aimed at the fibroid to destroy it (ExAblate). Sedation is given, as it can take an hour or more to destroy multiple fibroids. The recovery time is usually just a day or two. For women who do not want children and just have heavy periods from fibroids, a Mirena IUD may be helpful too. This is a small device that is inserted into the cavity of the uterus. It secretes a hormone that will keep your periods fairly light. Some women even stop having any bleeding with the Mirena. It is a contraceptive, but is reversible when you remove the device.

Fibroids do not usually go away on their own, so ignoring the symptoms is not a good idea with one exception. They will shrink after menopause. So if you are close to menopause and the symptoms are not life altering, then it may make sense to wait. For everyone else, however, please talk to your doctor. If your periods are so heavy that they are having an effect on your life, if your belly is starting to expand, or if you are unable to conceive; it's time to do something. Fibroids tend to just grow and grow, so waiting may mean that they get so big that your doctor will have to make a big incision to remove them rather than being able to take them out through a scope now. In any case, it certainly won't hurt to talk to your doctor and find out what your options are.

Endometriosis

2011-02-27T08:30:00.000-08:00

Endometriosis is a condition where the same type of cells that grow inside the uterus and come out every month with a period start growing somewhere else. They can grow on ovaries, intestines, bladder, or anywhere in the belly. In very rare cases, they can even grow somewhere outside of the abdomen. As these cells grow, they can bleed at the time of a woman's period, which can cause pain. Cysts can develop on the ovaries, and nodules of endometriosis can develop almost anywhere. Because these cells are not supposed to be where they are, they can also cause an inflammatory response. The body will try to attack them, which can lead to toxins and substances being secreted which may increase pain and impair fertility. Nobody knows exactly what causes endometriosis. The leading theory is that menstrual blood with living cells backs out the fallopian tubes during a period (which we know is true) and the live cells implant and grow where they land. There may be some type of immune defect in women with endometriosis that allows this to happen without the body just clearing away the foreign cells. The problem with this theory is that it does not explain the rare cases where endometriosis grows somewhere where the menstrual blood cannot reach (such as the lungs). For now, however, it seem the most plausible explanation.

The symptoms of endometriosis are usually worsening pain with a woman's periods and/or infertility. Usually, when she is just starting to have periods, there isn't a lot of pain. As the endometriosis grows, the pain will get worse and worse. Pain can then start to develop in between periods. Eventually, there can be pain all the time that gets a lot stronger during a period. Some women, however, will have no pain or only very mild pain with endometriosis. They may only have infertility, or it can be discovered at the time of an ultrasound or even just a physical exam.

The diagnosis of endometriosis is difficult. Sometimes it can be seen on an ultrasound or felt during a pelvic exam, but a lot of times it cannot. Doctors often will rely on a woman's history of pain, although that is not 100% reliable either. The only way to know for sure is to look inside the belly and see it. This is often done by laparoscopy. This is a surgery where a small scope (usually a centimeter or less in diameter) is placed through an incision in the belly button, and other instruments are placed through another one or two small incisions down near the pubic bone or out near the hip bone. The surgeon can then look around and under all the structures in the pelvis to find the endometriosis. If there is endometriosis, it can be removed, lasered, burned or otherwise destroyed. In severe cases of endometriosis, the DaVinci robotic system can be helpful. It allows finer control that is helpful in removing nodules and cysts and getting rid of scar tissue. Sometimes a larger incision will be needed, although this is unusual. Endometriosis is graded on a scale of one to four, with one being very minimal disease and four being severe endometriosis.

Treatment for endometriosis can be surgical, medical, or both. The surgical treatment described above is used to remove as much endometriosis as possible. There can be microscopic disease, however, that cannot be seen and therefore is not removed. So medical treatment is often used afterwards to treat the microscopic disease. Medical treatment involves hormone or medications to shut down the growth of the endometriosis. It can be used as a first-line treatment or after surgery. Birth control pills are an easy treatment option. Birth control pills can give you some nausea for the first few weeks, breakthrough bleeding especially if they are not taken consistently, and raise the risk of blood clots in some women. They work moderately well at keeping endometriosis at bay. Progestins are based on the hormone progesterone, and they are very good at treating and preventing endometriosis. There are pills (Aygestin is an example), shots (Depo-Provera), implants that go in the arm (Implanon) and IUD's (Mirena) with progestins, and all will work on endometriosis. Depending on how they are given, they can also cause some irregular bleeding, constipation, bloating, and can sometimes increase appetite in the pill form. Lupron is an injection that induces a menopause-like state, and that will also keep endometriosis from being able to grow. It can cause hot flashes, moodiness, headaches and should only be given by itself for 6 months because of the risk of bone loss with longer use. Danazol is a medication that is similar to male hormones like testosterone. It is a pill and is also very good at treating and preventing endometriosis. It can cause acne, hair growth in a male pattern, and rarely deepening of the voice. Aromatase inhibitors such as Femara are a new treatment option. They keep the body from being able to make estrogen, which is what makes endometriosis grow. The side effects are similar to Lupron. Pregnancy is also very good at treating endometriosis, as is breast feeding. However, this is obviously only appropriate if you want to conceive.

When endometriosis causes infertility, things get more complicated. Even small amounts of endometriosis appear to decrease fertility, but the medical treatments outlined above will all prevent pregnancy. Surgical treatment can be used to remove as much endometriosis as possible and free up fallopian tubes and ovaries that may be scarred or blocked by the disease. Fertility treatments are then usually given to improve the chances of conception and speed up the process, so that the endometriosis does not have a chance to grow back. In severe cases, IVF (in vitro fertilization or the test tube baby procedure) can be helpful. By removing eggs and having the fertilization and early growth happen in the lab away from the endometriosis, a lot of the harm that endometriosis does can be avoided. If the endometriosis has damaged the fallopian tubes, then IVF will also help. Since the eggs do not have to travel through the tubes with IVF, it can improve pregnancy rates and lower the risks of tubal pregnancies. After a successful pregnancy and hopefully a period of breast-feeding the baby, going on medical treatment like birth control pills can prevent more endometriosis from growing.

As a woman ages, endometriosis tends to become less and less of a problem. In the menopause and the few years before menopause, hormone levels decrease enough that endometriosis can't grow as well as it used to grow. Prior to that, the goal is to keep the patient out of pain. This is a chronic illness, and something one will have to deal with until menopause. Realistically, treatment for moderate or severe endometriosis usually involves surgery, medications for several years until the pain comes back again, and then surgery again followed by more medication. In very severe cases, hysterectomy (removing the uterus and ovaries) is performed once the patient is done with child-bearing. Mild cases can often be managed just with medications.

If you are suffering from endometriosis, talk to your doctor. Gynecologists and Reproductive Endocrinologists are trained to diagnose and treat endometriosis. You should not need to suffer. There are so many treatment options out there, there is one for you!

Putting Fallopian Tubes Back Together After a Tubal Ligation

2011-02-25T15:56:00.000-08:00

Life throws you curve balls sometimes. The decision you made to have your tubes tied was perfectly reasonable at the time. You had no idea what life had in store for you, and now you find yourself wanting another child. Well, you probably have some options.

Depending on what method was used to "tie" your tubes, there may be a way to put them back together. If your tubal was done at the time of a c-section or a day or two after a vaginal delivery, there is a good chance that there is enough tube left to put back together. If your tubal was done through a scope that was placed through a small incision in your bellybutton, then it may or may not be possible. If the doctor put a clip or a ring on the tubes, this can usually be reversed. If the doctor cauterized or "burned" your tubes, then it may not be possible. Cautery, or burning, causes heat to travel through large sections of the tube and usually damages too much of the tube. If this is what was done, then IVF (in vitro fertilization or the test-tube baby procedure) may be the only option left. No matter how the tubal ligation was done, IVF is a possibility that should be considered. Please see the previous blog on the subject for a full discussion on the subject.

Putting the tubes back together takes a skilled surgeon trained in microsurgical technique. This usually means finding a Reproductive Endocrinologist, although there are a few Ob/Gyn's with enough training to do them. Traditionally, the surgery is done by making an incision on the belly very much like a c-section incision. A large microscope or special magnifying glasses called "Loupes" are then used to do the procedure. The surgery can also be done through a scope placed through a much smaller incision in the bellybutton (laparoscopy), although this is technically more difficult. Very recently, the DaVinci robotic system has made do the surgery with a scope much easier and it has great success! I have started using the DaVinci system and have a patient with an ongoing pregnancy from it. The system allows excellent magnification and lets the surgeon have greater control. The system can scale down the surgeons movements, so that he or she does not need to try to make steady tiny little movements to sew the tubes back together. He or she can make normal movements and the DaVinci turns them into tiny movements on the tubes. Patients heal faster and return to their normal activities faster as well, because the incisions are much smaller than with the traditional, larger incision technique.

No matter how the procedure is done, the first thing that happens is that the two remaining parts of the fallopian tube are located. When we say "tie your tubes", one imagines tying a knot or bow in the tube. In reality, a piece of the middle of each tube is usually cut out, and the two ends of the remaining tube are sealed. To put the tubes back together, the surgeon will find the sealed ends and cut away until he or she gets to the openings. Very fine suture (thinner than a hair) on tiny little needles will be used to sew the inner canals of the tubes back together. The outer coverings of the tubes are then sewn back together with slightly thicker suture. Saline with blue dye is usually infused through the uterus and out the ends of the tubes to make sure that they are patent the whole way through.

The recovery time is usually about 4-6 weeks with the tradional larger incision method (laparotomy) and 4-6 days with the scope or DaVinci method. The success rates vary depending on how much tube was left to put back together, the age of the patient, and whether there are any other underlying fertility problems. They are in the 70-80% range for women under 35 and drop to 20-30% for women over 40. One final thing to know about tubal reversals is that they are rarely covered by insurance. Because you are the one that made the decision to tie your tubes, your insurance company does not usually feel the need to pay to reverse that, unfortunately. Costs vary center to center, so speak to your physician about what the costs will be.

Tips for Trying to Conceive

2011-02-23T16:16:00.000-08:00

So far, I've blogged about different topics in infertility. Let's take a step backwards and go over some of the basics in trying to conceive. The most fertile period of a woman's cycle is right around ovulation. Determining when ovulation takes place is therefore key to getting pregnant. If a woman's cycle is more than 36 days or less than 25 days in length, then she may not be ovulating at all. So, she should see a doctor. For everyone else, ovulation usually occurs about 14 days before the start of the next period. We count menstrual cycles from the start of a period (don't count spotting, wait until it is more of a full flow) to the start of the next period. So if you cycle is 28 days long, you are probably ovulating on day 14. If it is 30 days long, you are probably ovulating on day 16. You get the idea.

You can use two methods to pinpoint when you are ovulating a little more accurately. Basal Body Temperature Charts are fairly inexpensive, but can be a little frustrating at times. You'll need a thermometer to start. Digital ones are probably the easiest, as you will need to determine your temperature to a tenth of a degree (e.g. 98.6). Each morning, before you get out of bed or do anything else, take your temperature. You then plot each temperature on graph paper or there are App's and websites (e.g. fertilityfriend.com) that will do it for you. What you are supposed to see is that your temperature hovers around one area, drops down, and then jumps up to a new temperature where it stays until you get your period. The day of ovulation is the day it drops down. This can sometimes be a little hard to pinpoint until you see it jump up. By the time it jumps up, however, it is too late to try to conceive. If you cycles are like clockwork, however, you can use these charts to predict when you will ovulate next cycle. If you don't see the dip or the jump up, don't panic. These temperature charts can be a little hard to interpret some times. Try one more method before you determining that you are not ovulating.

The other method is using ovulation predictor tests. These look just like home pregnancy tests, but they are for figuring out when you are ovulating. Unfortunately, they do vary in quality, so be careful which brand you buy. Consumer Reports tests them every once in a while, and ClearBlue Easy usually comes out on top. That is the brand I usually recommend. The box will have several tests in it (usually about 5), so that you can test for several days in a row. Testing once a day should be plenty. They should turn positive 24 to 36 hours before you actually ovulate. If you are someone who drinks lots and lots of water, you may want to slow down for the days you are testing. If your urine is too dilute (for instance, if it does not seem to have more than just a tinge of color to it), then you may not be able to find a positive. Some women with a condition called PCOS or women in menopause can also get false positive tests. All in all, though, these tests are extremely accurate. The ClearBlue Easy Fertility Monitor is a small computer that uses the ovulation predictor strips to determine the day of ovulation. They are also highly accurate. If you are finding a positive test with the "pee on the stick" variety, the monitor is not likely to add anything. It can be helpful, however, if you are having trouble with the sticks. Check eBay before you buy, as there are usually quite a few of them for sale there for a lot less than retail.

Now that you know when you are ovulating, the next step is to time intercourse to that. It turns out that the best day to have intercourse for conception is the day before you ovulate, which is the day the ovulation test turns positive. This is because the sperm will last 2-6 days, but the egg will only last 12-24 hours. So you want the sperm waiting for the egg, not vice versa. If you want to have intercourse on the day of ovulation as well, that may be helpful. Beyond that day will not be useful at all. The other thing to consider is the length of time it takes a man to recover and build back up his sperm counts. Intercourse every day for more than 2 or three days in a row will start to deplete his sperm stores. So before you ovulate, you don't want to be having intercourse more than every other day. Don't try to store up sperm either, though. If it has been more than 5 days, the sperm may be a little old and won't do as well either. So, to sum it all up, have intercourse every 2-4 days before ovulation, on the day before ovulation (the day the ovulation test turns positive), and then possibly the day of ovulation too. After that, relax and forget about days of the cycle for a while.

There does not seem to be a position that is better for conceiving, but you do want to stay laying down afterwards for at least 15 minutes. Try not to use lubricants, as they often have chemicals in them which can kill sperm. If you do need a lubricant, try PreSeed or ConceiveEase. These were both designed to be "sperm friendly". They are not in all pharmacies, so check the internet to see where you can get them near you. There is a misconception that these two products will increase your chances of conceiving, though. They won't increase your chances, they just don't decrease your chances. So if you do not need a lubricant, then save your money. Egg whites and mineral will also do as a lubricant, but they can be a little messy. You also want to avoid ibuprofen (Advil, Nuprin, etc) and naproxen sodium (Aleve) and any prescription product in this family of medications (NSAID's) like Celebrex. They may interfere with the eggs ability to ovulate from the ovary. Tylenol is fine, if you need a pain medication. Both partners should stay out of saunas, hot tubs, hot baths, etc while trying to conceive. Avoid alcohol and PLEASE don't smoke. Smoking kills both eggs and sperm. Marijuana is also a bad idea. It is a mild estrogen and will lower sperm counts and may interfere with ovulation.

Those are the basics of how to try to get pregnant. If you have being using these methods for 6 months or more without success, it may be time to see a doctor. Your gynecologist may be able to help, or you could see a specialist called a Reproductive Endocrinologist. This link:

http://www.socrei.org/detail.aspx?id=4725

will allow you to search for a board certified Reproductive Endocrinologist near you. If you don't have either one of those near you, try your family doctor. I wish you all the best of luck!

Do The Right Thing

2011-02-22T09:54:00.000-08:00

So far, this blog has been about different fertility topics. Today, I need to vent just a little bit. I was raised that you treat others the way that you would want to be treated and that you do the right thing no matter what. I have tried to live my life in this manner, but lately I feel like part of a dying breed. Does anyone else still believe in the Golden Rule?

A patient recently had the company she works for treat her badly. They sent out a memo that said that her insurance would cover IVF treatment, when it really did not. She was ready to start, when we discovered the error. The HR person who had sent out the wrong info, told her it was just a "clerical error" and no big deal. Another woman had a friend who had volunteered to carry her baby for her, as this woman had medical problems that would have made pregnancy a life-threatening stituation. It was an amazingly wonderful thing to do. Apparently the friend changed her mind, though. Instead of admitting that she didn't want to do it, she refused to return phone calls or talk to the woman. The worst, however, and what got me up on this soapbox, was this example: a patient had a doctor tell her that her only option was IVF and, if she tried to do anything else, he would call her insurance company and tell them that she was undergoing medically unadvisable treatment. Well, I don't think it was her only option. Even if he truly believed it was, threatening patients with trying to cut off their health insurance is most certainly not doing the right thing!

So here is my plea and my pledge. I know times are tough these days. It feels like it is "everyone for themselves", but that's no excuse. We should still treat eachother with kindness and decency. So, please, let's try to do the right thing. I promise that I will do my best to treat everyone with dignity and care, as I would want to be treated. I promise that I will try to do the right thing at all times, even when no one is looking. I hope you will too.

Recurrent Pregnancy Loss

2011-02-20T12:38:00.000-08:00

Recurrent pregnancy loss is defined as 3 or more miscarriages, with or without intervening successful pregnancies. Although this is the definition, I think it is somewhat cruel to make a woman who is had only 2 miscarriages wait for a third one before offering her any testing or help. One miscarriage in a woman's reproductive life is quite common and doesn't mean it is likely to happen again, however, and so we do not usually test after just one. We will, therefore, start testing after 2 miscarriages. The good news is that, even after 3 miscarriages in a row, the vast majority of women will still have a successful pregnancy in the future.

There are many causes of recurrent pregnancy loss. Some can be treated, and others cannot. One of the more common causes that I see is problems with the uterus. A polyp or a fibroid inside the uterine cavity can cause miscarriages. These tend to be in the first trimester (first 12 week of pregnancy), although they can happen later too. Some women have an abnormally shaped uterus, and that will lead to miscarriages. The uterus forms from two separate tubes. The bottom half of both tubes fuses together. Then the wall that fuses together is resorbed to form a big opening, which is the uterus. The second half of the tubes does not fuse together, and that is what forms the fallopian tubes. Mistakes can happen as the uterus is forming. The tubes can fail to fuse together at all or only partially fuse together, in which case you end up with 2 small uterine cavities. Because the space inside each uterus is smaller than it it supposed to be, the woman can go into labor earlier than she should. Most babies will make it to viability, but occasionally you will see a miscarriage before viability. More commonly, in women who have had recurrent pregnancy loss, you see that the tubes did fuse together; but the fused wall did not completely vanish. The cavity of the uterus can be two separate openings, or it can be heart-shaped, depending on how much of the wall was resorbed. The wall that is left behind is very fibrous and has a terrible blood supply. Any embryo implanting on this wall will not be able to get enough of a blood supply to grow and survive, and so a miscarriage happens. If the embryo implants on a side wall instead, it will survive. Because the cavity is misshaped, however, there can be preterm deliveries or babies that stay breech with these pregnancies. This is called a uterine septum.

To diagnose uterine problems, we usually do a special type of ultrasound. It is called a sonohysterogram or saline-infusion sonohysterogram. Before the ultrasound is performed, a speculum is placed into the vagina. The cervix is usually cleansed with an antiseptic like Betadine, and then a small tube is threaded through the cervix and into the uterus. The speculum is then removed, and an ultrasound is performed. During the ultrasound, a small amount of saline (usually just a tablespoon or two) is infused through the tube in the uterus to expand the cavity of the uterus. With the cavity full of saline, it is very easy to see if there are any abnormalities. When the saline is put in, it can cause mild cramping, and you will get a watery discharge for a little while after the test. But don't worry, if you are thinking its going to be like an HSG (hysterosalpingogram), it is nowhere near as bad! Another way to diagnose uterine anomalies is with an HSG. Please see my previous blog on tubal factor infertility for a full description of the HSG. I tend not to use the HSG because it is more uncomfortable, requires x-rays and therefore radiation, and can miss some polyps and fibroids.

If your doctor does find something wrong with the uterus, he or she will probably recommend a hysteroscopy. The is a procedure where a scope is threaded through the cervical canal and into the uterus. The polyp, fibroid or septum can then be removed from inside the uterus. You do need some anesthesia for this procedure, but you will probably feel pretty close to back to normal by the next day. The malformation that results in two separate uteri is not usually surgically corrected. One would have to cut open both uteri and sew them together, and this tends to cause as many problems as it corrects.

Another condition that can lead to multiple miscarriages is a problem with the blood's ability to keep from clotting. Our blood contains many factors that either promote or prevent the blood from clotting. They are all in a very delicate balance that is supposed to prevent your blood from clotting in your blood vessels, and cause it to clot when there is a tear or cut in the blood vessel that needs to be stopped up. Some people have a defect in one of these factors that either causes blood to not clot when it was supposed to (hemophilia) or clot when it is not supposed to (thrombophilia). Thrombophilias will lead to miscarriages. The blood vessels supplying a very early pregnancy are very small. Even a small blood clot can mean a big loss to the baby. In the same vein (ouch! sorry for that very bad pun!), some women will make antibodies that attack their own blood vessels (anti-phospholipid syndrome). If the blood vessels swell from the attack, the pregnancy's blood supply can also be affected. Both of these conditions are diagnosed by blood tests to look for the antibodies and clotting factor defects. The treatment varies, depending on which factor is affected, but it usually involves blood thinners like heparin.

Rearrangements in either partner's chromosomes can also cause miscarriages. Sometime a piece of one chromosome will switch places with a piece of another chromosome. This is called a translocation. Usually, the person with the translocation will not even know that there is a problem. He or she has all the right genes, and they are functioning correctly. They are just in different places than they are supposed to be. Most cells in our body have 2 of each chromosome. Someone with a translocation will have one chromosome where the piece is switched and another that is normal. When that person makes sperm or eggs, only one of each chromosome is given to the egg or sperm. So if the sperm, let's say, gets one of the chromosomes that has a piece that is missing and it doesn't get the copy of the other that has that piece, now it is missing a whole bunch of genes. At this point, any resulting pregnancy is unlikely to survive. This is diagnosed with a blood test to look at the chromosomes (called a karyotype) and should be done on both partners. Obviously, we do not have the ability to correct a person's chromosomes, so this is not a treatable condition. We can however, still help prevent miscarriages caused by the translocation. IVF (in vitro fertilization or the test-tube baby procedure) can be done. Before the embryos are chosen for implantation into the uterus, one cell is removed from them and the chromosomes are looked at. In this way, we can find the embryos that either got both of the normal copies of the chromosomes involved (ideal) or at least have both chromosomes with the switched pieces so there are no genes missing.

There are a few hormonal problems that can lead to miscarriages as well. Both underactive and overactive thyroids can cause miscarriages. High levels of a hormone called prolactin can also lead to miscarriages. Both of these are diagnosed by blood tests and treated with medication to correct the hormonal imbalance. Progesterone is the hormone most closely linked with miscarriages. It is the signal that keeps the uterus from starting a period when you are pregnant. If progesterone levels are low in a pregnancy, it will cause the uterus to start bleeding and even miscarry. Having said that, however, progesterone is rarely the cause of miscarriages. The body is very good at keeping a pregnancy going by making progesterone. When you see low progesterone levels during a miscarriage, which happens a lot, it is because the pregnancy has already stopped growing and the body knows it doesn't need progesterone any more. In my 20 years of treating recurrent pregnancy loss, and I used to be part of a multi-discipline referral service for pregnancy loss that saw lots of patients, I have only seen 3 patients where a lack of progesterone was actually the cause of the patient's miscarriages.

Another issue that can lead to recurrent miscarriages is diminished ovarian reserve. The blog previous to this one goes into great detail in describing this condition, but basically it is a low number of and/or poor quality eggs. As women get older and ovarian reserve goes down, miscarriage rates go up. A twenty year old has about a 10% chance of miscarrying when she gets pregnant. A 45 year old will have greater than a 50% chance. Some women have poorer egg quantity/quality than we would have predicted by their age, however. These women will have miscarriage rates that are higher than expected too. This cannot be treated. We have not found a way to improve the quality or quantity of eggs in a woman's ovaries. IVF can be helpful, as it let's us pick out the best quality embryos. Testing the chromosomes during IVF to look for abnormalities in the embryos can also help eliminate embryos that are destined to cause miscarriages.

If you search the internet, you will find sites talking about immune testing for recurrent pregnancy loss. This is a highly controversial subject. The data is not at all convincing. The American Society for Reproductive Medicine has said that such testing should only be done in the context of a research protocol. It can be expensive as well. Until we can give better answers as to what, if any, immune factors are important, I would advise against immune testing.

One last word on recurrent miscarriages: take time grieve the loss of the pregnancies. Even when the miscarriage happens early in a pregnancy, it is still a loss that you will feel. You need to take some time to mourn the loss. If not, those emotions will come out some other way at some other time. So give yourself permission to be sad for a while.

I hope that gives you more information on recurrent pregnancy loss. If you are suffering from this condition, talk to a Reproductive Endocrinologist or your Gynecologist. Many of the causes can be easily treated. Remember, however, that all women have a chance of miscarrying. So even after treating the causes of the recurrent loss, there is still a small chance (10% for most women) of another miscarriage. So don't get discouraged if you do end up with another miscarriage on the treatment. You still have a 90% chance of being successful next time!

Age, Fertility, and Donor Eggs

2011-02-19T11:41:00.000-08:00

Unfortunately, there really is such a thing as a biological clock. A woman's fertility is directly linked to the number and quality of the eggs in her ovaries, which declines as we get older. Unlike men, who make new sperm all the time, women were born with all the eggs they are ever going to have. As a matter of fact, a woman starts losing eggs before she is even born. The ovary starts off with about 6-7 million eggs and is down to 1-2 million by birth. By puberty, the ovary has 300,000 to 500,000 eggs left. 400-500 of those will ovulate, and the rest will just die off over time. By the time of menopause, there are very few eggs left. This loss of eggs has a direct effect on fertility. It also appears that the best quality eggs ovulate early on in a woman's life, which is another reason why it is so easy to get accidentally pregnant as a teenager and difficult to get purposely pregnant as a 40 year old.

This loss of egg quantity and quality (ovarian reserve) over time starts to affect a woman's fertility in her late 20's. The decline in fertility is usually pretty gradual until the end of her 30's. Somewhere around age 40, the dropoff will become significantly faster with the average age at which it becomes impossible to get pregnant being age 42. Every woman is different, however. Just as some women going through menopause in their 40's or late 50's instead of their early 50's, the changes in fertility can happen faster or slower in certain women. I have patients in their 20's who are already having trouble with diminished ovarian reserve and patients in their 40's who are not. These are the exceptions, however, so most women will follow the time line above.

There are ways to determine a woman's ovarian reserve. The most common method is with a blood test to look at FSH and estradiol levels on the second, third, or fourth day of your period. FSH, as I have said in previous blogs, is the hormone your pituitary makes to tell the ovaries to get eggs maturing and ready for ovulation. At the beginning of a menstrual cycle, which is when this test is done, the ovaries haven't started to do this yet. So FSH is being produced at a high rate to get the ovaries started. As the number and quality of eggs left goes down, it takes more and more FSH to get the ovaries going at the beginning of a cycle. Therefore, the higher the FSH level is at the beginning of a cycle, the poorer the ovarian reserve is. FSH levels can vary depending on the lab they are measured in, but in general an FSH level under 10 mIU/ml is reassuring. FSH levels between 10 and 15 mIU/ml are concerning. It may still be possible to get pregnant with an FSH level in this range, but it is more difficult and often takes more aggressive therapy. Miscarriage and chromosome abnormalities (such as Downs Syndrome) rates start to go up too. FSH levels over 15 mIU/ml are associated with sporadic pregnancies, high miscarriage rates, and higher chromosome abnormality rates too. Pregnancies occur, but they are fairly rare (about 3 -5% of women with FSH levels over 15 will be able to conceive). The estradiol level is used as a quality check on the FSH levels. Estradiol levels should be under 70 pg/ml. When they are higher, FSH levels will be artificially low and cannot be used to determine ovarian reserve. When this happens, the test is usually repeated in the next menstrual cycle.

Another test used to look at ovarian reserve is AMH (anti-mullerian hormone). This is a substance that is made by the eggs in the ovaries. Therefore, the more AMH there is in the bloodstream, the more eggs there are in the ovaries. Levels over 1.5 ng/ml are desirable. Below that, the quantity of eggs left in the ovaries has started to decline enough that it can affect fertility. It is still fairly controversial as to whether AMH tells you anything about the quality of the eggs. You can also count the number of follicles in the ovaries at the beginning of a cycle. Follicles are the sacs in which the eggs grow. This is called the Basal Antral Follicle Count (BAFC). Obviously, the more follicles seen in the ovaries, the better the ovarian reserve is. A final common test of ovarian reserve is the Clomiphene Citrate Challenge Test. In this test, the FSH and estradiol levels described above are done on day 2.3, or 4 and then Clomid (a mild fertility medication that is described in a previous blog) is given from day 5 to 9 of the cycle, and then the FSH and estradiol are repeated again after the Clomid (on day 10). The FSH levels should both stay under 10 mIU/ml, and ideally the day 10 FSH level should be lower than the original FSH level. The estradiol level should start under 70 pg/ml and go up significantly after the Clomid is taken. This test will often times pick up more subtle problems with ovarian reserve, and it is also helpful if the estradiol levels at the beginning of the cycle are always too high to interpret the FSH level.

The other factor that needs to be considered when determining a woman's chance of getting pregnant is her age. Age is an important factor in a woman's ability to conceive. A woman over 40 with a completely normal Clomiphene Citrate Challenge Test only has about a 10% chance of getting pregnant, whereas a 25 year old woman would have a least a 70% chance. We therefore are more optimistic about the chances for younger women with high FSH levels and more pessimistic about older women with normal FSH levels.

Once a woman starts showing signs of diminished ovarian reserve, there is no way to reverse the process. So time is of the essence. Fertility medication, inseminations, and sometimes even IVF are recommended for younger women with FSH levels under 15 mIU/ml. For older women with FSH levels over 10 mIU/ml or any woman with an FSH over 15 mIU/ml, donor eggs may be recommended. This is a process where IVF (in vitro fertilization, see previous blog on the subject) is performed using a young woman's (usually in her 20's or very early 30's) eggs. The egg donor is given injectable fertility medication to produce more eggs than the one that is usually produced in a menstrual cycle. The eggs are then removed from the donor's ovaries, mixed with the patient's partner's sperm (or donor sperm) in the lab, and then 1 or 2 of the resulting embryos are placed back into the uterus of the woman with the diminished ovarian reserve (recipient).

While the donor is taking the fertility medications, the recipient is usually given a medication to shut down her own menstrual cycle so that it can be tracked with the donor's cycle. Lupron (see previous blog on IVF) is usually the medication used for this. It is given by injection. Lupron does not usually cause any side effects in this scenario; but for the few days that it is given without estrogen, it can cause hot flashes, night sweats, and headaches. The recipient is also given estrogen to build up the lining inside the uterus to make it a good place for an embryo to grow. Estrogen can make you a little nauseous, give you a stretchy mucus discharge from the vagina, and sometimes is associated with a sense of well being and energy. The estrogen can be given by pill, patch, or injection. Once the eggs are removed from the donor, the recipient is started on progesterone too. This is the hormone the ovaries make after ovulation, and it tells the uterus to get ready for an embryo to implant. Progesterone can be given by injection or with a suppository or cream that goes into the vagina. There will also soon be a ring that goes into the vagina and secretes progesterone. Progesterone can make you a little constipated and tired.

After a few days on the progesterone, the embryo(s) are placed in the uterus. This procedure feels something like a PAP smear. A speculum (that metal or plastic instrument that is used during a PAP smear) is placed into the vagina, and the cervix is cleaned off. A small tube with the embryo(s) is then threaded through the canal in the cervix and up to the top of the uterus. The embryos are placed at the top of the uterus, and the tube is removed. Ultrasound is commonly used to watch the tube and make sure it is in the right place before the embryos are deposited. Your doctor will probably ask you to have a full bladder for this part. Now there is nothing left to do but continue the estrogen and progesterone and wait. The chances of conceiving with donor eggs will vary center to center, but they are usually very high. Donors also tend to make a good number of eggs, so there are usually extra embryos to freeze as well. The chances of miscarriage or chromosome abnormalities is low as well. Donated embryos can also be used. The process is the same for the recipient, except that Lupron is not usually necessary. Frozen embryos donated by another patient are used instead of donated eggs. This is usually less expensive than donor egg cycles, but donated embryos are harder to find and most clinics have a waiting list for them.

Beware of therapies that say they will lower your FSH levels too. It's not the FSH level itself that is the problem, it's what it says about the eggs. As I described above, estrogen will lower FSH levels. Many herbal remedies have mild estrogens in them, and so your FSH levels will look better. However, they cannot give your more or better quality eggs. DHEAS is another controversial treatment recommended for diminished ovarian reserve. Although there is some promising data, most of the data is much more pessimistic. I tell my patients that it may be worth a try so that you feel like you have done absolutely everything you can before moving on, but I am not at all convinced that it will help.

I think this is one of the most confusing and distressing issues for couples struggling with infertility. It's highly technical, and you may feel lost in all the numbers and statistics. The internet and your friends are also full of stories of women who do conceive at older ages and with higher FSH levels. Remember, I said that pregnancy is still possible even with high FSH levels or in women over 40. It's just unusual. The reason these women are posting on the internet or telling your friends their stories is because they are the exception to the rule. For every woman who beats the odds, there are close to one hundred women who cannot. Try to be realistic (yes, I know that's not easy). There is a chance you will be able to get pregnant, but you need to acknowledge the fact that it may not happen. I believe in miracles (I have 2 myself (see my first few blogs for the full story)), but I also prepared myself to live without kids or to try donor egg. Dealing with diminished ovarian reserve is awful, and I am sorry if it is happening to you. You have every right to feel angry, frustrated, depressed, and desperate. Remember that you are not alone. Talk to your friends or your doctor, if you can. There are actually some pretty funny infertility humor sites on the internet that may make you feel a little better too. Try to make a plan on how long you want to try and where you will draw the line. Consider all the options, even adoption, and give yourself time. At first, you may rule out an option like donor egg. Reconsider all the options after about 6 months or even a year. Your mind will have had time to process what is going on and you may find that options you considered out of the question now seem more reasonable. Above all, hang in there!!! You are still a wonderful person with a lot going for you, even if it doesn't feel like it right now.

In Vitro Fertilization

2011-02-17T10:26:00.000-08:00

IVF is the procedure in which eggs are taken out of the ovaries, fertilized in the lab, and then some of the resulting embryos are placed back into the uterus. It has the best pregnancy rates of all of the fertility treatments, and it is the most expensive. It can be done with a woman's own eggs or with an egg donor's eggs. The partner's sperm or donor sperm can be used.

The first step in an IVF cycle is oftentimes birth control pills. This seems odd to most women, since birth control pills are used to prevent pregnancy. They do two key things for us, though. By shutting down ovulation and letting the ovaries rest for a few weeks, we get a more uniform group of follicles (the sacs with the eggs). The rest period also allows any Clomid or other fertility medications to get out of your system. The second thing it helps with is timing. I know that if I give a patient birth control pills and have her stop them on a Thursday, say, she will get her period on Sunday or Monday. That is handy for timing cycles and giving everyone a good idea of when the different procedures are likely to be. The birth control pills are usually taken anywhere from 2.5 to 4 weeks, but it can go even longer than that. Sometimes estrogen is used instead of birth control pills, and some cycles are done without either.

Next comes the injections. This usually involves a combination of medications including FSH with or without hCG, and a medication to inhibit ovulation. The FSH with or without hCG is used to stimulate the ovaries to mature follicles/eggs and get them ready for ovulation. These days, they are usually given under the skin of the belly once a day. Common names for these medications include: Follistim, Gonal F, Bravelle, Menopur, Repronex, and low-dose hCG. For a complete discussion of these medications, see the previous blog entitled "Injectables". The medication to keep you from ovulating (those eggs are microscopic, if they get out of the ovaries, your doctor will not be able to find them!) can be given two ways. The traditional way is with a medication called Lupron. Lupron is an unusual medication. Before it shuts down your pituitary's ability to trigger ovulation, it actually stimulates the pituitary. This can be helpful or undesired. If your doctor thinks you need a little extra boost in the beginning of the stimulation phase, then he or she can use the Lupron to get your pituitary sending out your own FSH to supplement the FSH you are already taking. This is called a flare or microflare protocol (depending on the dose of Lupron given). The Lupron is usually started at the beginning of you cycle, right before the FSH medication is started. The Lupron is then continued through the stimulation phase. After a few days, the Lupron will turn from a stimulant to an inhibitor. So by the time your follicles are big enough to be at risk of ovulating, the Lupron is now inhibiting ovulation. If the stimulation phase of Lupron is not needed, the Lupron is usually started while you are on birth control pills to get it out of the way. The Lupron is then continued through the stimulation phase. Another way to inhibit ovulation is with a newer group of medications that don't have the stimulation properties that Lupron does. They simply shut down the pituitary's ability to trigger ovulation. The advantage to this is that they can be given just for the last few days of the stimulation phase. The two medications used in this manner are called Ganarelix and Cetrotide.

You will be closely monitored with blood tests and ultrasounds every 3-4 days at the beginning and 1-2 days near the end of this stimulation phase to make sure your response is ideal. The follicles and the lining inside the uterus will be measured to see how well they are growing. As the follicles grow, they make more and more estrogen, so the estrogen levels in your blood will be monitored too. Most centers will ask you to come in first thing in the morning, so that they can get the blood test results back the same day. Hopefully, this will also keep the disruptions to your daily schedule to a minimum too. During this time you may feel full or bloated as the ovaries grow in size. The mucus from the cervix becomes stretchy, and there is lots of it. The higher estrogen levels can make you a little naseous, and you may feel like you have more energy. Near the end of the cycle, a dull-achy sensation is usually felt in the pelvis as room becomes tight down there. Once your doctor thinks the eggs are ready, he or she will ask you to take an injection of a large dose of hCG. This does a final maturing process on the eggs and gets them ready for fertilization. This injection is often given into the muscle of the buttocks, although it is sometimes given like the others into the belly. At this point, you are done with the FSH, hCG, and inhibiting medications.

The next thing that happens is the egg retrieval procedure. This is usually done about a day and a half after the final hCG is given. Anesthesia is given to make you comfortable and very sleepy. Most centers use a combination of medications that will put you under enough that you should not feel or be aware of anything. Once you are comfortable, an ultrasound probe is placed into the vagina. The ovary is located on the ultrasound screen. Then a needle is run along the ultrasound probe, through the wall of the vagina, and into the follicles in the ovary. The fluid is drained out of each follicle that has developed that cycle, and the egg should come along with the fluid. Once one ovary has been completed, the same procedure is carried out on the other ovary. This usually takes about a thirty minutes, but definitely depends on how many follicles you have. You will feel sore afterwards, and perhaps a little crampy too.

Once the fluid has been removed from the follicle, it is handed to the embryologist. This is the person who will be taking care of your embryos while they are in the lab. He or she will look at the fluid under the microscope and find the eggs. The eggs are then placed in petri dishes and the sperm is added. If there is a sperm problem, then ICSI (intra-cytoplasmic sperm injection) may be performed. This is a procedure where a single sperm in injected into each egg to ensure that sperm and egg are getting together. Later on, the eggs are checked for signs of fertilization. Not all eggs will act like they are fertilized, even with the ICSI procedure. The fertilized eggs are then kept in the incubators to grow and divide. The embryologist will check on the periodically to make sure that they are dividing the way they are supposed to. In this country, most embryos are allowed to grow 3-6 days before they are put back into the uterus, although there are special circumstances where they may be put back on the 2nd day too. A procedure called assisted hatching may be performed prior to putting the embryos back. There is a shell around the embryos called the zona pellucida. The embryo must break out of this shell (hatch), before it can implant in the uterus. Sometimes, especially in older women, this shell is too hard and thick for the embryo to break out. This can keep you from getting pregnant, so we give those embryos a little help. The embryologist will make a small hole in the zona pellucida. This acts like a perforation does, it gives the embryo a place to start breaking out of the shell. This is called assisted hatching.

The procedure to put the embryos back into the uterus does not require anesthesia, usually. It feels a lot like a PAP smear does. Your doctor may ask you to come in with a full bladder, which helps straighten out the uterus and makes it easier to see on ultrasound. A speculum will then be placed into the vagina, and then a small tube called a catheter is passed through the canal in the cervix and into the uterus. The embryos are then placed in the upper third of the uterus, which is where they like to implant. This usually takes just a few minutes to do. The embryologist may be present for this, and he or she will then check the catheter afterwards to make sure that no embryos remain in the catheter.

How many embryos are put back into the uterus at one time will vary. Your doctor will take your age, medical history, and your embryo quality into consideration. The American Society of Reproductive Medicine has the following guidelines: when transfering embryos on day 3, one to two embryos be transferred for women under 35, two to three embryos for women 35 to 37, three to four embryos in women 38 to 40, and no more than 5 embryos in women over forty. For embryos that are 5 or 6 days old (blastocysts), no more than 2 be transferred in women under 38 and no more than 3 in women 38 and over. The lower number for each age group should be used for good quality embryos. Extra healthy embryos can be frozen and kept for future use too. Following these guidelines will help prevent disasters like the octomom from occurring. She was 33 at the time of her IVF cycle, and therefore should have had only one or two embryos transferred.

During this period, your doctor may ask you to take a few other medications. Antibiotics are often prescribed to prevent infection during the embryo transfer. Some clinics use anti-inflammatory steroids, baby aspirin, and extra estrogen too. Most clinics will also ask you to take progesterone too. This is a hormone that your ovaries make after ovulation. It tells the uterus to get ready for embryos to implant and keeps your period from coming until a pregnancy has a chance to declare itself. When the fluid is taken out of the follicles to get the eggs, a lot of the cells that make progesterone come out too. To keep you from getting your period too early, extra progesterone is therefore given. There are several different ways to give progesterone, and more are coming soon. The traditional way is with an injection that goes into the buttocks. It is reliable, but obviously not the most comfortable option. There are creams and suppositories that go into vagina. They are a less painful option, but can sometimes cause some bleeding of the cervix. This can be distressing, especially if you are hoping to become pregnant. There will also be a ring that goes into the vagina soon.

I think, and I have done 2 IVF cycles myself, that the hardest part of the IVF cycle is this next part: the waiting. You will have to wait about 2 weeks from the day the retrieval is done to find out if you are pregnant or not. You can't cheat and do a test earlier, because pregnancy tests look for hCG. Since you took a big shot of hCG right before the egg retrieval, a pregnancy test will come out positive afterwards. Urine tests are not as accurate as blood tests, so your doctor will want to do a blood test. Depending on which type of progesterone you are taking, it will probably keep you from getting your period. So if you do see any bleeding, don't assume that it is your period and stop your medications. About a third of normal pregnancies will have some bleeding in the beginning, so keep taking that progesterone and call your doctor!

If you are pregnant, your doctor may ask you to continue the progesterone through the first few weeks of prengnancy. If you have extra embryos frozen, don't worry. They will wait until you are ready for your next child. There have been successful pregnancies with embryos that had been frozen for more than 10 years!

"Injectables"

2011-02-16T09:33:00.000-08:00

The term "injectables" refers to a group of fertility medications called gonadotropins. They are given by injection, of course. These medications either have FSH or FSH and LH in them. FSH and LH are the two hormones the pituitary makes to get the ovaries to mature eggs and get them ready for ovulation. In a natural menstrual cycle, several follicles (the sacs the eggs matures in) will start to grow. It is a race, with each follicle trying to grow the fastest. As the follicle in the lead grows, it produces lots of estrogen. The estrogen from the lead follicle causes the amount of FSH being produced to decline. The declining FSH levels keep the slower ones from being able to grow very well. In the meantime, the lead follicle has made even more FSH receptors, and so it still get enough FSH to keep growing even in the declining FSH environment. Once ovulation is triggered by the presence of a mature egg in the lead follicle, all of the others in the race either ovulate (if they are mature enough) or die. Without fertility medication, one egg will usually make it to ovulation and the others die off. If you flood the system with FSH from injections and keep the FSH levels high, you can level the playing field and get multiple eggs to mature at the same time.

There are several different brands of injectables. Follistim, Gonal-F, and Bravelle all contain FSH without the LH. Follistim and Gonal-F come premixed in a pen. There is a barrel to the pen which contains the FSH, a dial at the top for entering to dose to be given, and then a small needle at the bottom. The injection is usually given in the belly. The medication needs to be placed just below the skin, not into a blood vessel or a muscle, so it is easy to do. The amount of fluid that comes out is very small, and so it is not very painful at all. If the thought of feeling the needle go through the skin is bothering you, anesthetic creams such as Emla can be used to numb the area before the injection is given. The creams should be applied about an hour ahead of time for the best effect. Bravelle comes as a powder in small glass vials. You will also get another set of glass vials with saline in it (called the "diluent") to mix with the FSH powder and dissolve the FSH for injection. They have a clever cap, called a "Q-cap". The Q-cap goes onto the syringe with which you are going to give the injection. The Q-cap with the syringe snaps onto the vial with the diluent, and you suck that up into the syringe. You then snap the cap onto the vial with the powder, squirt the diluent into the powder, give a swirl or two to mix it, and suck it back up into the syringe. The Q-cap is the removed and a needle is attached to the syringe for injection. Bravelle can be given like the Follistim and Gonal-F (under the skin of the belly) or into a muscle (usually the buttocks). Bravelle is what is called "highly purified FSH". That means that the FSH is obtained from the urine of women in menopause. It is then purified to remove other substances (please see previous blog on injectables for a more detailed explanation). Both Follistim and Gonal-F are not obtained from urine. They are made from what is called "recombinant DNA technology". This means that the gene that codes for human FSH is placed into a group of cells in the lab, which are then stimulated to make the FSH from the gene.

Menopur and Repronex are injectables that are have both FSH and LH activity. They are like Bravelle in that they are highly purified from urinary sources and are mixed with the Q-cap technology. There are times when having LH stimulation along with the FSH is helpful. Normally, women make enough LH that we don't worry about giving them extra. Some women, however, have a condition where their bodies have decided that they are too thin or too stressed to make it safe to risk getting pregnant, so they don't ovulate (see previous blog on ovulation for more details). These women don't make FSH or LH and so need both. The other time that LH activity is useful is when large doses of FSH are being used, such as in IVF (in vitro fertilization or the "test-tube baby procedure"). When larges doses of FSH are given, it can confuse the pituitary, which usually makes both FSH and LH. The pituitary thinks its job is done, since there is lots of FSH around. It then doesn't make the LH. Another way to get LH activity is to use hCG. hCG is the hormone that is made in pregnancy, but it works on LH receptors. The body can't tell the difference between the two. As a matter of fact, I didn't quite tell you the truth in the first paragraph. The LH activity in Menopur and Repronex is mainly from hCG that is added not LH. So if Follistim or Gonal-F are used, small amounts of hCG can also be used to give the LH effect needed.

Injectables are usually used in combination with intra-uterine inseminations (IUI) or with IVF. In both cases, the goal is to get multiple eggs ovulating. When used with IUI, the goal is usually to get approximately 3 eggs ovulating. In IVF, we will often try to get 10-12 mature eggs. In order to ensure that we are not getting too few or too many eggs, very careful monitoring is necessary. An ultrasound to measure the size of the follicles and a blood test to look at the patient's estrogen level are done before the medication is started (usually about day 3 of the cycle). The patient is then asked to take about 3 days of the medication (once a day, usually) and then brought back in for another ultrasound and estrogen level. The doctor then compares the two ultrasounds and estrogen levels to see how fast the follicles are growing and eggs are maturing. The dose is changed, if necessary. The process of taking the shots and coming in for monitoring is then repeated every 1-4 days until the eggs are ready. Once the eggs are ready, a large dose of hCG is usually given to get the eggs ready for fertilization and an IUI or IVF is performed.

Side effects of the injections are mainly from making the ovaries larger. This can give you a heavy, achy sensation in your pelvis. This can increase at the time of ovulation and feel like menstrual cramps for a while. With larger doses, and therefore larger ovaries, you can feel full or bloated too. Because each follicle makes estrogen, and you will have multiple follicles, your estrogen levels will be higher too. This can make you feel a little nauseous, and will give you that stretchy mucus from the cervix that you usually don't see until ovulation. So don't worry, you haven't ovulated early, the ovulation-type mucus is just early. You can also notice more breast tenderness at the end of your cycle. Estrogen does give some women a sense of well being and more energy than usual too. They even get that nesting instinct that pregnant women get. So if you find yourself organizing everything in site, it's the estrogen! The injectables derived from urine can also cause fevers and flu-like symptoms on rare occasions (see the blogs on injectables? and IVF, not so fast! for a description of my own experience with this side effect).

There are some risks to injectables as well. The obvious one is multiple pregnancies. As I have said before: more eggs means more chance of pregnancy, but also more chance of ending up with triplets, quadruplets, etc. That is why your doctor will monitor you closely. He or she may even cancel a cycle, if there are too many eggs developing. This is frustrating and disappointing, but nowhere near as bad as losing quadruplets in your fourth month of pregnancy before they are even viable. So remember, your doctor has your best interests at heart. If he or she is telling you that the cycle needs to be canceled, listen. Multiples carry a high chance of miscarriage, prematurity, still birth, and birth defects. Even careful monitoring cannot completely eliminate the risk of a multiple pregnancy, though, so keep that in mind. If you are going to use injectables with IUI, you may want to have a conversation with your doctor and partner about what will happen if you do end up with triplets or more. There are options, and it is easier to make decisions about what you would and wouldn't do before you are in the throws of the hormonal storm that is pregnancy. IVF can reduce the risk, as we can control how many embryos are placed back into the uterus. More and more, physicians are recommending that just one or two embryos be put back at a time with IVF to try to reduce the risks. Therefore, if you doctor is giving you the choice of IVF or IUI with injectables, seriously consider doing the IVF. The chances of getting pregnant are better and the risk of multiples is lower.

The other risk to injectables is something called Ovarian Hyper-Stimulation Syndrome (OHSS). This occurs when the ovaries overreact to the medication. Sometimes you will see signs that this is going to occur before ovulation. In that case, canceling the cycle and keeping ovulation from happening will prevent the OHSS. Using a medication called Lupron to trigger ovulation instead of hCG can also be helpful. More often, though, it happens after ovulation or after the eggs are taken out for IVF. With ovulation or the egg retrieval, most of the fluid in the follicles either bursts out or is taken out. The ovaries become smaller, and the bloating and fullness gets better. With OHSS, however, the follicles are still going and they fill back up with fluid. So the first sign we usually see is that he patient starts getting bloated or feeling full all over again. At that point, we bring the patient in to the office to see exactly what is going on with the ovaries. To treat OHSS, we ask the patient to take it easy and don't do a lot of running around. This may mean that you get put under "house arrest". This is all that is usually needed to make the OHSS better, but it may take a few days or even a week or two to happen. In rarer, more severe cases, fluid also starts accumulating in the belly as well as in the ovaries. These women will be more bloated and uncomfortable. In this case, we can put a needle through the wall of the vagina (we use anesthesia, don't worry!) and drain the fluid out. This usually makes the patient feel significantly better immediately. In extremely rare cases, fluid can accumulate around the lungs or heart. This often requires that the patient be hospitalized and monitored closely. That is why we monitor patients taking injections so closely, to keep that from happening. With the newer, finer control of medication doses in the pens, it is also less likely to happen. I haven't seen a case of severe OHSS with fluid around the heart, for instance, in about a decade. Pregnancy can also cause OHSS after injectable medication. Pregnancy hormone stimulates the ovaries to make progesterone, which is necessary for pregnancy. In stimulating the ovaries to make progesterone, the ovaries can also be stimulated to grow bigger. It is not dangerous to the pregnancy at all, but it will take longer for the OHSS to resolve than without a pregnancy. Multiple pregnancies can cause even worse OHSS, which is another reason to try to avoid them.

Hopefully, I haven't scared you too much. Injectables should be treated with a healthy amount of respect. In the hands of a well trained doctor with access to monitoring, however, the risks can be minimized and the benefits can be wonderful!

Clomid

2011-02-15T16:26:00.000-08:00

Clomid (or clomiphene citrate) is one of the main fertility medications used in this country. It is a pill, and it is usually given for 5 days near the beginning of the cycle. It's simple to take and inexpensive. Check with your local pharmacy, but it now one of Target, Sam's Club, and Walmart's $9 prescriptions. Clomid has been around since the 1960's, and so we have a lot of experience with it.

Clomid works by blocking estrogen receptors. The pituitary monitors estrogen levels to figure out what the ovaries are doing. When the receptors are blocked, the pituitary can't see the estrogen being made by the ovaries. This makes the pituitary think that the ovaries are not working, and it will send out more hormones (FSH and LH) in an effort to get the ovaries working again. This extra FSH and LH can get a woman who is not ovulating to ovulate. It is also used to "superovulate" woman who are already ovulating. The goal with superovulation with Clomid is to get two, sometimes three, eggs ovulating rather than just one. More eggs means more chance of getting pregnant. It also means more chance of ending up with more than one baby too. Clomid has an 8-10% risk of creating twins, and a rare chance of triplets or more occurring.

Clomid does have some side effects. The most common side effect is hot flashes. These are just like the hot flashes women in menopause get, and they are a result of blocking the estrogen receptors. A hot flash is an episode where a woman feels very, very hot for a few seconds and then returns to normal. She may turn a little red too and may even feel sweaty. These are not dangerous, but they can be annoying. Because there is a possibility of multiple eggs ovulating, one can feel pelvic discomfort too. This is usually an ache or crampy feeling very low in the pelvis . It can feel worse with sudden jarring movements too. Many women say it feels like menstrual cramps. Moodiness can also occur. This is similar to the feeling of PMS, with a "quick to tears, quick to anger" feeling. There are two side effects to watch out for: headaches and visual changes. If you seem to be having a lot more headaches than usual or you notice changes in your vision, call you doctor. These will go away when you stop the medication, but we don't want you to be in pain or drive around with impaired vision. Your doctor can switch the medication to another type, so you will still be able to try to get pregnant.

Clomid is often combined with intrauterine inseminations, which is a procedure where sperm is put into the uterus on the day of ovuation (see the previous blog entry on male factor infertility for a more in depth description). This is because Clomid can thicken the mucus in the cervix and make it harder for the sperm to get through the cervix and into the uterus. An injection of hCG is often used to time the IUI. hCG will cause ovulation to occur approximately 36 hours later, and this is handy for scheduling the IUI. The combination of Clomid and IUI has a 10% chance of success each cycle. This may seem low, but consider that a couple who has already been trying for a year to conceive has about a 3% chance of conceiving by continuing to try on their own and a fertile couple has about a 20% chance each time they try. Usually Clomid is given for 3 to 6 cycles before other options are recommended. There is a question as to whether long term use (greater than a year) may raise the risk of ovarian cancer. Although most studies do not show an increased risk, it is still better to be safe and limit Clomid's use to 3 to 6 months.

There are other medications that work similarly to Clomid and can be used when Clomid is causing side effects like headaches or visual changes. The most commonly used are Femara and tamoxifen. Neither of these are FDA approved for fertility treatment, as their main use, and FDA approval, is for the prevention of breast cancer. There is quite a bit of data, however, on their use in fertility. They appear to be safe and effective. They have similar side effects to Clomid, but usually don't cause the headaches or visual changes.

In summary, Clomid is an easy to administer, mild fertility medication that is often the first-line treatment choice for ovulation problems, a single blocked fallopian tube, unexplained infertility, or women whose partners have sperm issues (see previous blog entries about tubal disease and sperm problems). It will induce ovulation and can oftentimes get 2-3 eggs ovulating.

A Male Side to Infertility

2011-02-14T14:58:00.000-08:00

When you look at couple having trouble conceiving, about 30% have a female issue, 30% have a male issue, 30% have both male and female issues, and 10% are unexplained. So that means that there is a sperm problem in 60% of couples who are struggling with infertility. That is why we always look at sperm, even when we know there is a female problem such as irregular or no periods. There is no use in fixing the ovulation problem with fertility medication, if there is a sperm issue that hasn't been addressed.

The first step in diagosis is a semen analysis. The male is asked to ejaculate into a sterile container and the semen is then evaluated. Most fertility centers will have a special room dedicated to this function. There is usually a lock on the door for peace of mind and appropriate magazines or videos, if needed. Many centers, like ours, will also allow the patient to produce a specimen at home and bring it in for analysis. Usually there is a time limit of one hour from when the sperm is produced to when we want it in the office. These are usually visits that are scheduled in advance, so that the medical technician who evaluates the sperm has time to look at the sample right away. So you do not have to worry that we are going to surprise you with a cup and a demand for sperm! To get the best sperm, it is also important that the last ejaculation before the semen analysis be 3-5 days beforehand. The quality of the lab that the analysis is done in can have an impact on how accurate the results are. Sperm swim quite fast, and so counting them can be difficult. If possible, try to have the semen analysis done in a fertility center. They count sperm all day long and so are usually quite good at it. As I said before, fertility centers will also have a dedicated room. Many labs do not, and that can be a problem. If you do not live near a fertility center, you can ask your doctor for a recommendation.

A semen analysis should look at a few things. The volume of the semen sample should be measured, as well the sperm count per milliliter and a total sperm count for the specimen. Opinions vary on exactly what a normal sperm count is, but most would agree that it is over 20 million sperm per milliliter. The number of sperm that are moving should also be calculated. At least 30% should be moving. The movement is graded and varies from just shaking in place, swimming in circles, moving forward but not in a straight line, and moving forward in a straight line. Obviously, moving forward is desirable. The shapes of the sperm are also examined. There are several different ways that this can be done. The most common method these days is called the strict Kruger method. This is a very picky way to look at sperm, but it has been shown to correlate with the ability of sperm to fertilize eggs in the lab. 4% or more of normally-shaped sperm is a good number for this method. The technician will all look at the thickness of the semen, its pH, the presence of white blood cells, and whether the sperm are sticking together. A report is generated for your doctor with all of this information.

If a problem is seen on the semen analysis, further testing may be required. Low sperm counts can occur when there is a hormonal problem, so blood tests are usually done to look at the patient's hormone levels. It is also possible that a blockage has occurred. A physical exam can be done, and sometimes ultrasounds of the testicles are done as well. Vericose veins can form around the testicles, and these will lower sperm counts. Ultrasound will show vericose veins. In extreme cases, a blood test to look at the patient's chromosomes may be needed. Abnormalities in the Y-chromosome can lead to very low or no sperm production. Lifestyle alterations such as quitting smoking, staying out of hot tubs and saunas, putting laptops on a table rather than in the lap, discontinuing marijuana use, and taking multivitamin supplements may be suggested.

If sperm counts are found to be slightly low, then intra-uterine inseminations (IUI) can be helpful. This is a procedure where the sperm are washed and placed in a very small volume of fluid. A small tube, or catheter, is then threaded through the cervical canal and into the uterus. The sperm is deposited at the top of the uterus, and the catheter is removed. It usually takes a minute or two to do, and it feels like a PAP smear. If your cervical canal is very twisty or turns sharply, it can take a little longer and be a little more uncomfortable. Most fertility centers are open 365 days a year, so that inseminations can be done even if you are ovulating on a weekend or holiday. This gets millions more sperm to the eggs. With intercourse, 99.9% of the sperm never make it into the uterus. If the sperm counts are on the low side, then this becomes a real issue. Getting the sperm into the uterus and beyond the mucus in the cervix where a lot of sperm get stuck can be a great help. Often the IUI is combined with fertility medication for the female. This may not, on the surface, make sense; but it does help. Each egg is different. Some are easier and some harder to fertilize. Producing more than one egg will give the sperm more chances to be successful.

More serious sperm issues often require IVF (in vitro fertilization). The female partner is given fertility medication so that several eggs are produced. They are removed from the ovaries and fertilized in the laboratory. This can be done by placing the sperm and eggs in direct contact with eachother, or by a technique callled ICSI (intra-cytoplasmic sperm injection). With ICSI (pronounced ick-see), a single sperm is injected into each egg ensuring that the sperm are able to penetrate the egg. This can give a couple a great chance of being able to conceive, when there was little chance beforehand. When there are blockages, a urologist can remove sperm from behind the blockage to use with IVF/ICSI too.

Another option is to use donated sperm. There are many excellent sperm banks in the United States, and they will ship sperm all over the country. Sperm donors are screened ahead of time to make sure that they are in good health, have good sperm, have no history of genetic diseases in the family, and have no infectious diseases that are likely to be passed through the sperm. Donor sperm is frozen and quarantined for 6 months, and then the donor is rescreened for infectious diseases. This ensures that he was not in the early stages of an infection, and the testing was falsely negative, when the sperm specimen was obtained. The FDA monitors sperm banks in this country to ensure they are doing this correctly. The sperm bank will give you a lot of information on the sperm donor, and some will now even give you pictures. The donor sperm is usually used in combination with the IUI described above.

I should add a final note on vasectomies. If a vasectomy has previously been performed and now pregnancy is desired, then there are several options. If it has not been too long since the vasectomy was performed, less than 10 years is best, then a urologist may be able to reverse the vasectomy. This is a surgical procedure where the 2 ends of the vas deferens are sutured back together with very fine sutures. Success rates vary, but are generally good. Another option is to do IVF/ICSI with an aspiration of sperm from behing the vasectomy site (as described above). This is a simpler procedure from the male standpoint, but more involved from the female standpoint. The final option would be to use donor sperm or donated embryos to conceive. Donated embryos would mean that it is neither the female nor the male's genetic child, and so this is usually done when there is also an egg issue as well. Adoption, of course, is also always an option in any of the above scenarios.

Blocked Fallopian Tubes

2011-02-13T17:15:00.000-08:00

Fallopian tubes can become blocked without you knowing or feeling it. Women with blocked tubes still ovulate and get their periods. Although sometimes blocked tubes can cause pain, usually you can't feel it at all. Therefore your doctor will need to order a test, if you want to find out whether your tubes are blocked.

The traditional gold-standard test for determining whether tubes are blocked is called a hysterosalpingogram or HSG. A small tube, or catheter, with a balloon on the end or a stopper-like device is placed into the canal of the cervix. A special liquid called contrast, which shows up white on x-rays, is then infused through the catheter into the uterus and out the fallopian tubes. X-rays are used to watch this happen. It can tell you about the cavity of the uterus as well as whether the tubes are open. It is definitely uncomfortable as the contrast is infused. Usually, it feels like strong menstrual cramps and only lasts a few minutes. Taking some ibuprofen or naproxen sodium beforehand can help, as both of these medications help keep the uterus from cramping. Check with you doctor before taking them, of course. After the HSG, you will have a sticky discharge as that contrast comes back out, so you may want to bring a pad along with you (the ones the x-ray department gives you may be humongous!). The risks to the procedure include infection (rarely, bacteria form the vagina will come along for the ride), allergic reactions to the contrast (tell your doctor about any shellfish, iodine or contrast allergies), and the risk from the small amount of radiation from the x-rays. Sometimes you can get spasms of the tubes that make them look like they are blocked, when the actually are not, too. The test should be done right after your period ends. This way you won't be pregnant when the test is done, and the lining inside the uterus is nice and thin. This helps with being able to visualize the cavity of the uterus well.

Normally, you can't see the fallopian tubes on ultrasound. Mixing something like protein or air, which shows up well on ultrasound, can make the tubes visible, however. Recently, a device called FemVue has made it fairly simple to infuse a mixture of saline with tiny little air bubbles into the uterus and watch it flow out the tubes on ultrasound. This has a few advantages. First of all, there is no radiation like you get with x-rays. Secondly, you can take a look at the walls of the uterus and the ovaries, which you cannot see on an x-ray. It appears to be less uncomfortable too, perhaps because the saline is so much thinner than the contrast used in an HSG. The disadvantage is that you need a doctor who is trained in how to use the device. It has the same risk of infection (rare) as the HSG too.

Finally, the patency of the tubes can be tested at the time of surgery. Saline with a little blue dye can be infused in the same way as it is in the HSG. The surgeon is watching the ends of the fallopian tubes to see if the blue dye comes through.

Some women may not need any of the above tests, though, at least not right away. It has been shown that you can predict most of the women who are going to have blocked tubes by looking at their medical history and doing a blood test for an infection called Chlamydia trachomatis. If a woman has never had any surgery in her pelvis, never had her appendix out, does not have moderate to severe menstrual cramps (signs of endometriosis), and has never had a sexually-transmitted infection or pelvic inflammatory disease (PID); then she is at low risk for tubal blockage. Chlamydia often has no symptoms, and so a blood test should be done to see if she has ever been exposed to Chlamydia trachomatis. If not, then studies show that her risk of having blocked tubes is less than 10%. At that point, both the patient and her doctor can decide whether the doing further testing is worth it.

If your tubes are blocked, then there are several options. If only one tube is blocked, then sometimes just getting you ovulating on the side that is open is all it takes. This will happen about 50% of the time without any intervention, but it is impossible to predict the pattern. Clomiphene citrate (a mild fertility medicine) is often used to get 2 eggs ovulating instead of one. This will increase the chances that at least one of those eggs is on the side that is open.

If both tubes are blocked, then the choice is either to open the tubes or perform IVF (in vitro fertilization or the "test-tube baby" procedure). Because eggs are taken out of the ovaries and then fertilized embryos are placed into the uterus with IVF, the tubes do not need to be open. Unblocking the tubes may or may not be possible. If the tubes are blocked right where they enter the uterus, then it may be possible to open them. Small guidewires can be placed through the blockage to open it up. This can be done under x-ray or with a scope that is placed into the uterus. If the tubes are blocked at the other end, near the ovary, then it also may be possible to open them. This is done by placing a scope and other instruments through small incisions in the bellybutton and down near the pubic bone. The delicate fingers at the ends of the tubes are teased apart. Oftentimes, they are too damaged and scarred together, however, to get apart.

If a woman has had her tubes tied and now wants more children, then the options are also surgery or IVF. The tubes can be sewn back together with very fine suture, if there is enough tube left. The best tubes are ones that were tied at the time of c-section or had a ring or clip put on them. Tubes that were cauterized or "burned" can have severe damage. Many times they cannot be put back together. In that case, IVF is still an option.

No matter how a fallopian tube is opened, doing so puts the patient at risk for a tubal pregnancy. This is when a pregnancy implants in the fallopian tube rather than in the uterus. This can be very dangerous, because there is not nearly enough room inside a fallopian tube for a pregnancy to grow. If not caught in time, the fallopian tube will eventually rupture and the patient will start bleeding into her belly. At this point, it becomes a life-threatening situation. Therefore, women who have had surgery on the tubes or have blocked tubes need to be followed very closely at the beginning of pregnancy. If caught in time, it can be treated with medication.

Sometimes, when the tubes are blocked down near the ovaries, they will fill up with fluid. This is called a hydrosalpinx. The fluid backs up into the uterus and it is very toxic to embryos. If a woman has a hydrosalpinx, then it should be removed. Even if the other tube is open or IVF is planned, removing the hydrosalpinx will keep the toxic fluid from entering the uterus and killing any embryos there.

Fortunately, blocked fallopian tubes make up only a small portion of infertility cases. There is testing that can be done to determine whether a woman's tubes are blocked, for those who are at risk of tubal damage. If one or both fallopian tubes are blocked, there are options. So talk to your doctor!

Not Ovulating?

2011-02-12T11:15:00.000-08:00

There are lots of reasons why a woman wouldn't ovulate, but let's take a step backwards and try and determine whether you are ovulating or not. If your periods do not come at all, or they are more than 40 days apart, then there is a very good chance that you are not ovulating. There are also some women who appear to have regular periods but are still not ovulating. Although this is fairly unusual, it can happen.

There are several ways to determine whether you are ovulating. The least expensive way is with something called Basal Body Temperature Charts (or BBT's). You will need a thermometer. They do make special BBT thermometers, but a digital thermometer will also do. Do not use the ones that go in your ear. They can vary depending on how far into your ear you get the probe, and you want a very accurate temperature for this. There are many websites where you can print out a graph for your temperatures, and some of them will even plot them for you. There are even ap's for that! First thing in the morning, before you have gotten out of bed or done anything, take your temperature. Plot it on the graph. Do this every morning from the first day of your period until the first day of your next period. If you are ovulating, you will find that your temperatures hover around the same number until about 14 days from your next period. They will then dip down for a day, go up to a new temperature, and then hover around that new higher temperature until you get your next period. If you can see that on your graph, then you are ovulating. The dip is the day you are ovulating. If you cannot see that, you may not be ovulating. It can be hard to interpret these some times, so if you don't see what I just described, don't get discouraged. Try one more method to see if you are ovulating before you decide.

Another option is to try ovulation predictor tests. These look just like the home pregnancy tests you can buy, but they are to determine when you are ovulating instead. Unfortunately, different brands vary in their accuracy. We have had the best luck with the ClearBlue Easy brand. They are very accurate, and their digital ones are very easy to read. They either give you a smiley face, if you are ovulating, or nothing, if you are not. ClearBlue Easy also makes a hand held computer device (fertility monitor) too. If you are finding positive tests with the regular "pee-on-the-stick" kind, then you don't really need the fertility monitor. If you are not having luck with the stick version, then the monitor may be helpful. You can usually find quite a few of them on eBay. Inside the box of sticks you will find instructions on when to start testing based on how long you cycle is. The tests usually turn positive about a day before you actually ovulate. If you find a positive test, then you are almost definitely ovulating. If you get your period 13-16 days after the positive test, then you are definitely ovulating. If you do not get your period in that time frame (and you are not pregnant), then you may have something called PCOS (see below). PCOS can give you false-positive ovulation tests. Ten percent of ovulating women will not get positive ovulation tests, unfortunately. So if you are having regular cycles but can't find a positive ovulation test, you may still be ovulating. Talk to your doctor.

The final way to determine whether you are ovulating or not is to have your doctor do a blood test to look at your progesterone level. Progesterone is a hormone that your ovaries make after you ovulate. The best way to test your progesterone level is to draw the blood about a week before your next period is due. If your progesterone level is over 3 ng/ml, then you are ovulating. If your cycles are too irregular to predict when your next one is coming, then it can be drawn 3 weeks or more after your last one.

OK, so now you know how to figure out if you are or are not ovulating. Lets talk about reasons for not ovulating. Both underactive or overactive thyroids can affect ovulation. Other symptoms of thyroid disease include feeling hot when everyone else is cold or vice versa, unexplained weight gain or loss, hair loss, fatigue, nervousness, or skin changes. It is diagnosed by blood tests and is easy to treat.

A more uncommon reason for not ovulating is an excess of a hormone called prolactin. Prolactin is the hormone involved in breast feeding, and so many women with high prolactin levels will also have a milky discharge from the breasts too. Just like breast-feeding women do not get regular periods, women with high prolactin levels who are not breast feeding will do the same.

Extreme stress or excessive dieting or exercise will also lead to ovulation problems. A woman's body is designed to decrease her fertility if it thinks there isn't enough food around to support a pregnancy or baby or there is too much stress (perhaps predators chasing you?). So if a woman has very low body fat or a low dietary fat intake or is under extreme stress, she will stop ovulating. This is common with marathon runners, ballet dancers, women on death row, and body-builders. It can definitely happen with less extreme cases too. Decreasing the amount of exercise, increasing calorie and especially fat intake, or changing the stressful situation can reverse the ovulation problems.

Another very common reason for not ovulating is something called PCOS or polycystic ovarian syndrome. This is a condition where eggs cannot mature enough to be able to ovulate. These semi-mature eggs produce a lot of testosterone and other male hormones. These male hormones feed back to the pituitary (the gland in your head that controls your menstrual cycle), and they confuse your pituitary. Your confused pituitary send out the wrong hormones to the ovaries (too much LH and not enough FSH), and keep your ovaries from being able to ovulate. This causes more testosterone production and the cycle just gets worse and worse. All the sacs with the stuck eggs look like cysts on the ovaries, which is why it's called "polycystic". Women with PCOS usually have other signs of high testosterone levels such as acne; hair growth on the face, chest, back or belly; and sometimes even male-pattern balding. It is a called a syndrome rather than a disease, because what causes it can vary woman to woman. One of the main causes is insulin-resistance. This is a condition where a woman's insulin is not working as well as it should. It can lead to diabetes, when it gets very bad. The ovary has insulin receptors. When it sees too much insulin, it stops ovulating and makes male hormones and therefore PCOS. Women with this condition often times (about 50% of the time) are overweight, and many also have a family history of adult onset diabetes in her older relatives. PCOS needs to be diagnosed by your doctor. He or she will do blood tests and perhaps and ultrasound as well.

About 10% of women who do not ovulate have no defined reason why they are not ovulating. It appears that their pituitaries just do not send out the right signals. There are also other much rarer hormonal causes. Most of these will have other signs and symptoms that bring that person to the attention of a doctor.

No matter why you are not ovulating, you need to see a doctor! If the lining inside the uterus does not shed with a period at least every 6 weeks, it can start to turn abnormal. It can even turn into cancer. My cousin died from this type of cancer in her 30's, so this is serious! If you are not ovulating because of extreme stress, exercising, or dieting; then you are also at risk for osteoporosis and bone breakage. If your prolactin levels are high, then you may have a tumor on your pituitary. Although these tumors are usually benign, they can permanently affect your vision if they grow too large. Thyroid disease and PCOS have implications for the rest of your health as well, so go see your doctor. Most of these conditions are very easy to diagnose and treat, so why not go see someone today?

Do I Need to See a Doctor? What will happen if I do?

2011-02-11T16:26:00.000-08:00

Are you wondering whether it might be time to talk to a doctor about your fertility? Do you know who to talk to? These are questions I get asked a lot. The answers vary depending on your situation. If you have been trying to conceive for more than a year without any success, it's time to see a doctor. If you have been having unprotected intercourse for a year without a conception, even if you haven't been actively tracking menstrual cycles and ovulation dates, it's time to see a doctor. If you are 35 or older and you have been trying to conceive for 6 months or more, it is also time to see a doctor. This is because a woman's fertility declines as she gets older. A woman over 35 does not have as much time left to conceive, therefore she needs to be seen sooner. You should also see a doctor if your cycles are not regular, even if you haven't started trying yet. A normal menstrual cycle (from the start of one period to the start of the next period) is usually 26-35 days. It's OK for the length of your menstrual cycle to vary by a few days each month. If your cycle lengths vary more than a few days, or you skip cycles altogether, you need to speak to a doctor. You should also see a physician if your cycles are less than 26 days or more than 35 days in length. Of course there are other reasons you may want to talk to your doctor too. Severe pain with your periods, a known fertility problem like a fallopian tube that has been removed for an ectopic pregnancy, or a husband who had trouble conceiving with a previous partner are all good reasons to talk to a physician.

The next question, of course, is what type of physician should you see? Here you have several options. A General Practitioner or Family Practice doctor will have a little bit of training in infertility. He or she may be able to answer your questions and do some preliminary testing. Some even feel comfortable prescribing mild fertility medications like Clomid. An OB/GYN will have had a little more training. They should be able to do testing to help you figure out why you are not getting pregnant. Depending on the results, they may be able to treat you or they may need to refer you to a specialist. A Reproductive Endocrinologist is an OB/GYN that has done an extra 2 or 3 years of training in infertility after his or her OB/GYN training. They can do the testing and all of the treatment too. So, who you see depends on what you want. If you want to keep it low key and you have a good relationship with a GP or OB/GYN, than that's a good place to start. If you want one-stop shopping, where you are not going to get shuttled to another doctor, start with an Reproductive Endocrinologist.

Whomever you see, they are likely to start with some questions about your general health, menstrual cycles, family history and your husbands health too. It is helpful if he can come along to the first meeting with the doctor. He can provide information about his health and family history that you may not know. It also great to have 2 sets of ears listening to what the doctor says! Next the doctor will probably want to do some tests. Usually, he or she will order some blood tests to look for hormonal problems like an underactive or overactive thyroid, high prolactin levels (the hormone that is involved in breast-feeding), to make sure that you are ovulating, and to see about the quantity and quality of your eggs. He or she will also likely order a semen analysis on your husband. Tell your husband not to worry, though. He is unlikely to be handed a cup and asked for a sperm specimen on the spot. This is usually a test that needs to be scheduled, and you can always asked to schedule it for the future if your doctor suggests doing it now. The doctor may do an ultrasound to look at your uterus and ovaries too. The final test that is often ordered is a hysterosalpingogram. This is a test where dye or contrast is infused through the cervix and allowed to fill up the uterus and flow out the fallopian tubes under x-ray. It will tell the doctor whether your tubes are open or not. Recently, we have started using a device that allows us to combine the ultrasound and tube evaluation into one. This has the advantage of being one procedure instead of two, more comfortable than a traditional hysterosalpingogram, and no radiation because it is done without x-rays. This may be available at your doctor's office too. If you are due for a PAP smear, your doctor may want to do that as well.

Although the thought of going to see a doctor about fertility problems can be daunting, I think you will find that you feel better after you do it. You will get answers as to what has been going on, and you will get a plan of action. Most fertility issues can be solved with resorting to expensive treatments or risking having triplets or more. A good physician should be able to answer your questions and explain things in a way that you understand. He or she should be able to give you treatment options and let you decide what you want to do too. If you doctor is not doing that, ask them about it or get a second opinion. Asks friends, family members, and coworkers for suggestions. You can ask you GP or OB/GYN for their recommendation for a good R.E. too. If you don't have anyone to ask, see who is available in you area. Board certification is always a good thing to look for in a doctor. There is a separate board certification for Reproductive Endocrinology. Beware of websites that rate doctors, they tend to attract frustrated patients who want to vent (and it often times is not the doctors fault that they are not getting pregnant), and it is easy for an unscrupulous doctor to write his or her own good reviews. There a lots of terrific doctors out there, and we love helping couples have babies. It's the most rewarding job! If yours is not acting that way, then find one who does!

My Journey Continued: The End

2011-02-08T14:31:00.000-08:00

I finally got to do my IVF cycle a little over 3 years after I had first started trying to conceive. The stimulation phase with the injectable medication went well. It looked like I was making lots of follicles and my estrogen levels were nice and high! I felt great on the new medication. No fevers or flu-like symptoms, just that great sense of energy and well being that I had felt the first time. The egg retrieval went smoothly, and I didn't feel a thing. Afterwards, I felt like I had menstrual cramps, but that was about it. We got seventeen eggs!!! I was on cloud nine! Surely one of those contained the baby I so desperately wanted. The day of my egg retrieval, the medications from the compassionate care program mysteriously arrived. I sent them back thinking how sad it was that I ordered their medications for hundreds of patients, and they couldn't be bothered to help me in any kind of a timely fashion.

Not all of the eggs fertilized, which is fairly typical. The fertilized ones were allowed to grow in the incubators for three days. On the third day, my husband and I came in to have 2 of the embryos put back into my uterus and see how many more we would have to freeze. I knew the minute I saw my doctors face that something was wrong. He explained that we only had 2 embryos that had survived. One was a six cell and one was a 5 cell embryo. Normally, embryos are between 6 and 10 cells by the third day, so one of these was definitely behind schedule and neither was going to make first in class. They were also fragmented. Fragments are tiny balls of material that get kicked out of the cells. They are a sign that the embryo is unhappy and trying to get rid of stuff it doesn't like. Highly fragmented embryos like mine do not have as good a chance of success as non-fragmented or minimally fragmented embryos. Never the less, these two embryos did have a chance of being able to make a baby, so in they went. It was a quick painless procedure much like the inseminations.

Next came the waiting. I tried to be realistic (the chances were not great), but I also tried to be somewhat optimistic (what embryo wants to implant in an unhappy pesimistic mom?). In the end, I gave up and tried my best not to think about it at all. Two weeks later, the pregnancy test came back negative. My doctor tried to cheer me up. "We can try again", he said. "OK", I said, but in my heart I knew that I was near the end of the line.

The next IVF cycle was even worse. I had lots of eggs, but only one embryo to transfer, and it looked terrible. I cried the whole way home. 2 weeks later, there was another negative pregnancy test, and I knew that I was done. I had been fighting this battle for three and a half years and I didn't have it in me to fight any more. I told my husband that we would just have to be a wonderful aunt and uncle, take lots of trips to exotic places, and get another puppy. I almost believed myself, when I said it. I decided to give myself 3 months without thinking about it, and then I would re-evaluate. There was one more option, but it involved using another woman's eggs. I was only 33 years old, and so that option would be open to me for another decade or so. Even then, I wasn't sure I had the energy to go there.

7 weeks later, I woke up on a Sunday and realized that I had never gotten another period after the last IVF cycle. Like any good infertility patient, I had a cabinet full of home pregnancy and ovulation tests. I took a home pregnancy test, and it immediately turned positive. I just stared at it. It had to be a mistake. I showed it to my husband, and he said "what does this mean?" I was afraid to say it out loud. "I think I might be pregnant!" A blood test the next day at work confirmed that I was indeed pregnant. My son, Samuel, was born 7 months later--a little early, but happy and healthy. I was crazy enough to try again on my own to get pregnant a year after Sam was born, and I was again blessed. This time it was a daughter. They are my little miracles. I cannot believe that I was lucky enough to have them.

Looking back, I definitely gained something from going through all of that. It has given me a unique insight into my patients. I could have read about the side effects of the medications or listened to patients describe what an egg retrieval feels like, but it wouldn't be the same. I have walked a mile in my patients' shoes, and it has made me a better doctor.

My Journey Continued: IVF? Not so fast!

2011-02-07T11:36:00.000-08:00

IVF (in vitro fertilization or "test-tube baby" procedure) seemed both exciting and scary all at the same time. For the first time, we were going to be able to see the eggs and determine whether the sperm could fertilize them. We would watch the embryos grow and divide and pick the best ones. This procedure has a significantly better chance of pregnancy than IUI. It also means undergoing a procedure to take the eggs out. For this, anesthesia is usually given, but afterwards you definitely feel sore. The medications would be the injectables again, and here I had another dilemma. At the time, the highly purified medication that I needed was brand new. We weren't as good at controlling it as we were with the older urinary medication. Therefore, the pregnancy rates weren't as good either. (Now we have tons of experience and have figured out the quirks of genetically engineered and highly purified FSH. So this is no longer an issue.) I wanted my best chance, but I knew it would make me sick. After days of agonizing, I decided I would tough out the fevers and use the urinary medication. I was so desperate to have a baby. That turned out to be a big mistake!

After 2 days on the urinary medication, I knew I was in trouble. The fevers were higher, and I felt like I had the worst flu of my life. I could barely move. I changed my mind and went back to the highly purified medication, but the fevers didn't stop. After 2 more days, I couldn't even get out of bed. I confessed to my doctor what I had done. He was, of course, furious. We decided it was best to just forget the IVF cycle and stop the medication until I was feeling better. I didn't get better, though. After another week of being sick, things got even worse. I woke up from a nap, and it felt like my heart was going to jump out of my chest. I was breathing very rapidly, and my hands and lips were all tingly. I tried to call for my husband, but he was outside. I couldn't get off the couch. I laid there for a while until my husband finally came back. He took one look at me and called 9-1-1.

The ambulance came and took me to the hospital--my hospital, the one I had done my residency in and was now working as a fellow. I wasn't sure if that was a good or a bad thing. I recognize the doctor on call immediately upon entering the ER. We had clashed a few times over whether a patient had a GYN or surgical problem. I thought, "Oh, boy, I hope he still likes me!" He asked me a few questions about what was going on and ordered some labs. As they were being drawn, a new doctor appeared and said that it was now his shift. I had never met him before. He was very kind and very worried. My temperature was 106 degrees and my pulse was 220 beats per minute. He also pointed out that, despite my high temp, I was not sweating at all. Despite drinking all the Gatorade I could tolerate, I was severly dehydrated from the weeks of fever. If he didn't bring my temperature down, I could end up with brain damage. They started pouring in fluids through an IV. I started to feel a little better. Then I became very, very cold! They had only given me a thin sheet, and between the airconditioning in the ER, the lovely hospital gown I was dressed in, the room temperature fluids being poured into my body, and my fever; I felt like I was packed in ice. I asked the nurse if I could have a blanket, and he said he would ask the doctor. After about 20 minutes of shivering and waiting for a blanket, I gave up and cajoled a volunteer into getting me one. I guess I wasn't much of a VIP, despite the fact that I worked in the hospital!

About this time, my doctor appeared. It was one in the morning, and I felt terrible for having gotten him out of bed. I apologized profusely, and he looked at me like I was crazy. I was his patient, colleague, and friend; of course he was going to come in and see me! We talked, and he said that he have never seen a reaction go on this long. He wanted me to see an infectious disease specialist in the morning to make sure we weren't missing something. He said he thought I probably just had "sick-as-hell" disease (a play on words with Sickle Cell Disease), and I smiled and remembered why I had chosen him. He has this amazing calm demeanor and ability to make you smile, even when thing were not going well. A quality I have definitely tried to emulate in my own practice!

I saw the infectious disease doctors, who were baffled as well. They said that they would do some research and get back to us. By the time they called back to say that they hadn't found anything, I was starting to feel better anyway. They said that doctors and nurses always get the most rare and horrible complications, and that was certainly true of me. That didn't make me feel any better.

I was finally back to normal, and I wanted to get going again. It was clear, however, that I was not going to be able to use the highly purified medication either. I had reacted to that, and no one wanted to see if it would happen again! The genetically engineered FSH was available in Europe, but not in the US. The FDA has a program, however, that allows non-FDA approved medication to be given to an individual on a compassionate care basis. This is only done if you can prove that there are no FDA-approved medications that the patient can take, and that the medication is necessary. It involves a HUGE amount of paperwork. Both my doctor and I dove in and started the paperwork. The manufacturer of the new medication also wanted a paperwork filled out. It took 2 weeks to get it all done, but we finally did it. Then started the waiting. Months and months went by, and I didn't hear anything. I called the manufacturer and they said it was "in the works". After an entire year of waiting, I finally caught a break. It didn't come form the manufacturer, though, at least not directly.

At that time, there was only one manufacturer of these types of fertility medication. They were in the midst of changing over all their plants from urinary medications to the genetically engineered one, and it caused a shortage of the urinary medication in this country. The shortage was terrible. Patients had to delay or cancel cycles, because we couldn't get them enough medication to complete the cycle. Finally, the FDA stepped in and said that we could import medication from Europe until the crisis was over. This was my chance! I found a reputable pharmacy in London and had them ship me the medication I needed. I was set!

My Journey Continued: Injectables!

2011-02-04T09:49:00.000-08:00

The next step after my surgery was to try an injectable fertility medication. This is either FSH or a combination of FSH and LH, the hormones the pituitary makes to tell the ovaries to mature eggs for ovulation. It's stronger than Clomid and can get more eggs ovulating then Clomid. More eggs means more chance of getting pregnant, but more chance of ending up with more than one baby. Most women who end up with triplets, quadruplets, etc used these medications. The injections are once a day from about the third day of the cycle until the eggs are ready. That usually takes 8-10 days. Because of the risk of a multiple pregnancy, you need blood tests and ultrasounds of the ovaries every 1 -3 days while you are taking the medication. It's a big step from Clomid, but I figured that I could handle it. I wanted a baby, and I was willing to do whatever it took!

My doctor ordered the medication, and I picked it up from the pharmacy. It was close to a $1,000 of medication in little glass vials. Yikes! I decided to seatbelt it in to the passenger seat of the car, so it didn't accidentally go flying! I got it home safely and opened it up. There, among the neatly-ordered vials, I hoped, was my baby. Now, I had a decision to make. Was I going to the the injections myself or teach my husband how to do them? I had the training to do them, but I found the idea of sticking a needle into myself surprisingly daunting! My husband was an insurance underwriter with no medical training whatsoever--also daunting! In the end, I did a combination. There were nights where I just couldn't bring myself to jab the needle into my body. On those nights, my husband stepped in. Other nights, it seemed like a piece of cake. I still have no idea why some nights were so hard, but I am glad that my husband was willing to help.

I felt great on the injectables! No more hot flashes. I had all this energy and a strong desire to organize everything in sight. This is the same nesting instinct that pregnant moms get, and it's not uncommon on injectable medications. I knew the eggs must be about ready, for instance, when I found myself cleaning out closets at three in the morning! I'm sure my husband thought I had gone nuts! I could definitely feel my ovaries, though. It felt like I was walking around with two large grapefruits in my pelvis. I didn't care, though, those were my potential babies in there!

After a few days, however, I started to notice that something was wrong. I was getting fevers, aches and chills that would start an hour after I took the shot and wear off a few hours before the next shot. I went to my textbooks. I discovered that this was a rare febrile reaction to the medication. In those days, most of the injectable medication were made from the urine of women who had gone through menopause. The ovaries stop working after menopause, but the pituitary still sends out lots of FSH and LH in a desperate attempt to get them working again. This FSH and LH is eventually excreted into the urine. Unfortunately, there are a lot of other things in the urine and some of those ended up in the medication. I was reacting to one of those extra things, and my body was trying to attack it. It was a Sunday when I figured this out, and I didn't want to bother my doctor. I took one last shot and suffered through the fevers. I called a different medication into the pharmacy on Monday morning. This one was "highly purified" and so had less contaminents. I let my doctor know what I had done and why, and he took the opportunity to teach me about the purifying process. It reminded me that I was both a patient and a fellow studying infertility.

These days, most injectable medication is made by genetically engineering FSH (so it doesn't come from a human or from urine) or is highly purified. Febrile reactions are pretty much a thing of the past, thank goodness!

I did the IUI again and waited. Right on cue, my period started. Despite lots of nice looking follicles (sacs with eggs) and a great estrogen level, it hadn't worked! The second cycle was harder. I wasn't having the fevers, but I was having more trouble giving myself the shots. I was starting to get discouraged. I had been at this fertility treatment stuff for 8 months and trying to have a baby for over 2 years with nothing to show for it. It felt like my life was on hold. I didn't want to buy any new clothes, because I was going to need maternity clothes soon. I didn't want to plan a vacation, because I didn't know whether I would be pregnant or not. My parents were living in Colorado, and I turned down a chance to go out and ski, because you can't ski when you are pregnant. All that optimism now felt ridiculous. I couldn't get away from infertility either. I spent all day treating it only to come home at night and treat my own. I was drowning! I decided to redouble my efforts to stay positive and keep going. What else was there to do? So on I moved to the third cycle. Unfortunately, the third cycle did not work either. Now I was facing the most expensive and invasive option: IVF.

My Journey Continued: The Diagnosis

2011-01-24T13:22:00.000-08:00

When all the testing results were finally back, I sat down with my doctor. He explained that they were all normal. My heart sank. I had been hoping for an easy fix, and that wasn't to be. 10% of couples end up with the diagnosis of unexplained infertility. It is one of the more frustrating diagnoses, but it also has one of the better treatment success rates. My doctor suggested I try Clomid and IUI's. Clomid is a pill that you take for 5 days at the beginning of your cycle. It fools your body by blocking estrogen receptors so that your body thinks the ovaries have stopped making estrogen. This causes the pituitary to send out more signal to the ovaries to get them working again, and this can cause multiple eggs to be produced in a single cycle. It raises the chance of twins to 8-10% and rarely can cause triplets or more. Although I should have been more worried about having multiple babies (the risks of birth defects, prematurity and other problems are higher); like most women struggling with infertility, I just wanted to be pregnant. Besides, it was the side effects of Clomid that had me worried. Clomid can cause hot flashes like women in menopause get, emotional changes (a lot like PMS), pelvic discomfort, and rarely headaches or visual changes. I could handle all of those except the emotional changes. I'd never really had PMS, and I didn't want to start. How was I going to take care of my patients, if I started weeping at the drop of a hat? I wanted a baby, though, and so I took the Clomid.

The first thing I noticed was the hot flashes. They would come at any time of the day or night. My husband accused me of trying to give him hot flashes, because I would throw all the covers onto him in the middle of the night. Patients must have wondered why I would suddenly turn red and unbutton my labcoat in the middle of a consultation. They were an annoyance for sure, but I didn't mind them. It meant I was one step closer to having a baby! I also became aware of my ovaries for the first time in my life. I could feel this dull ache when I got up out of a chair or went over a pothole in the road. The emotional changes didn't really happen. If anything, I was happier because I was actively doing something to help get pregnant. I considered myself lucky.

The first challenge to this happiness came when my very good friend and his wife appeared at our front door with "good news". They were pregnant after just a few attempts. My heart broke. I was happy for them them, but sad and angry for me. I wanted to shout "that's not fair! You've barely been trying, and I have been trying everything possible for almost 2 years without success. It's my turn, not yours! Go back and try some more." Instead, I congratulated them and gave them both hugs. I asked the appropriate questions about due dates and names. I gave them suggestions for OB's. This was just the first in a long line of friends and family who get pregnant easily while I struggled. It never got any easier, but I never gave in to my inner demons and expressed anything other than hapiness for them. Perhaps I got some kharma points for that.

After the Clomid, I had an IUI. This is a procedure where my husband's sperm was washed and concentrated down into just a few drops of fluid (0.5 ml). A speculum is then placed, and a small tube or catheter with the sperm is threaded through the cervix and into the uterus. The sperm is then deposited at the top of the uterus. Although it sounds a lot like the HSG, it is much less uncomfortable. The amount of fluid is so small that it does not make the uterus cramp. The worst part of this procedure was that is was done by my male colleague and doctor, who, up to this point, had not seen me undressed. The drive to become pregnant trumped modesty, however, and the IUI went off without a hitch. The next two weeks were hell. There was nothing to do but wait and wonder. I analyzed every little twinge or wierd feeling to see whether it might indicate a pregnancy. Since, by this point, most of my office knew what was going on, they kept asking me how I was feeling too. It became a kind of ritual:
"How are you feeling?"
"OK, but tired."
"Oh, that's a good sign!"
"I hope so!"

Unfortunately, 2 weeks later I got my period. The happiness disappeared. My coworkers stopped asking how I felt. It was like being on a giant roller coaster. I did 2 more cycles of Clomid and IUI's, but they didn't work either. Up and down went the roller coaster. Time to regroup with my doctor. He suggested a surgery called a laparoscopy. A small incision is made in the belly button, and one or two more small incisions are made down near the bikini line. A scope and other instruments are then placed into the belly to look at the uterus, fallopian tubes, and ovaries. I had fairly bad cramps with my periods, and my doctor suspected I might have endometriosis. This is a condition where the same cells that line the inside of the uterus and grow and come out with your period start growing somewhere else in the pelvis. It can cause painful periods and infertility. I agreed. My good friend and colleague agree to assist in the surgery. I had the surgery on a Friday and was back to work on Monday. There was some endometriosis in there, and they lasered it. My one ovary was also stuck to my pelvis, which can make it hard for the fallopian tube to reach the eggs. They unstuck that as well. Up went the roller coaster. Perhaps this is why I wasn't getting pregnant! I was again happy and optimistic!

My Journey Continued: The Testing

2011-01-21T13:54:00.000-08:00

I had a bunch of prescriptions for different testing to be done. This was it--I was on my way. The easiest to get done seemed to be the bloodwork, so I started with that. Unfortunately, as the employee of a large University, I was very limited as to where I could go for bloodwork. After several phone calls, I was informed by Human Resources that going to the hospital lab was my best option. So on my lunch hour, I went down to get the labs drawn. It took half an hour just to register me in the system, but the rest went smoothly. I was informed that it would take 7 - 10 business days to get the results back. Ugh! I had thought they would be back in a day or 2. No matter, I told myself, just stay busy and don't think about it.

Next was the hysterosalpingogram. This is an x-ray test where contrast (a kind of dye for x-rays) is injected into uterus and through the fallopian tubes to see if the tubes are open. I had heard horror stories about this test. Patients had complained that the pain was worse than labor pains! I scheduled the test for my lunch hour. I wondered what I would tell everyone, if I was in too much pain to go back to work. Other than the doctor treating me, nobody knew that I was having problems getting pregnant. I took 3 ibuprofen tablets before heading down to the radiology department. When I got there, the radiologist who was going to do the test recognized me. NOT the anonymity I was hoping for!! He was very kind and understanding, though. A speculum was put in, and my cervix was grasped with a clamp called a tenaculum. It caused this dull achy feeling throughout my pelvis. The contrast was infused through a tube in the cervix, and I felt strong menstrual cramps. The radiologist asked me to turn on my side and then on the other side. This was not easy with all those instruments in my cervix, but I managed. I could feel the nurses watching me: here was an actual doctor undergoing a procedure. How would she react? I was wondering the same thing. I had ordered hundreds of these tests on other women. I told them that it was "uncomfortable, but not that bad." Most of them had agreed with that description afterwards, but a few had thought it was terrible. Would I be one of them? When the radiologist was finished, the nurses expressed their surprise. I hadn't given them any indication of pain. I told them that it was uncomfortable, but not that bad. I smiled to myself. The radiologist explained that my tubes were open and my uterus looked normal. I was relieved, but also frustrated. Why wasn't I getting pregnant? I wanted an answer.

The final test was the semen analysis. I brought a cup home for my husband. He looked startled for a minute, when I described what he was supposed to do with the cup. He recovered quickly, though, and took it in stride. I told him that I needed the specimen the next morning, so I could bring in to the lab when I went to work. This, of course, meant more people were going to know what was going on, but I didn't see a way around it. Looking at sperm is not easy. They swim pretty quickly. You want a lab that does many analyses a day, or you may not get accurate results. I woke up the next morning to a blizzard. Oh well, I thought, I still have to go to work. I'll just bring it with me as I had planned.

The problem with transporting sperm specimens is that sperm like to be pretty close to body temperature. So you can't just plunk the container on the seat next to you and drive it in. I tucked it in my waistband of my pants and buttoned my coat over it. There, I thought, no one will see the bulge through my coat. When I got to work, however, there was no one in the lab to take the specimen. The blizzard was causing traffic accidents all over New Jersey, and our technician had been caught in one. Now what? I couldn't leave it in my desk, it would get too cold. I wasn't sure where to leave it in the lab, and I didn't want it thrown out. After a few seconds of panic, I decided the only option was to leave it in my waistband. So I put on my white coat and buttoned it over the container. I saw 2 patients this way. If they noticed, they certainly didn't say anything! I was so worried that it would shift and fall out or that the lid would come loose and the contents would spill. That would have been very embarrasing! When I went back to the lab, the technician had arrived. I gratefully handed over the specimen and explained the situation. The technician didn't react at all to the fact that I was trying to conceive, and for that, I was grateful. Now all I had to do was wait for results, which I still think is the hardest part of infertility--all that waiting and hoping and worrying!

The start of a journey

2010-11-14T15:30:00.000-08:00

I’ve never blogged before, but I have a unique perspective on fertility problems, so I thought I would try. I have suffered through infertility, and I am a fertility doctor. I’ve seen both sides.

My own infertility treatment journey started one Saturday morning, in the office where I was doing my fellowship. We had just finished with the morning clinic: seeing patients, doing inseminations, and making medication decisions. I had finally worked up the nerve to ask for help. My husband and I had been trying to conceive for a year and a half. I knew all about how it was supposed to work. We’d been tracking ovulation, spending hundreds of dollars on ovulation and home pregnancy tests. We’d tried having intercourse every other day (like I knew we were supposed to), every day (ouch!), and every third day. I was frustrated, scared, and just plain angry. My body had betrayed me. I had wanted children for as long as I could remember. I had waited through medical school and residency (too stressful and time-consuming, not fair to a child). Now was the time…and it wasn’t working!

I found my attending doctor in front of the coffee machine. “Can I talk to you about something?”, I asked. I explained what was going on. I must have looked like a deer in the headlights, but he was kind and sympathetic. I have learned a lot on how to be a doctor from him. He never talked down to or over the head of a patient. He managed to explain complex concepts without using medical jargon and always made sure the patient understood everything that was going on. He never rushed a patient (which sometimes made his office hours very late), and he loved job. Everything I wanted in a doctor and everything I wanted to be in a doctor.

My new doctor ordered a whole bunch of tests and reassured me that he would do his best to give me the child I always wanted. I went home with a smile. I now had some hope. Maybe it would turn out to be something simple to fix. Even if it wasn’t, at least I was doing something. I had a great doctor on my side. Things were looking up.