Thrombophilias and Unexplained Infertility

Hereditary thrombophilias do not cause unexplained infertility. Read all about it: http://is.gd/5oM7M

Single Embryo Transfer Encouragement Program in USA Today

On December 1st we launched our eSET Encouragement Program. The article explaining the program was outlined in USA Today.

The Pap Smear Guidelines and Fertility and Life & Style

My opinion on the new Pap smear guidelines and the effect on fertility and my quotes in an article on Celine Dion's recent IVF disappointment are now on the Reproductive Partners blog. http://www.reproductivepartners.com/blog/

Fertility Drugs and Ovarian Cancer

You can read about the latest study about fertility drugs and ovarian cancer at our Reproductive Partners blog.

All new posts will be at the Reproductive Partners blog.

Sex ratio in blastocyst transfer

Do we see more boys then girls born as the result of blastocyst transfers. Check out the new RPMG blog.

By the way, in the future my posts will be at the RPMG blog.

Arthur L. Wisot, M. D.

RPMG and Dr. Wisot in ELLE

Girl Crazy: Women Who Suffer from Gender Disappointment

Reproductive Partners was cited in an article in the November 2009 issue of ELLE magazine, “Girl Crazy: Women Who Suffer from Gender Disappointment.” The article profiles women whose lives are disrupted because they have not been able to have the girl child that they are craving. According to the author, they resort to a variety of techniques to try to achieve their elusive dream from folk remedies to IVF with preimplantation genetic screening (PGS), also know as preimplantation genetic diagnosis ((PDG) for chromosomes. The focus of the article was the degree of emotional impairment from which these women suffer rather than the procedure itself. The article profiles a physician whose practice is devoted to IVF/PGS for gender selection, although the technique is widely available, including at Reproductive Partners.

The article states, “Physicians at other clinics, including California’s topranked Reproductive Partners Medical Group, use PGD as a screening tool to identify embryos with defects, and—if pressed— will reveal the sex of embryos in conjunction with other findings. ‘We would transfer embryos of one sex or another if that is the patient’s preference,’ says Arthur Wisot, its executive director and a clinical professor of reproductive medicine at UCLA. ‘We would do it if they seem like reasonable people and no one is hurt by it. But we certainly don’t advertise it and promote it the way Steinberg does. The people he services are more on the fringe, and he’s just playing to their neuroses.’”

Actually Reproductive Partners offers IVF/PGS for family balancing and we do not need to be “pressed” to reveal the sex of embryos. It is just not the only focus of our practice. We mostly employ this technology to detect embryos with chromosomal abnormalities, when appropriate, and diseases caused by known gene abnormalities carried by one or both parents. In fact, the most recent recommendation from the American Society for Reproductive Medicine has reduced the number of reasons for doing PGS for chromosomes because of evidence that it does not improve live birth rates in patients with advanced maternal age, previous implantation failure, recurrent pregnancy loss and even those who have recurrent pregnancy loss from chromosomal abnormalities.

Reproductive Partners Commended By Redondo Beach City Council

REPRODUCTIVE PARTNERS COMMENDED BY REDONDO BEACH CITY COUNCIL


Reproductive Partners Medical Group was awarded a Mayor’s Commendation at its September 1st City Council Meeting. The commendation, presented to Drs. David Meldrum, Arthur Wisot and Bill Yee by Mayor Michael Gin and City Councilman Steven Diels cited recognition of the practice “giving hope to many couples in our South Bay Community.”

Also attending was Councilman Diels’ wife, Elizabeth, and their eight-month-old son, Luke. In his remarks, Mayor Gin cited the fact that Reproductive Partners has been helping South Bay couples, like the Diels, achieve the dream of completing their family for over 24 years in their Redondo Beach location. The group has expanded to now include offices in Beverly Hills, Westminster and La Jolla.
The physicians at Reproductive Partners are responsible for over ten thousand births resulting from assisted reproductive technology. They offer comprehensive evaluation and practical treatment of all aspects of infertility care. Reproductive Partners is nationally recognized for their pioneering work in helping infertile couples.

Top Ten Misconceptions About Infertility Treatment

When a couple is having difficulty conceiving, accurate information about all aspects of their fertility can actually help them conceive more quickly. That information can go beyond the usual medical information about the woman’s cycle, timing of intercourse and other issues related to maximizing their chance of conceiving. It can also include information to make them better consumers by knowing where to get the best care and what treatments make sense especially if they need assisted reproductive procedures such as IVF. Because “misconceptions” can lead to a “missed conception,” I wrote my latest book, “Conceptions & Misconceptions” (Hartley & Marks Publishers, Pt. Roberts, WA 2004). The top ten misconceptions about infertility treatment are:

1. . “Our goal is to become pregnant.” Actually the goal should be to have a healthy baby. A lot can happen between pregnancy and a healthy baby. Keep you eye on the real goal.
2. “Success is not everything; it’s the only thing.” The point is, when you are searching for a doctor or clinic to perform an assisted reproductive procedure, the success rate of that center is not the only factor to consider.
3. “Ethics, shmethics! All we want is a baby.” It might seem best to do anything you can to achieve your goal. However, following ethical principles may protect you from potential harm.
4. “More is better.” One might assume that if something is good, more of it would be better. This is a misconception when applied to assisted reproductive technology. Too much of a good thing can quickly get you into big trouble. The most critical example would be that placing too many embryos back into the uterus for one's age in in vitro fertilization can lead to a triplet (or more) pregnancy which may present potentially dangerous problems for mother and children.
5. “Don’t worry; this is a ‘simple’ procedure.” This is an easy misconception to explain because there is no such thing as a simple medical procedure.
6. "Don't put all your eggs in one basket." If you are going through assisted reproduction, you will want all your eggs "in one basket." Not only will you want them in one basket, you will want to make sure that it's your basket. That's a metaphor for making sure that there are no mistakes made with your eggs. Furthermore, you want to make sure that someone doesn't take them out of your basket and put them in someone else's without your knowledge or permission like happened in the U. C. Irvine fertility scandal.
7. “Let the doctor decide: he/she knows best.” There are many things about which the doctor knows best. But does this mean that you should leave all the decisions to the doctor without any input from you? Of course not.
8. “There is such a thing as a free lunch.” If it sounds too good to be true, it probably is. . Since the early days of assisted reproduction, the enthusiasm of some of its practitioners has led to a variety of advertising claims and marketing schemes. You need to be a careful consumer.
9. “Don’t worry. I’m sure our insurance covers this.” Wrong. Most people do not have infertility coverage.
10. “Trust me. I’m a doctor.” If you are considering the possibility of ART, you are going to need to put a great deal of trust in a team of physicians, scientists, and other medical personnel. We feel that the vast majority of teams doing this work are deserving of your trust. But unfortunately, you cannot rely on blind trust.

If you keep these misconceptions in mind when you seek fertility treatment you will be a better consumer, which will make you more likely to succeed.

Erectile Dysfunction and Infertility

Studies have found that sexual dysfunction is present in about 20-25% of infertile couples. Clearly adequate sexual function will contribute to the success of fertility treatments, but more importantly, sexual dysfunction can be a source of stress and conflict within the couple’s relationship, and the stress in turn can reduce the chance of a successful outcome. Erectile dysfunction can be further worsened by performance anxiety and the pressure to time relations or a procedure to the woman’s ovulation.
Fortunately one of our physicians, Dr. Meldrum in Redondo Beach, CA, has developed an avid interest in this problem, and has developed a web site and written a book outlining the many things men can do to solve this problem. It turns out according to Dr. Meldrum’s research, that drugs such as Viagra should be the last resort.
Click on the following link to Dr. Meldrum’s web site, www.erectile-function.com, and you will learn about the physiology and biochemistry of erectile function so that you can start on the path toward a more pleasurable and fulfilling sexual relationship. Download his book, “Survival of the Firmest”, that will give you all the details.
If you prefer an in-person evaluation with Dr. Meldrum, you can schedule an appointment by calling 1-877-273-7763.

WFWW-Implantation Question

Ask Dr. Wisot

Questions from the reproductivepartners.com bulletin board

Q. When does implantation take place in IVF?

I have had IVF with blastocysts (5 day old embryos) implanted. When the blastocyst is placed in the uterus what stops it from falling out? And when would implantation occur? Immediately? Also, what criteria are used to judge the quality of blastocysts?

A. Embryos are sticky and can adhere to the surface of the uterine lining before they actually implant, which helps prevent them from “falling out.” In addition, we now use a substance in the fluid used to transfer the embryos to make it the same viscosity as fluid in the uterine lining, which prevents migration of the embryos in IVF. That’s so-called “embryo glue,” although it is not really a glue. Despite these measures, the embryos can float around somewhat, and that's why we want activity restricted for 48 hours after an IVF embryo transfer.

Implantation is defined as the process by which an embryo attaches to the uterine wall and penetrates the surface and the circulatory system of the mother. It starts between six to ten days after ovulation in natural conceptions, or egg retrieval in IVF, no matter how and when the embryos reach the uterus. Usually the degree of development of the embryo will determine when the process will actually begin. Most of the time, implantation occurs silently. There are no consistent signs or symptoms associated with it except that it occasionally can result in some vaginal spotting or bleeding which may be mistaken for the start of the next menstrual period.

In IVF, blastocysts are generally graded on the stage of their general development on a one to six scale, and the specific development of what will become the fetus and the placenta on A-B-C scales (A being best). Blastocysts graded at 3AA or higher would generally be considered good quality blastocysts, although this grading level is not required to create a healthy pregnancy. Many healthy babies have been born from embryos which have only reached the stage before blastocyst (morula) after five days of development. Of course none of this is known in a pregnancy conceived by conventional means as we have no idea of what was happening to that embryo, although they would be going through much the same process.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern California

Do blastocysts like fresh air?

WFWW-Do blastocysts like fresh air?

Embryos are very sensitive to their environment. Issues such as temperature, light and atmosphere are critical to proper embryo development and thus to a center’s success rates.

A study in the June 2009 issue of the journal “Fertility and Sterility” supports our decision at Reproductive Partners some time ago to use low oxygen incubators. In this study blastocysts were cultured in atmospheres with either 6% carbon dioxide (CO2) in air, the equivalent to 19% O2, a two-gas system; or 5% O2, 6% CO2, and 90% nitrogen (N2), a three-gas system.

Three hundred ninety six women, were randomized to 197 cultures with the three-gas system and 199 cultures with the two-gas system. The outcome with the three-gas system compared with the two-gas system showed a statistically significantly increased blastocyst rate (47.8% vs. 42.1%), mean number of blastocysts (3.8 vs. 3.3), and number of cryopreserved blastocysts (1.7 vs. 1.1). The mean number of transferred blastocysts was 1.2 versus 1.3. Culture with the three-gas system increased the relative birth rate by 10% compared with the two-gas system (42% vs. 32%, respectively), a statistically significant difference. The overall twin rate was 4.8%.
They concluded that blastocyst culture with low-oxygen (5%) versus high-oxygen (19%) concentration yielded a better blastocyst outcome and a marked improvement in birth rate.

WFWW-PGD for Single Gene Defects

Wisdom from Wisot Wednesday

What Do Women at High Risk for Genetic Diseases Think of PGD?

PGD is an IVF technology that can detect chromosomal abnormalities in the embryos of women at high risk for anuploidy, as well as single gene defects in the those of couples who carry the gene for a serious disease. One problem in applying this technology is that it is not widely known that it exists.

A survey reported in the journal “Fertility and Sterility” examined women’s attitudes about the technology at a national conference for individuals and families affected by hereditary breast and ovarian cancer.

Of the women surveyed, only 32% had ever heard of PGD before taking the survey. None of the women surveyed had actually used PGD, and 44% believed they would not use it in the future. However, 57% of attendees believed that PGD was an acceptable option for high-risk individuals, and 74% believed that high-risk individuals should be given information about PGD.
I am sure that if groups carrying genes for other single gene defect diseases such as cystic fibrosis, muscular dystrophy and Huntington’s Disease were surveyed, we would find the same lack of awareness of the technology.
The authors concluded that health care professionals who serve cancer patients should consider incorporating information about PGD into patient education. Further research is needed to survey physicians and genetic counselors about their knowledge and opinions of PGD. The same conclusion probably applies to couples carrying other single gene diseases.

WFWW-Gender Selection

Wisdom from Wisot Wednesdays

Can I do gender selection?

I have been an infertility patient with 2 successful frozen embryo transfers, one singleton and now a twin pregnancy, all 3 boys. I can't believe we are considering this already, but we've been throwing around the idea of trying again. I was wondering if I can do some procedure to do gender selection and look for any little girl embryos to transfer back.

There are two procedures you can take advantage of to try to increase your chances of a girl. One is sperm selection through a patented sperm selection technique called Microsort. This technique is 90% effective creating girl embryos; 70% success when boys are desired. It can be used with either intrauterine insemination or IVF depending on how many viable sperm of the desired sex are available after the separation process, as well as fertility issues in the intended parents.

If IVF is needed, as in your case, the process can be increased to virtually 100% accuracy by adding preimplantation genetic diagnosis (PGD) to select girl embryos. In addition to sorting the sperm to increase the number of girl embryos with Microsort, the embryos could be biopsied three days after retrieval and insemination. One cell is removed from the then six to eight cell embryos and sent to the genetics lab where from five to twelve chromosomes, including the sex chromosomes, will be examined. Chromosomally normal female embryos will be identified for transfer five days after retrieval.

There are some ethical issues related to this. First, Microsort is currently seeking FDA approval and their protocol requires that the procedure be performed for “family balancing.” That means a couple must have at least one child before seeking the procedure to balance with a child of the opposite sex. Second, if not enough sperm are available for insemination and IVF would be required for that reason only, the question of whether to do IVF, in others, just for sex selection raises an ethical dilemma since IVF is more risky, invasive and costly. If you want sex selection for whatever your situation, you will likely find differing answers among different doctors to all the ethical issues raised by sex selection.

WFWW-Progesterone Options for IVF

WFWW-Progesterone Options for IVF


If you ask women who have gone through an IVF cycle which the part they consider as the most difficult, it would likely be the progesterone injections. Traditionally progesterone in oil has been used and consists of deep intramuscular injections of an oily substance. Since IVF became a clinical treatment thirty years ago, we have been searching for an effective, more acceptable alternative. As you may be aware Reproductive Partners in Los Angeles and Orange counties currently has an ongoing study comparing an FDA approved vaginal medication with a new subcutaneous, easier injection.
One of our sister Integramed practices has just reported in the journal Fertility & Sterility results of a study comparing intramuscular progesterone with a variety of vaginal preparations. Among patients using vaginal progesterone, there were no statistically significant differences in outcomes between the vaginal and IM progesterone treatment groups. There was a 50.0% pregnancy rate among patients treated with vaginal progesterone and a 51.5% rate among matched IM progesterone patients. The live birth rates were 47% in the IM versus 47.5% in the vaginal progesterone groups. There were no statistically significant differences in miscarriage rates between groups.
Our current study goes one step further by comparing the only vaginal progesterone approved by the FDA for pregnancy support, Endometrin, with a new easy subcutaneous injection. If you meet the inclusion criteria you can still join the study and be eligible for free progesterone medication and an honorarium. For more information, call your nearest Reproductive Partners office or (877) 273-7763.

Sex Ratio/Identical Twins in Blastocyst Transfer

WFWW-Sex Ratio and Identical Twinning in Blastocyst Transfer


One of the most frequent questions I am asked is whether IVF treatment, and blastocyst transfer in particular, increase the number of offspring of one sex.

According to a compilation of four studies published in the June 2009 issue of Fertility & Sterility, a higher male-female ratio after Day 5 blastocyst transfer compared with Day 3 cleavage-stage ET was 1.29:1 in favor of male offspring. This is not high enough to recommend this as a sex selection technique, but will be somewhat reassuring to those wanting a male child.

The study also looked at the chance of identical twins (monoztgotic twinning-MZT) in Day 5 transfers which has been said to be increased over Day 3 transfers or natural conception. They reviewed the results of nine studies incorporating almost 41,000 cycles and found the risk of MZT after blastocyst transfer was significantly higher compared with cleavage-stage transfer by a factor of 3.04:1. MZT is not a desirable result as it can create a more risky pregnancy for the babies, especially if they are in the same amniotic sac.

Recurrent miscarriage question

Wisdom from Wisot Wednesdays


With eight previous miscarriages what tests should I DEMAND?

Q. I have just lost my 8th baby due to early pregnancy loss. All losses have been at 11wks or earlier. The hardest part was there was a great heartbeat and a perfect looking baby. My OB/GYN said I was having a textbook perfect pregnancy. Of course I let my guard down, got excited and lost the baby almost 2 weeks later. The OB who did the D&C said she would have testing done on the placenta. What tests is she talking about? And more importantly we want to have a baby and are ready emotionally to try again, so what tests should I have done before we try again?
Kelly

A. I am so sorry to hear about your repeated losses. You can be sure that your enthusiasm had nothing to do with the loss. The test the doctor wanted to do on the placental tissue was probably to examine the chromosomes to see if the baby was normal or abnormal. That could provide clues on what is causing the problem and how to deal with it.

Once you recover from this miscarriage you might want to see an Ob/Gyn who treats recurrent miscarriage or a reproductive endocrinologist to review your history and see what tests are appropriate. Yours does not sound like the typical case and I really can't tell specifically which tests should be done from this information. Generally the tests will check the following issues:
• the chromosomes of both partners
• the quality of the woman’s eggs with hormone tests
• abnormalities of the uterus
• infection with an organism-ureaplasma
• progesterone levels/development of the uterine lining
• abnormal antibodies in the woman’s blood
• heredity blood clotting problems in the woman

By the way, when anyone approaches a doctor I would recommend that one not start the interaction by “demanding” that something be done. Start by listening to the doctor’s advice and then add any “request” you may have with the reason you want something done. The best doctor-patient relationship is one of mutual concern, cooperation and trust. If one does not feel that their doctor is concerned about their problem, not willing to reasonably cooperate or they do not trust the doctor, it is best to find another doctor.

Arthur L. Wisot, M. D.

It has been a few months since I blogged on Redbook magazine's blog, The Infertility Diaries. In the feature, Wisdom from Wisot Wednesdays," I answered reader's questions. Since that blog no longer exists, I am going to resurrect WFWW on my blog. Here is the first entry. You can post new questions as comments to this message.

Wisdom from Wisot Wednesdays

When to perform an insemination?

Could you please give your opinion on what is the best time to perform an insemination (IUI) without any drugs in relation to the detection of the LH surge? Is it before or after detection of surge and please be specific with hours. There seems to be a lot of differing info on best times.

I usually recommend that a single insemination be done in a natural cycle the day after an LH surge is detected by an ovulation predictor kit. That’s because the surge usually precedes ovulation by 36 or more hours. You are detecting the surge sometime after it happened. Most women test once a day in the afternoon or evening, so they should be close to ovulation by the next morning. The egg has about 12-24 hours to be fertilized and the most sperm specimens can maintain good motility for 48 hours in the wash media, so the IUI does not have to be done at the exact time of ovulation. All the averages coincide the morning after the surge is detected, making it the most logical time to perform the IUI. Alternatives to using the urinary ovulation predictor kit to time intercourse or insemination are ultrasound or a variety of fertility monitors. In fact if at the time of the insemination, an ultrasound shows that the follicle is still present, we recommend doing a second insemination the next day as well.

Erectile Dysfunction and Infertility

Studies show that sexual dysfunction is present in about 20-25% of infertile couples. Adequate sexual function can contribute to the success of fertility treatments, but more importantly, sexual dysfunction can be a source of stress and conflict within the couple’s relationship. The stress itself can reduce the chance of a successful outcome. Erectile dysfunction can be further worsened by performance anxiety and the pressure to time relations to the woman’s ovulation.

At Reproductive Partners we are concerned about your mental well-being and want you to maintain a strong relationship during and following your fertility treatments. That can help attain the highest possibility of success and strengthen your relationship during the challenges of pregnancy and rearing your family.

Dr. David Meldrum of Reproductive Partners has developed a web site and written a book outlining many simple things men can do to help solve this problem themselves. According to Dr. Meldrum’s research, drugs such as Viagra should be the last resort. The critical factor for adequate erections, nitric oxide (NO), is positively influenced by factors such as increasing physical activity, reducing excess weight and fat and sugar intake, and by ingesting specific foods and nutritional supplements that maximize NO production. Dr. Louis Ignarro, who received the Nobel Prize for the discovery of nitric oxide, and who first defined the role of NO in the erectile response, has written the forward for Dr. Meldrum’s book. He states “I have no doubt that this book will help millions of couples around the world by improving male sexual performance.” In fact Dr. Meldrum’s non-drug regimen is helping some men have better erectile performance than they have ever had, even when much younger.

Click on the following link to Dr. Meldrum’s web site, www.erectile-function.com, to learn about the physiology and biochemistry of erectile function so that you can start on the path toward a more pleasurable and fulfilling sexual relationship. At the website you may also download his book, “Survival of the Firmest” that provides all the details. Individual consultations are also available at the RPMG Redondo Beach office or by phone with Dr. Meldrum by calling (310) 318-3010 to schedule a telephone consultation.

IVF Costs - Third Cycle Free

At Reproductive Partners Medical Group, we believe in success. Our expert physicians and staff have well over twenty years of experience and are dedicated to using our knowledge and expertise to maximize your chances to achieve your dream of having a baby.

Our financial program, called the SUCCESS PROGRAM is based on the philosophy that couples capable of getting pregnant with IVF usually do so within the first three cycles.

The Reproductive Partners SUCCESS PROGRAM is really very simple. If you pay our regular standard Global Rate for each of two complete IVF cycles at Reproductive Partners, transfer all embryos from those cycles, including frozen embryos, without achieving a viable12 week pregnancy your third IVF cycle at Reproductive Partners will be provided free for the same basic IVF procedures as in the first two cycles. Patients who have insurance coverage for IVF are not eligible.

There will be no age limits, no higher up-front fees as in money-back guarantee programs, no pre-payment for the second cycle until the first is completed, no mandatory procedures like hysteroscopy or IVIG injections and no arbitrary cancellations. If we determine that you are a candidate for and complete at least two cycles of IVF you may participate in the program. We expect our patients to succeed, and when success does not come quickly, we will go the extra mile for you.

Q&A

Q- How much time do I have to complete the three cycles?
A- You have 18 months from the start of birth control pills or Lupron in the first cycle, to the start of the third cycle.

Q- What about frozen embryos from the first two cycles?
A- All frozen embryos must be transferred without achieving a viable 12-week pregnancy before you will be eligible for the third cycle.

Q- In the third “free” cycle, what is covered and what is not?
A- All the same procedures that are covered in the Global Rate in your first two cycles are covered,

Here is a summary:

INCLUDED IN THE THIRD CYCLE -

BASIC PROCEDURES USED IN CONJUNCTION WITH IVF:
• Starting at the visit to begin birth control pills or Lupron:
• Ultrasound and estradiol monitoring of egg development
• Egg retrieval
• IVF laboratory work including preparation of sperm, identification of eggs, preparation of eggs for insemination, insemination of eggs, embryo incubation and monitoring and preparation for transfer
• ICSI (only if ICSI was paid for in the previous cycles)
• Assisted hatching
• Embryo transfer
• Progesterone level after transfer, ending with the first pregnancy test.


NOT INCLUDED IN ANY THIRD CYCLE -

IVF PRE-TREATMENT PROCEDURES:
• Consultations
• Pre-cycle lab work including infectious disease screening
• Semen testing
• Procedures such as trial transfer, hysteroscopy (if necessary)

POSSIBLE ADDITIONAL COSTS ASSOCIATED WITH IVF CYCLES:
• Anesthesia for retrieval
• Medications
• Surgical Sperm Retrieval
• Intracytoplasmic Sperm Injection (ICSI) (if not paid for in two previous cycles)
• Preimplantation Genetic Diagnosis (PGD)
• Cumulus co-culture
• Embryo freezing and storage or frozen embryo cycles
• In donor and surrogate cycles:
Administrative fees
Surrogate or donor recruitment, screening or remuneration costs
Pregnancy monitoring following the first pregnancy test

If a viable 12-week pregnancy is achieved within the first two cycles, including the use of frozen embryos, couples will not be entitled to a free third cycle. If three cycles are necessary, all must be completed in an 18-month period and only same procedures and category of cycle will be provided without charge. Other additional costs enumerated above are not provided without additional charge. All fees for each “paid” cycle must be paid in advance.

Infertility Success Story

This message appeared on the Success Stories section of the RPMG Bulletin Board and I wanted to share it with everybody:

My miracle twin boys are healthy, happy, energetic and almost 4 years old now. Thanks so much to all the Doctors at RPMG. I would like to especially thank the amazing doctors on my team: Dr. Wisot, Dr. Yee and Dr. Meldrum.

My story:

I found RPMG through a RESOLVE support group. This little purple flyer in a doctors office caught my eye, and changed my life.....It was for a support group, for an Organization called RESOLVE - the NATIONAL INFERTILITY ASSOCIATION ( a Non-Profit Organization). The women in the support group had so much information, I was taking lots of notes....they highly recommended RPMG and Dr. Wisot, IVF and acupuncture.
I was a complete rookie, didn't know anything about IUI's, IVF's, I don't know!. The entire staff at RPMG educated me. I soon became a support group leader for RESOLVE and I have referred over 50 patients to RPMG! Almost all of them have children now, thanks to RPMG. There are so many miracle stories from our little support group. I would highly recommend finding one in your neighborhood. Please email with any questions -about RPMG and my wonderful experience with them. My Email: Lisag@sbsdevelop.com.....I also have children's clothing line on the internet: www.wombmates.com - clothing for twins.... Last year, my friend and I bought lunch for the doctors at the Redondo Beach office as a thank you. My girlfriend and I cried, we were so happy...She too is another miracle success story from RPMG.

Wisdom from Wisot Wednesdays - The Final Round

Reprint from Redbook’s Fertility Diaries

Yes, it's true: I'm sad to say that this is the final installment of Wisdom from Wisot Wednesdays and the Infertility Diaries. You'll still be able to access the archives of past blogs, and everyone's favorite fertility expert, Dr. Arthur Wisot, will continue to take questions at the Reproductive Partners bulletin board (though the questions and answers will have to be a bit shorter over there). It seems only fitting that we're winding down with just one last question. But first, the doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answer is below, in bold. Baby dust to everyone.

Question: Hello, Dr. Wisot. I'm 31 years old and my husband is 35 years old. I have been trying to carry for 10 years already. I was diagnosed with PCOS and endometrial hyperplasia. I was treated with the hyperplasia and was put on Metformin for the PCOS. I started seeing an infertility specialist and he put me on a combination of Clomid and Dexamethasone. After the 4th cycle I was able to get pregnant but ended up to be a blighted ovum pregnancy, so I am going back for another cycle. My concern is that if I had hyperplasia, isn't it risky to let so much time go by for the hyperplasia to come back? Should I be considering other procedures to have done? I know that I can't afford IVF, but do you recommend something else that's less expensive? I was told by my OB-Gyn that I had to get pregnant soon because I've had the hyperplasia come back two years in a row. Please advise, and thank you.

Answer: I don't know what you mean by "so much time." If they start another cycle and get you to ovulate in a matter of a couple of months, it would be unlikely for the hyperplasia (increased growth in the lining of the uterus) to return in that period of time. The hyperplasia is caused by estrogen stimulation without any progesterone effect on the endometrium. So they could try to get you to ovulate again soon or give you monthly progesterone to try to prevent the hyperplasia from coming back while they are waiting to get you started again. Sometimes that hyperplasia can be relentless, so I hope they will get you right back into treatment; usually there is no reason to wait.
I have enjoyed answering all your great questions over the past few months. I wish you all a quick resolution to your infertility.

Wisdom from Wisot Wednesdays, Round 20!

Reprint from Redbook’s Fertility Diaries

Welcome back to our weekly Q&A with all-around great guy and fertility expert Dr. Arthur Wisot. If you've got a question for Dr. Wisot, just leave it in the Comments section. The doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: Hi, Dr. Wisot. My husband and I are dealing with male factor infertility. Our RE referred us to an urologist who we saw last week. My husband's numbers are pretty low: count 0.3; motility 33%; and morphology 0. When we saw our RE a few weeks ago, the impression that we got was that hopefully (but don't get your hopes too high up), the urologist will be able to find some viable sperm for IVF-ICSI. But the urologist seemed much more encouraging. He is doing blood work - hormones and genetics - but he told us to have two specimens frozen while we wait for the results. He told us that most likely we will be ready for IVF-ICSI in the next few months with two frozen reserves. We got two totally different impressions from the two doctors and I just wanted to get your opinion. Have you seen men with such low numbers have success with ICSI? Thanks.

Answer: All you need for ICSI is the same number of viable sperm that you have eggs. If his count is 300,000 with 33% motility (indicating viability) then you could produce 100,000 eggs and there would be enough sperm. Apparently your husband does produce sperm, so even if they could not get ejaculated sperm on the day of retrieval and the two backups fail, they could always resort to testicular biopsy (TESE). It sounds to me from what you write that you will be OK.

Question #2: I have been off the pill for two years, but only TTC one year. At the end of last October, I had emergency surgery to remove an ectopic pregnancy. They were able to save the ovary and tube, but results from last month's HSG showed that the tube on that side is blocked (although other side looks great), so I would have a 50/50 chance each month, except for the fact that my cycles are quiet irregular, averaging about 1 cycle every two months (going something like a couple of months of normal cycles, skip a month, skip three months). My gynecologist has given me the go ahead to start trying again and suggested seeing an RE if I don't get pregnant within the year, but with the one working tube and irregular cycle combination, I am wondering if I should consider seeing one sooner (my husband and I are both 31).

Answer: You have already had an ectopic pregnancy and now are faced with trying to conceive with irregular cycles and a blocked tube which means that you are going to have far fewer chances to conceive naturally. You also have fewer ovulations in a year than someone who has cycles every month and only those that occur on the good side count. In addition, tracking your ovulation will be difficult. With those odds I would recommend seeing an RE now. Your gynecologist is not in a hurry but I’ll bet you are.

Question #3: Hi, Dr Wisot. I'm 37 years old, trying to conceive two years, with unexplained infertility. We currently have a healthy 3 year old and did not have any problems with conception at that time. Have done two IUI's with Clomid, took one month off and became pregnant on our own, but miscarried after never seeing a heartbeat. My past few cycles I have had bleeding with BM's starting the days after ovulation, lasting about four days. Then two days later I start spotting until my cycle begins. I have not been back to my fertility specialist since last year, but was wondering if I my progesterone levels might be too low. What would be the symptoms of low progesterone? Thank you.

Answer: The signs of low progesterone include shorter luteal phases (the phase after ovulation) and abnormal bleeding in the second half of the cycle. Clomid can increase progesterone levels and lengthen the luteal phase. So I would suggest you go back to the fertility specialist and get this evaluated and treated, if needed.

Question #4: Hello, Dr. Wisot. I'm 26 and my husband is 36, and we have been trying to concieve for 19 months now. I had PCOS but was given Clomid. But instead of a positive pregnancy test, I have been having regular periods for two months and this is the third month. I want to know if there is any chance for me because this will be my last month — or do you advise I go another month because I if I stop Clomid, I don't know if I'll still get my period. Thank you.

Answer: I don’t know what dose you are on. In general women with PCOS (Polycystic Ovarian Syndrome) can benefit from metformin, a medication to reduce insulin resistance, in addition to an ovulation inducing drug like Clomid. Women taking Clomid for problems like no ovulation or infrequent ovulation can take the drugs for more than three months, or switch to another drug. I hope your Clomid cycles were monitored with ultrasound and an ovulation predictor kit to help time your attempts to conceive accurately and that they have made sure there are no other problems in addition to your lack of ovulation. If you feel you are not making progress, consider switching to a reproductive endocrinologist, or if you are already seeing one, get a second opinion.

Question #5: Hi, Dr. Wisot. I'm 36 years old, trying to conceive for 17 months without success. We have unexplained infertility. We've had three IUIs with Clomid, with BFN (big fat negative). The RE is suggesting either a laproscopy to rule out endometriosis (I have no symptoms other than infertility) then IUI, or straight to IVF. Due to religious reasons, IVF is ruled out for us. Should I have the lap and then try IUI again with injectibles? Thank you.

Answer: If you have ruled out IVF, you need to do everything to try to make conventional treatment work. Laparoscopy to rule out and/or treat endometriosis and flush debris out of the pelvis can be helpful. After that you can go back to a couple of cycles of Clomid or move on to injectable drugs with IUI to try to maximize your chances.

Wisdom from Wisot Wednesdays, Round 19!

Reprint from Redbook’s Fertility Diaries

Hello, hello, and welcome back to our weekly Q&A with tippy-top fertility expert Dr. Arthur Wisot. If you've got a question for Dr. Wisot, just leave it in the Comments section. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: Dr. Wisot, I have hypothalmic annovulation and my doctor has started me on high doses of Repronex on my last two cycles (both which ended in negative pregnancy test). I responded great, but my doses were like 250units for the first 5-6 days, then 150units for the last 3 days. Followed by IUI. Do you think too high of doses can cause poor egg quality? Should we start at a lower dose?

Answer: The dose needed is dependent on the exact cause of the lack of ovulation. If it's really hypothalamic (the hormones from the hypothalamus are dysfunctional), lower doses of pure FSH will usually work. Pure FSH drugs have no LH; the body manufactures it itself so you don't need extra LH. Repronex has both FSH and LH and the higher doses of LH can affect egg quality. If the problem is hypogondotropic (the body does not produce FSH or LH) then both are needed and in fairly high doses. But based on two cycles you can not assume that this is an egg quality issue. Even at a young age, all this can do is restore you to normal fertility for your age and that would give you a monthly fecundity rate (the rate at which women conceive per cycle at a given age) that would probably give you less than a 50% chance of conceiving in two cycles. It may need more time.

Question #2: Hi, Dr. Wisot. I am writing in reference to this week's #2 question about a husband taking Clomid that increased his sperm count "from 1.5 to 3 million in 12 weeks." Is Clomid often used to increase sperm count? I had asked you a question via this site a few months ago. I am 32, DH 38 diagnosed with male factor: low count. Of 3 sperm analyses his counts were: 2.92, 4.7, 7.1. We are currently in the middle of our 2WW with IVF/ICSI #1 (I'm a nervous wreck!), but in the meantime...would this be an option for us? For him to try the Clomid thing to increase his count? This would be so much more affordable for us. Again, thank you so much...for all that you do! Your shared knowledge and expertise is so greatly appreciated!

Answer: I am not an expert in male fertility so I turned to Dr. Jacob Rajfer, Professor of Urology at the UCLA School of Medicine, who is a male fertility expert extraordinaire. He says that Clomid may be used primarily in men who have both low counts and low testosterone levels. "Clomid is used to increase the testosterone levels within the testicle. This supposedly is "beneficial" for speramatogenesis (making sperm). Since each sperm takes about 70 days to form and then it takes about 12 or so days for it to transit from the testicle to the outside, Clomid should be used for a minimum of 3 months and preferably for 6 months, which includes two full spermatogenic cycles." But let's hope the IVF worked so you will not be confronted with this issue. If it doesn't, ask your doctor if this would be an appropriate course of treatment for your husband.

Wisdom from Wisot Wednesdays Round 18!

Reprint from Redbook’s Fertility Diaries

Hello again, and thanks for your patience! Our favorite fertility expert Dr. Arthur Wisot is back to answer your questions, plus share his thoughts on the Octo-Mom situation. If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: Dr Wisot. I have developed a peritubular cyst from my last cycle with repronex. I am having surgery this week to remove the cyst, but also do "ovarian drilling" to help refresh my ovaries. Do you think this is safe?

Answer: Ovarian drilling in the U.S has been largely abandoned because we have such good medications and IVF as a backup. It involves burning small holes on the thickened surface of the ovary in patients with polycystic ovaries. The main concerns about the procedure is that it may create adhesions to the ovary, creating an additional problem. I asked my new colleague, Dr. Andy Huang, how many he saw in his recently completed training in reproductive endocrinology. His answer was that he has never seen one.

Question #2: Dr. Wisot, once more thank you so much for your time and for all this invaluable information. It is very much appreciated. I am one of those super-lucky women who got and stayed pregnant — recently delivering a full term baby: My husband (who is now 41) and I (I'm 33) were trying to conceive for 3 years. The diagnosis was male factor (hypogonadotropic hypogonadism), though I also have Hashimoto's and possibly other autoimmune issues (positive ANA's) that may have contributed to infertility. We were finally gearing up for IVF with ICSI, but in the mean time my husband was on Clomid to see if it would boost his sperm count a bit ( I remained unmedicated). The sperm count went from 1.5 to 3 million in 12 weeks, and just as we were thinking "it's still abysmal" I got pregnant (!?!?). I just had my baby 3 weeks ago. My question is the following: As I approach my 6-week postpartum appointment with my OB, I know I'm going to get the "contraception talk." I know that I'd like to have a second child one day. Ideally I'd like to wait a bit, but beggars can't be choosers, plus neither my eggs nor my husband's sperm are getting any younger. It just feels so counterintuitive to use contraception: The chances me of getting pregnant (esp. while I'm breastfeeding) still seem close to nil, but why not maximize whatever little chances we have? On the other hand, I know that if we hit the jackpot again and the unimaginable happens and I get pregnant within the next 6 months or so, my chances of miscarriage or preterm labor are greatly increased. I know what an OB's take on this is (use contraception!) but I was wondering what an RE would have to say — especially given my history. I was also wondering: Generally, given my and my husband's history and age, how long after the pregnancy should we wait before proceeding to IVF for #2?

Answer: I think your instincts are correct. But I hope your doctor will not be giving you the contraception talk in this situation. If you don’t mind having your children close together you can throw caution to the wind. I am not aware that one increases the chances of miscarriage or premature labor by having your pregnancies close together unless you have an individual risk factor. Your husband’s age is not a critical issue; success in reproduction is more related to the woman’s age. So enjoy this baby, play around and when you are serious about wanting another get started with treatment again.

Question #3: Dr. Wisot, I am 29, diagnosed with unexplained IF (FSH 3). I am in the middle of my first IVF cycle. They removed 20 eggs. I was feeling great about the process until I learned that only 7 were mature. Of the 7, 5 fertilized and 3 made it to embryos — which were transferred back yesterday (varying grades). I am pretty shocked/upset by the fact that only 7 of the 20 were mature. My RE does not schedule follow through appointments until after the beta. I was just wondering what causes just a low rate of mature eggs. Does this mean I have egg quality issues? Is there anything that can be done to help eggs mature better? Thank you so much for your time.

Answer: This is one of the reasons that having a large number of eggs may not necessarily be a good thing. It may result in triggering early because of rising estrogen levels when many of the eggs may be immature. It is not a reflection of poor egg quality. The way to try to get better egg maturity is that if a new cycle is required to use a less aggressive stimulation protocol. Hopefully one or two of the three transferred will work.

Question #4: Hi, Dr. Wisot. Thank you for taking the time to answer these questions. Mine has to do with when is the appropriate time to test? We are doing our second medicated (150mg Clomid) with FSP-IUI. The doctor I am seeing has his patients do progesterone gel starting two days after the procedure through the 14th day after. They then tell me to test on that 14th day and if it's negative to stop the progesterone so I can get my period. My question is that in talking to other women, the length of time they are told to wait before testing varies from 12 to 17 or 18 days. What is the rationale behind what the number of days it takes before testing? When I asked the office about it they told me that if I didn't have a positive by 14dpiui I wouldn't get one... is that true? I have a hard time believing this because my cycle has always been 30 or 31 days and if I follow their instructions I'm testing at cd28. I do have a second question related to this: if we do get a negative on that 14th day but in fact it's too early to get a positive hpt result will stopping the progesterone gel cause a miscarriage?

Answer: Our rationale for our testing 16 days after ovulation/retrieval is that a blood test at that time is predictive of a successful outcome if the level is above 100. Tests before that may show pregnancy hormone in the blood or urine at the 14 days after ovulation as your doctor has requested. Keep in mind that urine tests can be unreliable. But it probably does not matter much in your case because most doctors don't use progesterone in addition to the Clomid, as the Clomid usually raises progesterone to adequate levels. So if you were pregnant, didn’t get a positive test and stopped the progesterone, it probably would not change anything. The length of your cycle is irrelevant; it’s the number of days after ovulation that counts.

Question #5: Hi, Dr. Wisot. We had our first IUI cycle in January and to our surprise we were pregnant! First beta was 18, then 79, then 954. At 6 weeks we had our first ob ultrasound and the baby was in my tube! Needless to say we were devastated. This was on a Monday, we were given a shot of methotrexate and on Thursday at 3 a.m. we rushed to the hospital in horrible pain and ended up having emergency surgery. My doctor was able to save my tube and he checked for any scar tissue and endometriosis and I didn't have any. I know that once you have one ectopic you have a higher risk of having another; my question is then is it safe to try another IUI cycle since I don't have any scarring and we conceived on our first try or do you recommend going right to IVF? Mind you we are self-pay as our insurance does not cover infertility. Thanks.

Answer: Ectopics suck. The risk of a recurrent ectopic is usually quoted at 10%. But you can fine tune that for you by getting a hysterosalpingogram and checking if your tubes are normal or may have some subtle abnormalities. If they look perfectly normal you would be on the lower risk side. Subtle abnormalities would put you on the higher side and you may want to use IVF although that does not eliminate the possibility of an ectopic; just significantly reduces it.

Question #6: Hi, Dr. Wisot. I am one of the lucky ones — I got pg my first try at IVF. At the time I was a healthy 34-year-old with no fertility troubles. My husband, however, had had cancer, so we ended up doing TSE with a nationally known specialist. We are trying again, and although I am 3 1/2 yrs older, my doctors are not changing my protocol (and I trust them, so that's not my question). My question is this: What other sorts of behavioral changes might improve our odds? I believe that there was a peer-reviewed study that indicated that acupuncture increased implantation and that caffeine has been linked to miscarriage in a minority of cases. I would be willing to hang upside down from a meat-hook for the entire two-week wait if I thought it would help. Our procedure is very costly (we have to relocate with a toddler to NYC) and due to the severity of my husband's IF, we may only have one or two more cycles that we can try. I'd sure love to give my little boy a sibling. Is there anything that you recommend, even from the perspective of a placebo effect? And if you do recommend acupuncture, what do I ask the acupuncturist to do, exactly? Thanks!

Answer: The two alternative methods that seem to improve success rates with IVF are acupuncture and Mind-Body programs. Find an acupuncturist who is trained and experienced in fertility issues and he/she will know what to do. Lifestyle issues usually include stopping smoking, recreational drugs, alcohol and caffeine and while in cycle limit exercise to a moderate recreational level and check any herbal medications with your doctor. I don’t know why you would need to relocate to New York to have IVF as there are now good groups in almost every section of the country.

Question #7: Hi, Dr. Wisot. What do you think of doing a "mock" cycle before a real egg donor cycle? I am researching clinics and one of them requires me to do a mock cycle before I get on the waiting list. They want to see if their drug protocol for getting my uterus ready works on me before they start an actual cycle. Is this really necessary? I have been through so much treatment already, the idea of spending a month stuffing myself with Lupron, estrogen, and progesterone doesn't really appeal. Plus, it will delay things by quite a bit. Also, one thing I've learned from treatment is that my body will not always respond to the same protocol the same way. What are your thoughts on the necessity of a mock cycle? Thanks.

Answer: I think the mock cycle is very important and recommend it to every recipient. The way the uterus responds in other cycles does not necessarily predict how it will on Lupron, estrogen and progesterone. When one is spending all the time and money on a donor egg cycle it is terrible to have to freeze all the embryos if the endometrial response is not adequate and doing that reduces the chance of success. The time it takes can be minimized by doing it just before the actual cycle and staying on Lupron until the real cycle begins. So you only need to do the BCPs and Lupron once.


Regarding Octo-Mom Feedback
Thank you to those of you who took the time to give me your thoughts. It's gratifying to see that people involved in this process understand the issues so well. Now here are my thoughts.
Every few years we are treated to a fertility misadventure that makes for great water-cooler discussion. But it also brings out a knee-jerk response that we need to regulate an entire specialty because of the actions of one ethically misguided physician.

Keep in mind that we know only one fact about the current situation: Nadya Suleman delivered octuplets. All the rest about her life and the doctor who reportedly performed the IVF procedure on her are the subject of anecdotal statements. However, there are mechanisms in place to deal with the questions about her ability to raise her 14 children and the alleged actions of Dr. Michael Kamrava. The Department of Social Services can evaluate her questionable suitability as a mother of 14, some of whom are reportedly disabled. The Medical Board had said they will review the doctor’s actions and if the Standard of Practice has been violated and there has been a potentially disastrous outcome, they can discipline the doctor. There is no need to impose arbitrary restrictions on an entire specialty because of one doctor’s actions. The fact that a recent LA Times article reported that another woman, Rosalind Saxton, wound up going to Dr. Kamrava after three other doctors turned her down, telling her to lose weight first, is testament to the fact that many fertility groups do have patient selection criteria and are acting responsibly.

Fertility is one of the most highly self-regulated of specialties. The Fertility Clinic Success Rate and Certification Act of 1992 requires all IVF centers to report their success rates to the CDC. Those rates, along with the average number of embryos transferred, are posted on the Internet and are available to the public. You cannot find success rates of individual doctors, practices or institutions in most other specialties. The problem is that there is no penalty for not reporting; those practices are just listed as non-reporters. Non-reporters usually say that they do not like the mandated format. That means that the standard format does not present their results in the best light or, more likely, their success rates may not measure up to national averages and they do not want their stats to be audited. Until reporting is truly mandatory, consumers should choose not to patronize non-reporting clinics. Surprisingly, Dr. Kamrava does report. His poor success rates were available to any consumer who bothered to look and should have been a red flag.

It’s true that some European countries have restrictions on the number of embryos that may be transferred. But in those countries, IVF is covered in their national health systems. I would personally have no objection to mandate all centers follow the guidelines, if there was universal insurance or government coverage for fertility treatments in the U.S. In fact, a small number of enlightened insurance companies are now covering IVF and contracting only with selected groups which follow the guidelines and have low high-order multiple pregnancy rates. Insurance coverage would take some of the pressure off patients to demand more embryos be transferred in an attempt to have quicker success because of financial pressures.

So let’s not throw out the babies with the bathwater. We can maintain our reproductive freedom. Informed consumers can do at least as much research when selecting a fertility clinic as they would when purchasing a refrigerator. Reducing the occurrence of multiple pregnancies resulting from fertility treatment relies on a combination of things: on the physicians' responsibility follow guidelines and to educate patients not to push for more drugs and embryos in the hopes of making expensive treatments work faster; on our society to provide insurance benefits for infertility, which will reduce the financial pressure on the patients who demand unsafe measures in order to achieve a quick pregnancy, regardless of the dangers involved; and on state medical boards who can and should hold those physicians who violate guidelines and cause a reproductive nightmare accountable for their actions.

First Time IUI without Meds or Ultrasound

Excerpt from the 03-12-09 Reproductive Partners Medical Group Bulletin Board

Q. I am 36 yrs old and my husband and I are going in for our first IUI in a matter of days after discovering that our fertility problems were related to his low motility. Being that this is my first time, I have been doing some of my own research so as to try to make it happen! My doctor's office does not use ultrasound to detect and I am not using any fertility meds. So, given that, I have some questions...I want to know how long my husband should abstain from ejaculation before going in with his specimen - is it about 3-5 days? What's best?

A. We usually recommend a 2-4 day interval. A shorter interval helps motility so I usually recommend on the short side when motility is the issue.

Q. Most importantly, I want to know when I should be going in for the IUI - I am only using ovulation strips to detect my LH surge and my doctor's office says to come in the day of the surge, however I have been reading that maybe it is best to come in the day AFTER the surge??? What would you recommend if there is no ultrasound to detect the follicle and it is all natural - no meds?

A. Since the surge occurs 36-44 hours before ovulation we feel the next day makes to most sense.

Q. And using the OPK, can you test first thing in the morning, even if the directions say to wait??

A. The early morning is not the best. We recommend midday to afternoon since most surges occur in the late morning.

Q. Also, how long does the sperm last when washed? Does it have the same lifespan as it would without or is it shorter?

A. Actually often longer. We can see good motility in some men 48 hours later.

Q. Thank you for taking the time to answer all my questions! I appreciate your help to time things as close as possible...My doctors office also only does one treatment vs. a 2nd day follow up, so I want to time it the best I can!!!


A. Good luck.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Redondo Beach, California

The Basic Infertility Evaluation

The basic elements of an infertility evaluation target ovarian function, tubal and uterine anatomy, ability of the sperm to reach the fallopian tube and male factor.

Improvements in diagnosis and treatment technology are changing the medical experience and chance of success for couples experiencing infertility. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve the couple’s ultimate goal, a healthy baby. Since women are often starting their families at later ages, the initial infertility evaluation in the female has evolved to focus more on ovarian function as an indicator of fertility potential. However, assessments of all the other factors are still important parts of the evaluation.

Following a history and physical examination, the initial tests used to assess the major causes of infertility are:

• Day 2 or 3 FSH (Follicle Stimulating Hormone) and estradiol (estrogen)
• Hysterosalpinogram (tubal dye test) and/or Sonohysterogram (ultrasound)
• Ultrasound to document the time of ovulation
• Post coital test to see if sperm can penetrate the cervical mucus
• Mid-luteal phase progesterone level
• Semen analysis

In the majority of cases this information is enough to indicate the appropriate initial treatment plan. Today laparoscopy is not routinely indicated, because it has the risks of surgery and does not usually change the initial treatment plan. It may be recommended in specific cases if there is suspected endometriosis or tubal disease based on the history, physical findings, ultrasounds or if there are other specific gynecologic reasons to perform this procedure.

When to Test for Infertility

Evaluation of infertility is warranted for a couple when the female partner is older than 35 and has been trying to conceive for 6 months without success. It is also indicated if the female partner is 35 years of age or less after the couple has been trying to conceive for one year. Immediate evaluation and treatment of infertility is warranted in cases of known problems such as anovulation, tubal occlusion, or severe male factor infertility. We also must be aggressive in evaluating and treat women 40 years and greater because of the increased potential for significant loss of ovarian reserve in this age group.

Day 2 or 3 FSH and Estradiol

These hormone levels are drawn on the second or third day of full menstrual flow. The purpose is to evaluate ovarian reserve. Diminished ovarian reserve may be suspected by elevation in either the FSH or the estradiol. An antral (early) follicle count can be used to further clarify the patient’s ovarian reserve. The ovarian reserve essentially tells us whether it is worthwhile to offer treatment to the patient using her own eggs.

The FSH levels will vary somewhat by the endocrine lab and the assay used. Unfortunately the prognosis is based on the highest, but not necessarily the most recent, FSH level. It is advisable to obtain an opinion and possible further testing from an infertility specialist for those patients with abnormal levels, especially those under age 38.

Day 3 FSH Level in relation to Ovarian Reserve*
Ovarian Reserve FSH Levels
Good < 10
Mild Decrease 10-12
Moderate Decrease 12-15
Severe Decrease > 15
*assumes simultaneous D-3 estradiol is <80pg/ml

Hysterosalpingogram & Sonohysterogram

The hysterosalpingogram (HSG) is still the best and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. In addition, a sonohysterogram (ultrasound after saline is placed in the uterus through a catheter) is a relatively non-invasive way of evaluating the uterine cavity alone if intrauterine pathology is suspected, but does not give you any information about tubal patency. Both tests can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps. But, only the HSG can evaluate tubal abnormalities such as occlustions or hydrosalpinges. Abnormalities on an HSG or sonohysterogram may warrant further evaluation with laparoscopy and or hysteroscopy.

Ultrasound

The proper development of the follicle, which contains the egg, and the timing of its release are critical to the evaluation of infertility. Ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.

Post coital test

Once the timing of ovulation is determined accurately, the next step is to asscess if the sperm can penetrate the cervical mucus. When ultrasound and the urine LH kit pinpoint the timing, the couple is instructed to have intercourse and come in the next morning, at which time a microscopic examination of the cervical mucus will show if there is dequate penetration of the sperm.

Midluteal Progesterone

Menstrual cycle regularity and premenstrual symptoms are reliable medical history indicating the probability of ovulation. However, some women ovulate but fail to produce adequate quantities of progesterone (luteal phase deficiency) following ovulation. The clinical tests for ovulation (e.g. temperature chart, positive ovulation predictor kit) are not sufficient to diagnose luteal phase deficiency. We recommend obtaining a progesterone level approximately 8 days after detection of the LH surge.

Semen Analysis

It is important to perform this test early in the infertility evaluation since in at least 40% of couples experiencing infertility the sperm quality will be a factor. The test will identify a potential male factor by checking the semen volume, sperm concentration, motility and morphology (appearance) in a semen sample.

With this streamlined work up, which can be completed within one menstrual cycle, a couple can be efficiently evaluated, specific major causes of infertility identified, and treatment options considered. As with all medical testing, an infertility evaluation must be tailored to each patient’s situation.

Credits –

This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available fertility treatments please visit www.reproductivepartners.com.

Stricter rules on fertility industry debated

Some doctors worry that octuplet mom Nadya Suleman's case may be used as a pretense to pass laws limiting abortion rights. Others fear a confusing patchwork of regulations.

By Kimi Yoshino and Jessica Garrison
March 6, 2009

Octuplet mom Nadya Suleman already had six children after five successful in vitro fertilization treatments, but one big dilemma kept gnawing at her: What was she supposed to do with her six frozen embryos?

"Those were my children," Suleman told NBC. "I couldn't live with the fact that if I had never used them . . . that I didn't allow these little embryos to live or give them an opportunity to grow." Now, anti-abortion groups in Georgia are using Suleman's story as a rallying call to enact stricter rules to govern the $3-billion fertility industry, which has some doctors worrying that the octuplets may be used as a pretense to pass laws restricting abortion rights.

Two other states, California and Missouri, are offering laws that critics say might create a confusing patchwork of regulations.

The Missouri bill seeks to adopt industry standards as law. The California law gives the state Medical Board oversight of fertility clinics.
But the Georgia bill, called the Ethical Treatment of Human Embryos Act, defines an embryo as a "biological human being" and prohibits the destruction of frozen embryos -- wading into a loaded debate over abortion rights and embryonic stem cells.

It is backed by the Georgia Right to Life organization and drafted by lawyers from the Bioethics Defense Fund, an anti-abortion, anti-stem-cell group.

The bill would set limits on the number of embryos that can be transferred to a woman to two or three. In Suleman's case, she said six embryos were transferred, far above the number recommended for a 33-year-old woman using younger eggs. With fewer embryos, the chances of multiple births decreases, along with the need for selective reduction.

"I want to make sure what happened in California doesn't happen in Georgia," said state Sen. Ralph Hudgens, a Republican from Hull, Ga. "There is nothing in this law to limit abortions. I can't believe that people are reading that into it."

The additional provisions, though, particularly the section that prohibits the destruction of embryos, has alarmed doctors and fertility industry groups. Louisiana is the only state with a similar law that prohibits discarding human embryos. The president of Georgia Right to Life issued a statement saying the bill would protect embryos as "living human beings and not property."

"The Georgia bill uses the octuplets as an excuse to pass an extreme anti-abortion measure introduced and promoted by and for Georgia Right to Life," said Sean Tipton, a spokesman for the American Society for Reproductive Medicine."

Dr. Arthur Wisot, a Redondo Beach-based fertility specialist, agreed, saying it could "set fertility treatment back to the Dark Ages."

On Thursday, lawmakers sent the bill to a subcommittee for further review. If a compromise isn't reached and it doesn't move out of committee by Monday afternoon, the bill will be held up until next year, though Hudgens said it is far from dead.

Unless the industry is careful, the country could end up with a mishmash of policies that forces patients to doctor shop from state to state in search of laws most favorable to their needs, said Jesse Reynolds, policy analyst for the Center for Genetics and Society. The group called this week for congressional hearings, noting that federal oversight is the best solution.

"I firmly believe that we can rein in the fertility business," Reynolds said. "It's a $3-billion industry that's completely outside of regulatory control. Bring it in, draw lines that we can agree on, while protective [of] reproductive rights and further encouraging reproductive health and reproductive justice."

The industry has long claimed that its voluntary guidelines are adequate. Doctors frequently cite their own efforts to decrease occurrences of high-order, multiple births.

In 1997, the percentage of in vitro fertilization procedures resulting in triplets or higher was 13.7%. By 2007, and by its own self-regulation, the industry average was down to less than 2%, said Dr. Robert Schaaf, the Missouri Republican who introduced legislation to make industry standards into state law.

Schaaf said that although the American Society for Reproductive Medicine standards have resulted in more success and less danger, laws are still needed.

"What if a woman says, 'I want to implant 10 embryos in there?' "Schaaf said.”I think it is within the realm of the state to make sure that doctors don't participate in things that are harmful to people. . . . To purposefully get pregnant with eight babies, is that something that should be a right? I would argue no."

IVF Success Rates

RPMG Announces 2008 Preliminary Results
Reproductive Partners Medical Group, Inc. has published its 2008 preliminary results on their website, reproductivepartners.com. When all the babies conceived in 2008 have been born, these results will be reported officially to the Society for Assisted Reproductive Technology (SART). The 2008 results from the Los Angeles and Orange County offices showed success rates of 63% (age under 35) 50% (ages 35-37) and 40% (ages 38-40) based on clinical pregnancies per retrieval. Cycles using egg donors had a success rate of 65% based on clinical pregnancies per embryo transfer. Complete reports for prior years as well as the results of all other centers reported can be found at the sart.org website.

Because the type and age of patients treated may vary from program to program, the comparison of cycle statistics is complicated. Couples should be aware of differences among programs as well as differences in specific characteristics when reviewing the data. There are a number of factors to keep in mind when reviewing data.

Only annual data should be quoted since short-term trends are unreliable. Outcomes should be reported only in terms of live births per cycle (clinical pregnancies for the last reporting year), retrieval or transfer. Success rates reported in the SART Data Registry format cannot be compared to programs which do not report to SART, since non-reporters may utilize formats designed to inflate their success rates.

In order to get a long-term view of our results we present a cumulative report of the last five years as well as 2008, the latest reporting year, on our website reproductive partners.com.

Wisdom from Wisot Wednesdays, Round 17!

Reprint from Redbook’s Fertility Diaries

Hello, everyone, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. We've got so much in store this week: Four great questions, an answer to last week's pop quiz ("What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck?"), and a question from Dr. Wisot to all of you! If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: We've been trying for two years and never once had a positive pregnancy test. Recently we went through extensive testing — I am completely healthy/normal however, we were diagnosed with male factor infertility. He's seen a urologist and received a clean bill of health. We've been to an RE and were told that given his SA, we should "Do not pass go, go straight to IVF/ICSI." I've come to terms with the path ahead of us, however despite my RE's frequent reassurance that "It only takes one!", I feel like I need another opinion on his stats to fully understand our chances of a successful pregnancy: SA #1 (WHO Methodology) Total Count: 208 million A - 0% B - 15% C - 4% D - 81% Total Motility - 31 million Kruger Morphology Normal - 3% Head Defects - 44% Acrosomal - 5% Neck Defects - 31% Tail Defects - 17% SA #2 (WHO Methodology) Total Count: 98.9 million A - 0% B - 21% C - 18% D - 61% Total Motility - 20.8 million Kruger Morphology Normal - 1% Head Defects - 44% Acrosomal - 3% Neck Defects - 28% Tail Defects - 24% His counts are high, but the motility and morphology numbers freak me out. Should we be concerned with chromosomal abnormalities or possible DNA fragmentation? As our start date to cycle approaches, I worry that there simply won't be enough "quality" sperm to choose from. Can you help me understand what criteria the lab technicians look for when selecting sperm for ICSI? Thank you.

Answer: Fertility treatment works best when we are correcting a problem, if that's possible. Here the problem is the motility and morphology. If they don't move well, they have much less chance of reaching the egg. If they are misshapen, they have much less chance of penetrating the egg. Fortunately, the speed and shape have nothing to do with the chromsome makeup of the sperm. So IVF with ICSI is a treatment that can overcome this problem. If you are young, you could try some IUIs, but I would usually not recommend spending too much time before moving on.

Question #2: Due to my husband's cancer treatments, he is unable to have children (based on a semen analysis in 2000). When I started my IF treatments in 2007 (no birth control since 2000), we did not do another semen analysis and used donor sperm. I'm now considering IVF (15 failed IUIs, medicated and not). Can we consider utilizing my husband's sperm? What's the minimum an RE will want to see in order to use his sperm?

Answer: The minimum number of viable sperm needed is equal to the number of eggs you produce. That's easy. The bigger question is whether the chemotherapy drugs may have damaged the sperm beyond their numbers, ability to swim and their shape. You should consult with his cancer doctor to get information on exactly what and how much of the drugs he received and what potential damage they could have caused beyond the obvious.

Question #3: Hi, Dr. Wisot! A few weeks ago, in your answer to my questions about embryo defragmentation, you mentioned looking at strategies to improve egg (or embryo) quality. What are some of the strategies you've used in situations with low ovarian reserve, lots of fragmentation in the embryos? Thanks for your thoughts!

Answer: Unfortunately I can not get into the details of prescribing and protocols here. Each fertility center has its ways of dealing with poor embryo quality. In the lab, procedures like co-culture, assisted hatching and defragmentation may be used. There can be modifications to the stimulation protocol. You may want to get an opinion from your doctor about what strategies he/she would suggest and then get a second opinion from another outstanding center. This is a difficult issue to resolve and it can't always be fixed.

Question #4: Hi. Some background: I have a small prolactenoma that I take Parlodel for. Have had regular prolactin levels for one year now and have been TTC since April 08. Husband's sperm is normal, he is 34, I am 30. My question: Ever since going off the pill I have had a very short luteal phase. My doctor thinks I am ovulating due to OPKs thermal shift. But luteal phase is 2 - 6 days. My doctor says that is not a concern; do you agree? I have an HSG scheduled for this week and if clear, the doctor suggests Clomid. Thanks for your thoughts!

Answer: You need to get into this more deeply than following your cycles with a temperature chart. You do fit the definition of a luteal phase defect just by the length of your luteal phase. I would guess that you are not seeing a reproductive endocrinologist/fertility specialist. Clomid is one way to overcome this problem, but your cycles need to be monitored by ultrasound following your egg development, confirming the egg's release and progesterone monitoring in the luteal phase.
Before I get to last week's quiz answer, I would like to get your perspective on the reproductive aspects of the Octo-Mom situation. Has it affected your confidence in the specialty as a whole? Do you think we should legislate how many embryos may be transferred? I'd love to hear what you think. Next week, I'll share my perspective.

Pop quiz answer:

Last week's question was, "What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck," while so many women struggle to have a child.

1. The girls are usually in the late teens, which biologically is the optimal age group for reproduction. (Please, don’t shoot the messenger.) Today, between education and careers, many women are putting off their childbearing until they are biologically more mature.

2. The guys are also at a peak of sorts. Most of the time they look at the post-prom hours with great anticipation. In fact, they frequently practice so they will give a stellar performance. They can regenerate their counts more quickly than their more mature counterparts. The increased, er, practice time improves motility and decreases DNA fragmentation so they are primed to perform magnificently from a reproductive point of view.

3. This is where the back of the pick-up truck comes in. Couples who are engaged in fertility treatment have sex, make love, have intercourse, or whatever you want to call it. In the back of the pick-up our two prom goers and have hot, steamy sex like two rabbits going at it, with similar results. There is no stress and the level of excitement improves the semen specimen further. The stress comes about two weeks later when she misses her period.

The point of all this is that one cannot expect fertility treatment to match the efficacy of this method. I’ve even had patients borrow a pick-up to try to regain their lost youth. But, believe me, it doesn’t work. What may help if you are not already at the point of IVF is to try to regain that spark that brought the two of you together and don't let the quest for a baby get in the way of what you once had. If you are having IUIs, try it the old-fashioned way after your IUI. Even if it is the IUI that ends up getting you pregnant, at least you’ll have had some fun trying.

Wisdom from Wisot Wednesdays, Round 16!

Reprint from Redbook’s Fertility Diaries

Hi, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. It was a short week and we've got just two questions. If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: With all your knowledge, do you find any belief in the Jonas Method?

Answer: No. It's really hard even for me to figure out how it's supposed to work but seems to be a method of timing that's more rooted in astrology than science. If one is reading infertility blogs, chances are that it's beyond the point of just a timing issue. Besides if timing was so critical, why does it seem that conception occurs 100% of the time on prom night in the back of a pick-up truck? Prom night is not timed to the cycle. There are at least three reasons girls get pregnant on prom night. Any guesses?


Question #2: (Subject: Botched IUI) We are trying to conceive with donor sperm. At the time of the botched IUI, we had planned to do an insemination at home (our attempt at a hail mary after 10 cycles of non-medicated IUI and our doctor suggesting that we stay the course) and two IUIs at the doctors office. My spouse had an urgent work trip come up the day before my LH surge so we decided to skip the at home insem because the tank is heavy and process sounded cumbersome with just one person. I went in for my IUI as usual and instructed them to send the remaining ICI preparations back for storage. A week later I received confirmation of the two vials being put in storage, except they had one IUI and one ICI. Despite my repeated clarification that there were two different types of sperm in the tank, they inserted unwashed sperm directly into my uterus. I ended up with an awful infection, which made my HSG two weeks later brutally painful. What, if any, lasting effects could this have on my fertility? We have obviously left this clinic and have found a wonderful RE who knows what she is doing! Thank you for any insight you might have.

Answer: The reason for the violent reaction to unwashed sperm is the presence of a substance in semen called prostaglandin. It can cause labor-like contractions of the uterus. There should not be any long-term medical consequences from this. Although semen is usually sterile, the donor could have an infection or the collection technique could contaminate the specimen with bacteria, causing the infection. Infection can cause damage to the fallopian tubes, although quick treatment will usually prevent that.

Wisdom from Wisot Wednesdays, Round 15!

Reprint from Redbook’s Fertility Diaries

Hello, all, and welcome back to our weekly Q&A with fertility expert Dr. Arthur Wisot. It's been a busy week for Dr. Wisot, between the Today Show and your bounty of questions! Before we get started, the doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: Dr. Wisot, how long can embryos be frozen and then successfully thawed/transfered? I have seven frozen embryos from 1994! We transfered five, resulting in twins and froze the rest. I am 40 now and have a feeling my eggs aren't like they were at 25. Thank you.

Answer: Theoretically, forever. We have had frozen embryos create healthy pregnancies up to 14 years after they were frozen. Apparently they do not get freezer-burn. But don't forget that not all may survive the freeze-thaw.

Question #2: Dr. Wisot, first, thanks. You're awesome. Second, my husband and I are both 36, and we've been trying to conceive for about a year. So far everything is super great (HSG, semen analysis, hormone levels, general health). We've done two cycles of Clomid with insemination, resulting in two and four follicles, but zero pregnancies. Much as I want a biological kid, I'm not interested in IVF (partly because of the money, partly because it seems to send couples to Stress Town — a place I'd rather not go). So, my question is, how many IUIs should we try before we know it won't take? Any other fertility meds I should look into? Tests? Anything else?

Answer: Thank you. The rule is that if a treatment has a good chance of working, it will work in three tries. After that the chance of success drops. So the sequence you are looking at is another cycle of Clomid with IUI, then there are some options. If you are really opposed to doing IVF you might want to consider a laproscopy to see if you have some endometriosis that can be treated. An alternative is to have a repeat HSG, but this time have them put in an oil-based dye which can deal with some immunologic issues and increases the chances that future treatment might be successful. And that next treatment would be injectable drugs with insemination.

Question #3: Dr. Wisot, could you give us a description from the RE perspective of fertility as it relates to a woman's age? (e.g., at 20 years old the average woman is very fertile and pregnancy is usually achieved within X months; at 45/50 the average woman probably will not be able to get pregnant, and points in between. Also, is there one age that really indicates a tipping point? 35 usually seems to be cited. Is there a big difference between 34 and 36 years old in the fertility world, for example? Sometimes you state "if you are young, I would advise XYZ". What is "young" from the RE perspective and what is "old"?) I have always wondered. Thanks so much! I hope you know how much we appreciate your answering our questions!

Answer: That appreciation keeps me going. Age is the most important factor determining success in reproduction. What you are referring to is the "fecundity rate" at various ages. I can't remember the exact monthly rates by age, but in the 20's it would be in the low 20%, 15% in the mid 30's, rapidly declining starting at about age 38, and by 45 would be less than 1%. You can probably search for exact figures. When I say "young," I usually mean under 35. I can't tell you if there is a big difference between 34 and 36 because it's an individual thing; significant for some, not for others. Bottom line: Whenever possible, reproduce early.

Question #4: Dr. Wisot, thank you for taking the time to answer questions. I am 38 years old and have a 5-year-old son who was conceived with Clomid and timed intercourse (first cycle). Been trying for over four years for #2. Multiple Clomid/IUI cycles and one non-medicated pregnancy (miscarried at 12 weeks) during that time. Had a laparoscopy before moving to injectables and discovered pelvic adhesions, so IVF seemed to be only route as the surgeon did not think adhesions could be cleared. FSH went from 6 to close to 9 in less than a year and antral follicle count last time we checked was very low (2 -3). To top it off, I have a unicornuate uterus with only one ovary and tube. With an FSH close to 9 and a low antral follicle count and only one ovary, would you recommend IVF? I am thinking it would not make a lot of sense but would appreciate your thoughts. Thanks.

Answer: I probably would recommend IVF, as time here is a major issue. Remember success in reproduction is about quality, not quantity, although quantity helps. With a single horn uterus we would be considering a single embryo transfer for you to avoid twins, so in IVF they would need to push for the best embryo quality possible.

Question #5: Hi, Dr. Wisot. Thank you so much for your time. You encouraged me to see an RE (Wisdom from Wisot, Round 9, Question 1), and we did, and we're now doing our first medicated IUI (today, in fact). I'm just wondering if you can tell me whether the protocol sounds typical to you. I took 100 mg of Clomid on cycle days (CD) 5-9, we had an ultrasound on CD 13, and today is CD 15. I did an HCG trigger on CD 13, and I'm supposed to do supplemental HCG injections on CD 16 and CD 19. Is that normal? What is the purpose of the last two HCG shots? Will that affect a home pregnancy test (I will be traveling, so I can't get a blood test at the clinic)? BTW, we did a saline contract sonogram for the spotting and it was fine — is the HCG meant to counteract the spotting? Also, is it possible I could have ovulated on CD 13 before the HCG shot (or before today, at least), since CD 15 is rather late in my cycle, or does the Clomid delay ovulation?

Answer: I'm so happy to hear that you were helped. Supplemental hCG injections is one alternative to supplement progesterone in the second half of the cycle as it prolongs the life of the structure that produces progesterone. The hCG can remain in your system for nine days so it could create a false positive pregnancy test for that length of time after the last injection.

Question #6: Thank you for your time. I am 38, G6 P3, (G2P2 unassisted prior to 37-year-old hubby). We've been trying for more children for five years. We had two unmedicated misscarriages (low progesterone assumed to be the cause). Then one unmedicated successful pregnancy (still rather low progesterone with supplements). We have done IUI four times with Clomid 150mg resulting with 3-4 follicles size 16-24 each time. Always followed with labs and ultrasound each time. Hubby has low motility and quantity 20-30 mil. We thought our chance with IUI would be wonderful. Is there a chance male progesterone could be effecting our chance at successful pregnancy? Any suggestions to improve our chance with hubby's lazy sperm :) Thank you.

Answer: First of all for the others, G means number of pregnancies (gravida); P means number of deliveries (para). I don't know what you mean by "male progesterone." There is no such thing. But low motility could be the reason that IUI has not worked. A urologist might be able to determine the cause of the sperm issues and recommend treatment. Or, you could move on to IVF with ICSI to overcome the sperm issues.

Question #7: Hi. I will be doing IVF and was prescribed gonal-f. My RE was initially going to prescibe the follistim pen but I had two unused vials of gonal-f from a different RE when we did IUI's, so he changed to gonal-f so I could use what we had at home, even though I said that I will use what he felt was most effective. Is there a difference between gonal-f and the follistim pen other than how it is administered? Are they equally effective? My RE says that they are essentially the same medication but I have found a study that said that IVF with gonal-f has poorer pregnancy results. Our infertility issue is endometriosis if that has anything to do with it. Thanks.

Answer: Most doctors consider Gonal-F and Follistim to be equivalent drugs. Apparently that one study has not been definitive enough to convince doctors to use Follistim universally. Endometriosis has nothing to do with the selection of stimulation drugs.

Question #8: Hello, Dr. Wisot. Thank you for taking your time. I am 30 years old and my partner is 34. I conceived but unfortunately it turned out it was a blighted ovum pregnancy in we are trying to conceive for the second time is it possible to have a second blighted ovum pregnancy twice?

Answer: The reason for most miscarriages is some variant of a blighted ovum, which is merely the failure to develop a fetus. At age 30, the incidence of miscarriage is about 20-25% of early diagnosed pregnancies, so the chance of this happening again is 20-25%. But look at it this way: You have a 75-80% chance of not having this happen again.

Question #9: Hi, I have a question about morphology. We are starting our second round of IVF with a new clinic. In our first IVF, and in all of the semen analysis they did in the tsting phase, I was told my husband's count, motility, and morphology were fine. He's 38, I'm 40. I had five eggs (poor quality) and all five fertilized without ICSI (this was October 2008). ICSI was never brought up even as a possibility based on the sperm testing. Now with this new place, they did another semen analysis, and they are telling me that his morphology is 3% and normal is 4% on the Kruger scale, and that if the semen on the day of retreival is the same, they will do ICSI. We have to pay for everything out of pocket, and ICSI would add another $3k that we weren't expecting. I've done some reasearch, and found many anecdotal discussions about the Kruger scale being too strict, and so I was wondering about your opinion. Aside from the money factor, I also hesitate to do ICSI, as I've read that there might be a small increase in possible birth defects. Is it possible that in five months, my husband's sperm would change that much to make ICSI necessary? I want to tell them not to do it, based on our history, but I don't want to be stubborn if it is really needed. Can the lab wait to see if they fertilize before performing ICSI, or does it have to be decided ahead of time? Also, is there anything he can do in the next 3-4 weeks before the retreival to improve his morphology? (vitamins, diet, etc.). He usually has a glass of wine every night, but stopped that last week, and he does drink a lot of caffeinated coffee and tea, could that affect it? Thanks for your thoughts on this!

Answer: Most doctors use the strict morphology as one criteria for recommending ICSI because sperm which are misshapen are much less likely to be able to penetrate the egg. You can compare the current sperm count to the last one, but based on the current one, ICSI would usually be recommended. It's not a decision you can go back and re-do. If the eggs do not fertilize, so-called "rescue ICSI" on the day after retrieval does not usually work well and the cycle is ruined. In a few weeks, lifestyle changes and vitamins will not result in a significant change.