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.
Wednesday, February 25, 2009
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.
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.
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.
Tuesday, February 17, 2009
Fertility Specialist Comments on the Nadya Suleman Octuplets
By Arthur L. Wisot, M. D.
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 those same countries follow the Golden Rule: the one with the gold rules. 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 baby 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. What’s needed to reduce the occurrence of multiple pregnancies resulting from fertility treatment is a combination of physicians’ responsibility to follow guidelines, educating patients not to push for more drugs and embryos hoping to make this largely uninsured treatment work faster, and society to provide insurance benefits for infertility to reduce the financial pressure on the patients to demand unsafe measures in order to achieve a quick pregnancy, disregarding the dangers involved. Finally, state medical boards can and should hold those physicians who violate guidelines and cause a reproductive nightmare accountable for their actions.
Dr. Wisot is a fertility specialist with Reproductive Partners Medical Group in Southern California and author of “Conceptions & Misconceptions” the informed consumer’s guide through the maze of in vitro fertilization (IVF) and other assisted reproduction techniques.
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 those same countries follow the Golden Rule: the one with the gold rules. 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 baby 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. What’s needed to reduce the occurrence of multiple pregnancies resulting from fertility treatment is a combination of physicians’ responsibility to follow guidelines, educating patients not to push for more drugs and embryos hoping to make this largely uninsured treatment work faster, and society to provide insurance benefits for infertility to reduce the financial pressure on the patients to demand unsafe measures in order to achieve a quick pregnancy, disregarding the dangers involved. Finally, state medical boards can and should hold those physicians who violate guidelines and cause a reproductive nightmare accountable for their actions.
Dr. Wisot is a fertility specialist with Reproductive Partners Medical Group in Southern California and author of “Conceptions & Misconceptions” the informed consumer’s guide through the maze of in vitro fertilization (IVF) and other assisted reproduction techniques.
Monday, February 2, 2009
Octuplets' mom was hoping for 'just one more girl'
Octuplets' mom was hoping for 'just one more girl,' grandmother says
Nadya Suleman, a 33-year-old mother of twins, octuplets and 4 other young children, loves being around kids and was not seeking fame or financial gain, her friends and family say.
By Jessica Garrison and Kimi Yoshino
Reprint from Los Angeles Times Article featured on January 31, 2009
Nadya Suleman's goal in life was to be a mother, her friends and family said. That is why, even with a brood of six, including 2-year-old twins, she decided to have more embryos transferred in hopes, her mother said Friday, of getting "just one more girl."
"And look what happened. Octuplets. Dear God," Angela Suleman said four days after her 33-year-old daughter became the second person in the U.S. ever to give birth to eight babies at once.
Suleman stressed that her daughter "is not evil, but she is obsessed with children. She loves children, she is very good with children, but obviously she overdid herself."
Angela Suleman said all the children are from the same sperm donor, but she did not identify him. Her daughter is divorced, but Suleman said the ex-husband was not the father.
Suleman said she is caring for her six grandchildren while their mother is in the hospital recovering. She said she had few details about how the octuplets were conceived and did not know the identity of the doctor or the clinic that transferred the frozen embryos into her daughter's uterus. Suleman said it was not Kaiser Permanente, where the babies were born.
Fertility experts have raised concerns about the number of embryos implanted and whether the procedure was within medical guidelines.
"I cannot see circumstances where any reasonable physician would transfer [so many] embryos into a woman under the age of 35 under any circumstance," said Arthur Wisot, a fertility doctor in Redondo Beach and the author of "Conceptions and Misconceptions."
Doctors probably could not deny treatment to a woman simply because she already has children, he said. However, he added, they should have taken steps to make sure she did not have so many babies at once.
"I certainly think you can talk to her about it if you feel like she's making a decision that's not in her best interest or the interest of her children," Wisot said. "You can send her for psychological evaluation, but I honestly don't know if you can say, 'No, I won't take care of you because you have too many children.' "
Dr. Geeta Swamy, an assistant professor of obstetrics and gynecology at Duke University, told The Times this week that the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists advise doctors "to curb these higher-order multiple gestations," she said. "But it really is still up to the individual physician. There aren't any laws or legal ramifications to it."
The California Medical Board, which investigates doctors, and the California Department of Public Health, which licenses clinics and hospitals, said no doctors or facilities are currently being investigated regarding the births. It is also unlikely that the Los Angeles County Department of Children and Family Services would get involved unless it receives a complaint of child abuse or neglect.
Allison Frickert, a friend of Nadya Suleman, said the mother was not seeking potential fame or financial benefit. "There was no overriding situation, other than having more children to love," she said.
"Her whole life, she couldn't wait to be a mom," Frickert said. "That was her No. 1 goal."
Friends and family also reported that Nadya Suleman worked as a psychiatric technician until she was injured on the job. Then she began having children and enrolled in school.
She graduated from Cal State Fullerton in 2006 with a bachelor of science degree in child and adolescent development, school officials said. She returned to pursue a master's in counseling, but last attended in the spring of 2008.
By juggling school and six children, Frickert said, Nadya Suleman proved to be "a lot more capable than the average person in handling stress."
She and her children live with her mother in a 1,550-square-foot home in Whittier, and her father has been working in Iraq as a translator to help support the family.
In 2008, Angela Suleman filed for bankruptcy, claiming nearly $1 million in liabilities mostly due to a bad housing investment, her bankruptcy attorney said. Suleman said Friday that she had withdrawn the filing and paid her debts.
As the media camped outside the house, Angela Suleman said in a telephone interview that she could not explain her daughter's decision.
Nadya Suleman has always loved children, her mother said. Then she sighed. "I wish she would have become a kindergarten teacher."
jessica.garrison@latimes.com
kimi.yoshino@latimes.com
Times staff writers Alan Zarembo, Tony Barboza, Corina Knoll, Richard Winton, Garrett Therolf, Janet Lundblad and Scott Wilson contributed to this article.
Nadya Suleman, a 33-year-old mother of twins, octuplets and 4 other young children, loves being around kids and was not seeking fame or financial gain, her friends and family say.
By Jessica Garrison and Kimi Yoshino
Reprint from Los Angeles Times Article featured on January 31, 2009
Nadya Suleman's goal in life was to be a mother, her friends and family said. That is why, even with a brood of six, including 2-year-old twins, she decided to have more embryos transferred in hopes, her mother said Friday, of getting "just one more girl."
"And look what happened. Octuplets. Dear God," Angela Suleman said four days after her 33-year-old daughter became the second person in the U.S. ever to give birth to eight babies at once.
Suleman stressed that her daughter "is not evil, but she is obsessed with children. She loves children, she is very good with children, but obviously she overdid herself."
Angela Suleman said all the children are from the same sperm donor, but she did not identify him. Her daughter is divorced, but Suleman said the ex-husband was not the father.
Suleman said she is caring for her six grandchildren while their mother is in the hospital recovering. She said she had few details about how the octuplets were conceived and did not know the identity of the doctor or the clinic that transferred the frozen embryos into her daughter's uterus. Suleman said it was not Kaiser Permanente, where the babies were born.
Fertility experts have raised concerns about the number of embryos implanted and whether the procedure was within medical guidelines.
"I cannot see circumstances where any reasonable physician would transfer [so many] embryos into a woman under the age of 35 under any circumstance," said Arthur Wisot, a fertility doctor in Redondo Beach and the author of "Conceptions and Misconceptions."
Doctors probably could not deny treatment to a woman simply because she already has children, he said. However, he added, they should have taken steps to make sure she did not have so many babies at once.
"I certainly think you can talk to her about it if you feel like she's making a decision that's not in her best interest or the interest of her children," Wisot said. "You can send her for psychological evaluation, but I honestly don't know if you can say, 'No, I won't take care of you because you have too many children.' "
Dr. Geeta Swamy, an assistant professor of obstetrics and gynecology at Duke University, told The Times this week that the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists advise doctors "to curb these higher-order multiple gestations," she said. "But it really is still up to the individual physician. There aren't any laws or legal ramifications to it."
The California Medical Board, which investigates doctors, and the California Department of Public Health, which licenses clinics and hospitals, said no doctors or facilities are currently being investigated regarding the births. It is also unlikely that the Los Angeles County Department of Children and Family Services would get involved unless it receives a complaint of child abuse or neglect.
Allison Frickert, a friend of Nadya Suleman, said the mother was not seeking potential fame or financial benefit. "There was no overriding situation, other than having more children to love," she said.
"Her whole life, she couldn't wait to be a mom," Frickert said. "That was her No. 1 goal."
Friends and family also reported that Nadya Suleman worked as a psychiatric technician until she was injured on the job. Then she began having children and enrolled in school.
She graduated from Cal State Fullerton in 2006 with a bachelor of science degree in child and adolescent development, school officials said. She returned to pursue a master's in counseling, but last attended in the spring of 2008.
By juggling school and six children, Frickert said, Nadya Suleman proved to be "a lot more capable than the average person in handling stress."
She and her children live with her mother in a 1,550-square-foot home in Whittier, and her father has been working in Iraq as a translator to help support the family.
In 2008, Angela Suleman filed for bankruptcy, claiming nearly $1 million in liabilities mostly due to a bad housing investment, her bankruptcy attorney said. Suleman said Friday that she had withdrawn the filing and paid her debts.
As the media camped outside the house, Angela Suleman said in a telephone interview that she could not explain her daughter's decision.
Nadya Suleman has always loved children, her mother said. Then she sighed. "I wish she would have become a kindergarten teacher."
jessica.garrison@latimes.com
kimi.yoshino@latimes.com
Times staff writers Alan Zarembo, Tony Barboza, Corina Knoll, Richard Winton, Garrett Therolf, Janet Lundblad and Scott Wilson contributed to this article.
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