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.