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.