Hello, all, and welcome back to our weekly Q&A with top fertility expert, the west coast's captain of conception, Dr. Arthur Wisot. 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, I have been diagnosed with Hypothalmic Annovulation. My lowest weight was about seven years ago when I was about 105lbs (I am 5'9"). But for the past five years I have maintained around 120-125lbs. I was on BCP for about nine years because I stopped getting my period, and when I came off them one year ago my period never started again. The doctor told me to gain weight and back off exercise. So now I am 143lbs, I have done two rounds of IUI with Repronex and no luck. The doctor thinks maybe it is because we used really high doses (like started at 250units for the first five nights) and possibly that caused poor egg quality. We were supposed to start again this week, but found a cyst leftover on my left fallopian tube. I am on BCP again to hopefully get rid of the cyst, but my question is...now that I weigh 143lbs, I have totally backed off on cardio and over exercising, do you think it is possible that I could start cycling on my own? Do you think its worth a chance to back off the meds and see I can get a period back? Please help, this has been the worst experience and so depressing. Thank you.
Answer: I see this sort of problem in my professional athlete patients who exercise at a competitive level and drive their body fat so low that they stop menstruating. And although they stop training, it takes a long while to get their reproductive function back. So, you are not alone.
I don't know your age, but if you are young you might want to stop the drugs and have your doctor monitor your ovaries to see if you ovulate spontaneously now that you are getting your body back to normal. Two rounds of fertility drugs in someone who is not ovulating is not enough of a test to say that this strategy won't work for you. I don't know how they could presume poor egg quality as the reason for lack of success if they do not do IVF and see your eggs in action. In general, the lowest dose of the fertility drugs that can achieve the desired result is best, so lower doses may be best for you.
Question #2: Dr. Wisot, I am 29, diagnosed with unexplained infertility. After three failed IUIs, I have just started round one of IVF. I responded very well to follistim during the IUI and produced 3-4 follicles with a dosage of 75 follistim. My doctor is proceeding with the antagonist protocol and I am on bcp now. Online I have read the antagonist protocol is normally used for slow responders--which I am not. Just wondering why doctors prescribe the antagonist protocol. Thanks for your assistance.
Answer: I think you are referring to an antagonist protocol for poor responders. The antagonist can actually be used for anyone and I know some very excellent doctors who use the antagonist in almost all their patients. It's the dose of the injectable fertility meds that determine the strength of the protocol.
Question #3: I had an HSG performed last week, and following the results I will now have an U/S this Friday. They said that my tubes were clear, and that there was good spillage, etc. But they said that I do have a fibroid. The HSG was painful, which prepared me to accept the fact that something was probably wrong, but I wasn't expecting a fibroid. How often have you seen fibroids affect fertility, and do you have any percentage of fibroids that require surgery to restore fertility? I remember having an U/S about five years ago for my gallbladder, but they checked out my uterus at the time, and said it was fine. Of course at that time I was on birth control.
Answer: Fibroids are very common and their effect on fertility depends on their size and predominantly their location. Those that protrude into the cavity (submucous) have the greatest adverse effect; those in the muscle close to the cavity (intramural) are in second place as fertility offenders. So your doctor will use a number of modalities to evaluate your fibroids potential effect on your fertility and miscarriage chance and then recommend treatment or no treatment.
Question #4: When I was 38, I had two, day 3 transfers with fresh cycles - both times 4 embryos were transferred. On the first I had a low beta (14) - no baby. The second resulted in my son. We never had a definitive reason for our infertility. A few months ago we transfered our 4 frozen blastocysts (3 from the 1st cycle and 1 from the second) which resulted in a low beta (7) and no baby. I am almost 42. I am having regular periods at 28 days and have a day 3 FSH of 8. I have read that the best number to look at to tell if a woman can get pregnant is the number on her drivers license. That even if you have a good FSH the chances of success are slim if you are of a certain age. What is your opinion on this?
Answer: Age is the most powerful determinant of reproductive outcome. As women age we see lower pregnancy rates, higher miscarriage and chromosomal abnormality rates on prenatal tests, all of which lead to lower birth rates. Having a low FSH is definitely an advantage as is previous successful pregnancy. The national live birth rates in your age group is low, but someone succeeds and it might as well be you. Slim chance beats no chance.
Question #5: Hi. I hope to do an IVF cycle in March and my husband may be away during part of it. I have read that frozen sperm is just as good as fresh for IVF. Do you agree?
Answer: It's pretty close to fresh in potency. All donated sperm today is frozen and we find very good results with fertilization by using ICSI to fertilize when frozen sperm is used. Just tell your husband all you need him for is the DNA in his sperm and the nighttime diaper changes, and have a good time on his trip.
For more information visit Reproductive Partners web site.
Thursday, January 29, 2009
Diet, Lifestyle and Male Fertility
Infertility affects approximately 15-20% of all couples trying to conceive, and about half of these couples have a male factor. There is good evidence that diet, lifestyle and nutritional supplementation can impact a man’s fertility. The list below includes habits male patients should avoid, and some to pursue.
Avoid smoking
Several studies have clearly shown that cigarette smoking lowers both sperm counts and sperm motility. If you smoke, now’s the time to quit. This is the single most important lifestyle change to promote fertility and your general health.
Avoid alcohol and drug use
We recommend that no alcohol be consumed by either potential parent while attempting to conceive. Recreational drugs such as marijuana, or steroids for body-building are never a good idea, but especially when you are trying to conceive. Also stop herbal supplements as well, as some may have an adverse effect on sperm.
Boxers or briefs
It is well known that the testicles should be cooler than the rest of the body for sperm production to be at its best. The harmful effect of a varicocele (varicose veins in the scrotum) on sperm production is believed to result from the extra warming of the area caused by the dilated veins. There is no scientific evidence to support the claim that boxer style shorts are better than jockey type, so it’s your choice, but boxers generally result in a happier female partner. Avoid other sources of heat exposure to the testicles such as hot tubs or prolonged baths.
Identify and avoid environmental hazards
If your work or hobby brings you into contact with environmental dangers such as pesticides, solvents, organic fumes or radiation exposure, you may be unknowingly affecting your fertility by impairing sperm production and quality. Always wear your protective gear and follow safety instructions.
Limit caffeine
Limit coffee or other caffeine-containing beverages to 1 or 2 drinks per day.
Avoid harmful nutritional supplements
Some types of nutritional supplements have a clearly damaging effect on male infertility. In particular, bodybuilding supplements including “hormone-like” substances such as DHEA or “andro” can actually stop sperm production completely. If you are taking any of these types of supplements, or other products intended to build muscle mass, stop immediately.
Sexual Activity
The likelihood of a woman becoming pregnant is much higher when she has intercourse as close to ovulation as possible. Some experts call the days before and the day of ovulation the “fertile window.” You can estimate the timing by using either basal temperature charts or an over-the-counter ovulation predictor kit which detects the surge of the hormone LH. The frequency of intercourse during the fertile window may make a difference, especially if there are some sperm issues. Some couples simply have relations every other day; others plan a two day period of abstinence before the anticipated ovulation day. The day of ovulation is usually the day after the surge of LH as seen on the urine test.
Avoid the use of any artificial lubricants such as K-Y jelly® or Replens®; Pre-seed is supposed to be conception-friendly. It also may help to have the woman not get up for at least 20 minutes to allow the sperm to begin to penetrate the cervical mucus.
Exercise
Moderate exercise may be beneficial for reducing stress. However, prolonged, competitive-level exercise may be just as bad as no exercise at all - so the key is moderation.
Proper diet
Just like your mother used to tell you, eating a healthy balanced diet is always a good idea. Here are some dietary specifics:
Nutrients and Male Infertility
Vitamins C and E -are essential antioxidants that protect the body’s cells from damage from oxidative stress and free radicals. Vitamin C is the most abundant antioxidant in the semen of fertile men, and it contributes to the maintenance of healthy sperm by protecting the sperm’s DNA from free radical damage. Vitamin E is a fat-soluble vitamin that helps protect the sperm’s cell membrane from damage. Studies have shown that vitamin E improves sperm motility (movement) and morphology (size and shape).
Selenium -is a mineral that functions as an antioxidant. Selenium supplements have been shown to increase sperm motility, and a combination of selenium and vitamin E has shown to decrease damage from free radicals and improve sperm motility in infertile men.
Lycopene -is a powerful antioxidant and carotenoid (plant pigment) that is abundant in tomatoes. This “phytonutrient” is normally found in high levels in the male testes, and research has shown that lycopene supplementation improves sperm parameters in infertile men.
Zinc - is an essential trace mineral that plays a role in sperm formation, testosterone metabolism, and motility. Zinc supplementation increased testosterone levels and sperm count in a study of 22 men, which resulted in 9 pregnancies.
Folic Acid -is a B-vitamin that is necessary for DNA synthesis. Low levels of folic acid have been associated with a decreased sperm count and decreased sperm motility. In an recent study, the combination of zinc and folic acid resulted in a 74% increase in total normal sperm count in subfertile men.
L-Carnitine - is an amino acid produced by the body, and functions to transport fat so that it can be broken down for energy. L-carnitine provides energy for the sperm, and is important for optimal sperm motility. L-carnitine has been shown to increase sperm quality and increase pregnancy rate.
Oxidative Stress and Male Infertility
Recent scientific evidence has revealed that a condition known as “oxidative stress” may, in fact, be a common factor in some of the causes of male and female infertility. Oxidative stress is caused by the presence of certain molecules known as “reactive oxygen species” in the semen. These molecules, which can damage the sperm cell membrane and DNA, are also known as oxidants. Oxidants are normally kept under control by the presence of antioxidants in the semen. Two of the most important antioxidants are vitamins C and E. When the amount of oxidants in the semen exceeds the amount of antioxidants, we say that “oxidative stress” is present. Oxidative stress has been clearly shown to reduce fertility. Some studies have shown that oxidative stress may be present even when a standard semen analysis appears normal.
Choosing a Safe Male Fertility Supplement
Several nutritional supplements are available which claim to promote male fertility. Below are several suggested guidelines to follow:
1. Use a supplement which is produced under the guidance of a scientific or medical advisory panel.
2. Since we know there are many antioxidant pathways which protect sperm, use a supplement which contains several antioxidants.
3. It’s probably best to avoid any supplement with herbal content. (ie., garlic, ginseng, green tea extract, etc.)
4. Since supplement manufacturers are NOT required to test their products for content accuracy or purity, consider supplements which have been third-party certified (NSF or USP).
5. Supplements which meet most of these requirements are: Fertility Blend for Men, Proxeed and Conception XR. There are others. You can search the Internet for more specific information.
For more information visit www.reproductivepartners.com or to schedule an appointment call (877) 273-7763
Avoid smoking
Several studies have clearly shown that cigarette smoking lowers both sperm counts and sperm motility. If you smoke, now’s the time to quit. This is the single most important lifestyle change to promote fertility and your general health.
Avoid alcohol and drug use
We recommend that no alcohol be consumed by either potential parent while attempting to conceive. Recreational drugs such as marijuana, or steroids for body-building are never a good idea, but especially when you are trying to conceive. Also stop herbal supplements as well, as some may have an adverse effect on sperm.
Boxers or briefs
It is well known that the testicles should be cooler than the rest of the body for sperm production to be at its best. The harmful effect of a varicocele (varicose veins in the scrotum) on sperm production is believed to result from the extra warming of the area caused by the dilated veins. There is no scientific evidence to support the claim that boxer style shorts are better than jockey type, so it’s your choice, but boxers generally result in a happier female partner. Avoid other sources of heat exposure to the testicles such as hot tubs or prolonged baths.
Identify and avoid environmental hazards
If your work or hobby brings you into contact with environmental dangers such as pesticides, solvents, organic fumes or radiation exposure, you may be unknowingly affecting your fertility by impairing sperm production and quality. Always wear your protective gear and follow safety instructions.
Limit caffeine
Limit coffee or other caffeine-containing beverages to 1 or 2 drinks per day.
Avoid harmful nutritional supplements
Some types of nutritional supplements have a clearly damaging effect on male infertility. In particular, bodybuilding supplements including “hormone-like” substances such as DHEA or “andro” can actually stop sperm production completely. If you are taking any of these types of supplements, or other products intended to build muscle mass, stop immediately.
Sexual Activity
The likelihood of a woman becoming pregnant is much higher when she has intercourse as close to ovulation as possible. Some experts call the days before and the day of ovulation the “fertile window.” You can estimate the timing by using either basal temperature charts or an over-the-counter ovulation predictor kit which detects the surge of the hormone LH. The frequency of intercourse during the fertile window may make a difference, especially if there are some sperm issues. Some couples simply have relations every other day; others plan a two day period of abstinence before the anticipated ovulation day. The day of ovulation is usually the day after the surge of LH as seen on the urine test.
Avoid the use of any artificial lubricants such as K-Y jelly® or Replens®; Pre-seed is supposed to be conception-friendly. It also may help to have the woman not get up for at least 20 minutes to allow the sperm to begin to penetrate the cervical mucus.
Exercise
Moderate exercise may be beneficial for reducing stress. However, prolonged, competitive-level exercise may be just as bad as no exercise at all - so the key is moderation.
Proper diet
Just like your mother used to tell you, eating a healthy balanced diet is always a good idea. Here are some dietary specifics:
Nutrients and Male Infertility
Vitamins C and E -are essential antioxidants that protect the body’s cells from damage from oxidative stress and free radicals. Vitamin C is the most abundant antioxidant in the semen of fertile men, and it contributes to the maintenance of healthy sperm by protecting the sperm’s DNA from free radical damage. Vitamin E is a fat-soluble vitamin that helps protect the sperm’s cell membrane from damage. Studies have shown that vitamin E improves sperm motility (movement) and morphology (size and shape).
Selenium -is a mineral that functions as an antioxidant. Selenium supplements have been shown to increase sperm motility, and a combination of selenium and vitamin E has shown to decrease damage from free radicals and improve sperm motility in infertile men.
Lycopene -is a powerful antioxidant and carotenoid (plant pigment) that is abundant in tomatoes. This “phytonutrient” is normally found in high levels in the male testes, and research has shown that lycopene supplementation improves sperm parameters in infertile men.
Zinc - is an essential trace mineral that plays a role in sperm formation, testosterone metabolism, and motility. Zinc supplementation increased testosterone levels and sperm count in a study of 22 men, which resulted in 9 pregnancies.
Folic Acid -is a B-vitamin that is necessary for DNA synthesis. Low levels of folic acid have been associated with a decreased sperm count and decreased sperm motility. In an recent study, the combination of zinc and folic acid resulted in a 74% increase in total normal sperm count in subfertile men.
L-Carnitine - is an amino acid produced by the body, and functions to transport fat so that it can be broken down for energy. L-carnitine provides energy for the sperm, and is important for optimal sperm motility. L-carnitine has been shown to increase sperm quality and increase pregnancy rate.
Oxidative Stress and Male Infertility
Recent scientific evidence has revealed that a condition known as “oxidative stress” may, in fact, be a common factor in some of the causes of male and female infertility. Oxidative stress is caused by the presence of certain molecules known as “reactive oxygen species” in the semen. These molecules, which can damage the sperm cell membrane and DNA, are also known as oxidants. Oxidants are normally kept under control by the presence of antioxidants in the semen. Two of the most important antioxidants are vitamins C and E. When the amount of oxidants in the semen exceeds the amount of antioxidants, we say that “oxidative stress” is present. Oxidative stress has been clearly shown to reduce fertility. Some studies have shown that oxidative stress may be present even when a standard semen analysis appears normal.
Choosing a Safe Male Fertility Supplement
Several nutritional supplements are available which claim to promote male fertility. Below are several suggested guidelines to follow:
1. Use a supplement which is produced under the guidance of a scientific or medical advisory panel.
2. Since we know there are many antioxidant pathways which protect sperm, use a supplement which contains several antioxidants.
3. It’s probably best to avoid any supplement with herbal content. (ie., garlic, ginseng, green tea extract, etc.)
4. Since supplement manufacturers are NOT required to test their products for content accuracy or purity, consider supplements which have been third-party certified (NSF or USP).
5. Supplements which meet most of these requirements are: Fertility Blend for Men, Proxeed and Conception XR. There are others. You can search the Internet for more specific information.
For more information visit www.reproductivepartners.com or to schedule an appointment call (877) 273-7763
Tuesday, January 27, 2009
Age and Ovarian Reserve: Predictors of Fertility Treatment Success
One of the biggest challenges in fertility treatment is the age-related decline in female fertility. It has been long recognized that pregnancy rates decline significantly as a function of chronological age. Decreased rates of conception as well as increased rates of miscarriage contribute to the significantly reduced probability of live births in women approaching age forty and older.
In populations where contraception is not used, the average age of the woman at the birth of the last child is only 40-41 in spite of the fact that women tend to have regular menstrual cycles nearly until menopause (average age 51). This decline in pregnancy rate is observed in natural conceptions as well as in advanced therapies such as in vitro fertilization (IVF). Although a decline in fertility is observed as early as age 30, this decline is relatively subtle until the late 30’s, after which fertility declines rapidly such that by age 45, the chance of a healthy childbirth is remote.
The underlying cause of age-related infertility is the increased tendency for the eggs of older women to result in chromosomally abnormal embryos. Abnormalities in the meiotic spindle (the apparatus that moves the chromosomes) may result in abnormal chromosome arrangements even prior to fertilization.
Thus in older reproductive-age women, a significant proportion of embryos (fertilized eggs) are chromosomally abnormal. Due to these abnormalities, these embryos are less likely to implant in the uterus. If they do implant, the pregnancy is more likely to result in miscarriage. Likewise, chromosomal abnormalities such as Down syndrome (trisomy 21) increase with advancing maternal age. These age-related abnormalities can be detected by prenatal testing such as early ultrasound with blood tests, chorionic villus sampling or amniocentesis. Results of IVF treatment with donor eggs provide the most compelling evidence that poor egg quality is the cause of age-related infertility. Pregnancy and miscarriage rates after egg donation correlate with the age of the egg donor, but not the recipient. National outcome data for IVF using the woman’s own eggs versus donated eggs show a steep age-related decline in live birth rate when a woman’s own eggs are used. This age-related decline disappears in donor egg recipients where the average age of the donor is relatively constant.
As a woman ages, there is a progressive loss of eggs and follicles (the structures that contain the eggs) through a process called “atresia”. By menopause, few or no eggs remain in the ovaries. At any given age, the number of eggs remaining (“ovarian reserve”) varies considerably among individual women.
Measures of ovarian reserve are available to assess relative “reproductive age” as opposed to chronological age. Ovarian reserve tests include blood tests such as FSH, estradiol, inhibin B and anti-mullerian hormone, as well as ultrasound assessment of the small follicles within the ovaries (antral follicle count). Women with low ovarian reserve have increased levels of FSH and/or estradiol, decreased levels of inhibin B and ntimullerian hormone, and/or decreased antral follicle count. Increased FSH helps to compensate for a poorly responsive ovary. Therefore, women may continue to have regular (often shorter) menstrual cycles in spite of significant loss of ovarian reserve.
Women with elevated FSH have lower pregnancy rates and do not respond as well to fertility medications, regardless of their age. Elevated FSH is a sign that the ovary is resistant to FSH usually due to lower numbers of eggs available. Consequently,
FSH elevation is a predictor of poor ovarian response to injectable fertility drugs (gonadotropins) with subsequent low numbers of developing follicles, eggs retrieved, and embryos available for transfer.
At Reproductive Partners, blood levels of FSH and estradiol, obtained on day 2 or 3 of the menstrual cycle, have provided the most utilized and reliable tests of ovarian reserve and treatment outcome. The antral follicle count may be a better predictor of ovarian response to gonadotropin stimulation.
Women with elevated FSH have lower success rates with IVF treatment. In fact, women with FSH elevation have traditionally been discouraged from participating in IVF treatment. There is no doubt that women with decreased ovarian reserve have a greater chance of cycle cancellation due to poor ovarian response (inadequate number of follicles for successful egg retrieval), lower numbers of eggs retrieved, and fewer embryos available for transfer. However, young women with decreased ovarian reserve have significantly greater implantation rate per embryo transferred than older women with similar ovarian reserve. In fact, some studies indicate that implantation rates are not significantly different than age-matched women with normal ovarian reserve testing. The conclusion from these studies is that chronological age may be a better predictor of oocyte quality and implantation rates than basal FSH level.
In conclusion, female fertility declines with age, and age is the most important predictor of treatment success. Ovarian reserve testing is an important indicator of response to treatment and pregnancy rates, and it is a recommended component of an infertility evaluation. However, most evidence indicates that FSH levels are more predictive of response to stimulation than of pregnancy rates, particularly in younger (< age 38) women. Caution should be exercised when applying strict FSH cutoffs, particularly for younger women who wish to pursue IVF treatment. It is appropriate to offer these women a trial of in vitro fertilization treatment, provided that they are carefully counseled about overall lower success due to cycle cancellation and fewer embryos from which to select for transfer. At Reproductive Partners we do not have arbitrary FSH cutoff levels above which we will not do IVF.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
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 infertility treatments please visit www.reproductivepartners.com.
In populations where contraception is not used, the average age of the woman at the birth of the last child is only 40-41 in spite of the fact that women tend to have regular menstrual cycles nearly until menopause (average age 51). This decline in pregnancy rate is observed in natural conceptions as well as in advanced therapies such as in vitro fertilization (IVF). Although a decline in fertility is observed as early as age 30, this decline is relatively subtle until the late 30’s, after which fertility declines rapidly such that by age 45, the chance of a healthy childbirth is remote.
The underlying cause of age-related infertility is the increased tendency for the eggs of older women to result in chromosomally abnormal embryos. Abnormalities in the meiotic spindle (the apparatus that moves the chromosomes) may result in abnormal chromosome arrangements even prior to fertilization.
Thus in older reproductive-age women, a significant proportion of embryos (fertilized eggs) are chromosomally abnormal. Due to these abnormalities, these embryos are less likely to implant in the uterus. If they do implant, the pregnancy is more likely to result in miscarriage. Likewise, chromosomal abnormalities such as Down syndrome (trisomy 21) increase with advancing maternal age. These age-related abnormalities can be detected by prenatal testing such as early ultrasound with blood tests, chorionic villus sampling or amniocentesis. Results of IVF treatment with donor eggs provide the most compelling evidence that poor egg quality is the cause of age-related infertility. Pregnancy and miscarriage rates after egg donation correlate with the age of the egg donor, but not the recipient. National outcome data for IVF using the woman’s own eggs versus donated eggs show a steep age-related decline in live birth rate when a woman’s own eggs are used. This age-related decline disappears in donor egg recipients where the average age of the donor is relatively constant.
As a woman ages, there is a progressive loss of eggs and follicles (the structures that contain the eggs) through a process called “atresia”. By menopause, few or no eggs remain in the ovaries. At any given age, the number of eggs remaining (“ovarian reserve”) varies considerably among individual women.
Measures of ovarian reserve are available to assess relative “reproductive age” as opposed to chronological age. Ovarian reserve tests include blood tests such as FSH, estradiol, inhibin B and anti-mullerian hormone, as well as ultrasound assessment of the small follicles within the ovaries (antral follicle count). Women with low ovarian reserve have increased levels of FSH and/or estradiol, decreased levels of inhibin B and ntimullerian hormone, and/or decreased antral follicle count. Increased FSH helps to compensate for a poorly responsive ovary. Therefore, women may continue to have regular (often shorter) menstrual cycles in spite of significant loss of ovarian reserve.
Women with elevated FSH have lower pregnancy rates and do not respond as well to fertility medications, regardless of their age. Elevated FSH is a sign that the ovary is resistant to FSH usually due to lower numbers of eggs available. Consequently,
FSH elevation is a predictor of poor ovarian response to injectable fertility drugs (gonadotropins) with subsequent low numbers of developing follicles, eggs retrieved, and embryos available for transfer.
At Reproductive Partners, blood levels of FSH and estradiol, obtained on day 2 or 3 of the menstrual cycle, have provided the most utilized and reliable tests of ovarian reserve and treatment outcome. The antral follicle count may be a better predictor of ovarian response to gonadotropin stimulation.
Women with elevated FSH have lower success rates with IVF treatment. In fact, women with FSH elevation have traditionally been discouraged from participating in IVF treatment. There is no doubt that women with decreased ovarian reserve have a greater chance of cycle cancellation due to poor ovarian response (inadequate number of follicles for successful egg retrieval), lower numbers of eggs retrieved, and fewer embryos available for transfer. However, young women with decreased ovarian reserve have significantly greater implantation rate per embryo transferred than older women with similar ovarian reserve. In fact, some studies indicate that implantation rates are not significantly different than age-matched women with normal ovarian reserve testing. The conclusion from these studies is that chronological age may be a better predictor of oocyte quality and implantation rates than basal FSH level.
In conclusion, female fertility declines with age, and age is the most important predictor of treatment success. Ovarian reserve testing is an important indicator of response to treatment and pregnancy rates, and it is a recommended component of an infertility evaluation. However, most evidence indicates that FSH levels are more predictive of response to stimulation than of pregnancy rates, particularly in younger (< age 38) women. Caution should be exercised when applying strict FSH cutoffs, particularly for younger women who wish to pursue IVF treatment. It is appropriate to offer these women a trial of in vitro fertilization treatment, provided that they are carefully counseled about overall lower success due to cycle cancellation and fewer embryos from which to select for transfer. At Reproductive Partners we do not have arbitrary FSH cutoff levels above which we will not do IVF.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
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 infertility treatments please visit www.reproductivepartners.com.
Wisdom from Wisot - Redbook Magazine Fertility Q & A
Wisdom from Wisot Wednesdays, Round 13! - Reprint from Redbook’s Fertility Diaries
Hello, all, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. LOTS of great questions this week, and, at the end, a follow-up to a question posed by the doctor last week. 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: Hello, Dr. Wisot. I am almost 36 years old, and I have tried Clomid and done 3.5 IUI's with injectibles, all unsuccessful (the half was one that was stopped because of too many cysts). I also had a large fibroid removed and laproscopy surgery to remove some cysts and scar tissue. I would like to try IVF, however my insurance doesn't cover any of it so it will be a real hardship financially, but I feel we need to try now before I get too old. My RE stated my issue is low ovarian reserve, my FSH level was 7 but my Estradiol levels have been pretty high. My question is, can you give some advice on what FSH levels, Estradiol & Progesterone levels would be okay for IVF and what levels aren't really worth trying? We will only have one shot at IVF and will go into debt for that one shot.
Answer: For IVF at 36, I would like to see a Day 3 FSH of under 10; probably not above 13. Estrogen levels should be under 80; ideally under 40, as a high baseline estradiol can also be a sign of ovarian reserve issues. Progesterone is not an issue because your progesterone will likely be supplemented during an IVF cycle. Another way of looking at ovarian reserve is the count of early (antral) follicles on Day 2-3. Ask your doctor to put this all in perspective for you regarding your chances.
Question #2: Dr. Wisot, I'm 35 years old, will turn 36 in March. I've been TTC since Oct '07 with all negative pregnancy tests. I am officially unexplained infertility. I've had 3 cycles of Femara with timed intercourse, and am on my 2nd cycle of Clomid and IUI. I've been a good responder to both Femara and Clomid. I had 4 follicles (10, 12, 13, 15mm) during my mid-cycle ultrasound on my first IUI. How many IUIs should I continue to have? And if we decide to go with IVF, what are the pros and cons of minimal stimulation IVF? Religiously, we are not certain we can go with the standard IVF. Thank you.
Answer: Generally in infertility, if a treatment is to have a good chance of working it will occur in three tries. I am seeing more couples with unexplained moving to IVF rather than injectable fertility drugs with IUI after Clomid fails because you have more control over multiple pregnancy and if three cycles of injectable fertility drugs fail, you will be facing IVF anyway. We have reduced our stimulation in recent years as we are transferring fewer embryos and in fact doing more elective single embryo transfers (SET) to avoid multiples. I don't know how you define "minimal," but your most cost-effective approach is to get pregnant in the first cycle so you need to create enough eggs to try to make that happen.
Question #3: We conceived our daughter our second month on Clomid (Month 1: 50 mg, no ovulation; Month 2: 100 mg, our daughter). I am nursing her and she is 14 months old. When she was 6 months old, I tried Clomid because we have always wanted our kids close in age (my periods hadn't returned with the breastfeeding, but we induced with provera and did Clomid 100 mg). The result was a late ovulation (Day 20) with only an 8-day luteal phase. We decided to wait to try Clomid again until she was nursing less.
However, the next month I was thrilled to ovulate on my own (albeit late–Day 28–with only a 7-day luteal phase). I have PCOS and considered that remarkable! The following month (no meds) it took me 50 days to ovulate, but my luteal phase was 13 days.
Hopeful that the ovulations and sufficient luteal phase meant increased fertility for me, we went back to the doctor and did another round of Clomid 100 mg. No dice; mid-cycle scan didn't look good and I never ovulated. We tried Clomid 100 mg again the next month and I had one 19mm follicle at my mid-cycle scan, but never ovulated it.
I’m confused. My body appeared to respond better without Clomid than with it. How did my body respond better to Clomid (at 6 months) when my daughter was breastfeeding significantly more? Since I had ovulated on my own and my luteal phase became sufficient, does this mean my daughter's breastfeeding is not the interfering factor? What would you suggest we do in order to get pregnant? I am 30. Thank you so much for taking our questions! It is greatly appreciated! Have a great day!
Answer: Understanding the benefits of nursing, how about waiting until you stop completely before you use hormonal means to try to conceive? Nursing increases prolactin levels which causes poor progesterone levels and a shortened luteal phase which happened to you with the Clomid. Also what about the exposure of your daughter to the Clomid? I usually tell my patients to stop nursing before using any hormonal treatment methods. I can't explain why you are having better cycles without the Clomid but at age 30 I would not use it anyway until you wean completely.
Question #4: In June 2005 I was diagnosed with PCOS and began taking Clomid to induce ovulation so I could get pregnant. To determine if I was ovulating, my doctor had me get my progesterone level checked at CD23. I only ovulated during two of the nine cycles I took Clomid (luckily, the last cycle my gyn was willing to prescribe it, I got pregnant). Recently a friend told me there is an increased risk of ovarian cancer with taking Clomid for more than three cycles. Is there any truth to this? Would I be further increasing my chances of cancer if I were to try Clomid again?
Answer: No. That has been shown to not be true. It actually applied to all fertility drugs, but women who ever conceived had the average risk. Then they found that many of the women who never conceived had a genetic reason for the infertility which is the same as the gene for early breast and ovarian cancer. The example of this was Gilda Radner, who described in her book, It's Always Something, her embryo transfer by my partner, Dr. David Meldrum (he's the sandy-haired Protestant) and then sadly developed ovarian cancer. Her efforts led to the discovery of the BCRA-1 and 2 gene which now can be tested for. To make a long story short—you have conceived, so, "Never mind."
Question #5: Dr Wisot, thank you for taking the time to answer our questions. I probably will be asked to wean my daughter before beginning a new round of IVF. What is the reason for weaning? Is it the drugs in the breastmilk? Hormone fluctuations or uterine contractions that can occur with nursing? If ovulation (monitored by basal temps and cervical mucus) and menses are occurring regularly while I still breastfeed, can I assume normal fertility has returned? Thanks again for your insight.
Answer: This must be, "I Am Breastfeeding and Want to Get Pregnant Week." It's as I explained above; it can cause a luteal phase defect and you don't want the drugs to cross over to the baby.
Question #6: Hi. I wanted to get your opinion on embryo defragmentation as a technique to help embryo quality. On my first (unsuccessful) IVF I had three day-3 embryos transferred and they were all poor quality with lots of fragmentation. I had never heard of embryo defragmentation before, and I'm having a hard time finding any information on it. From what I understand it's a manual process done only by highly skilled labs (mine doesn't do it). But I can not find any stats, risks, indications, or other information on the internet about it, and I've only found a few IVF clinics across the country who seem to perform it based on their websites. What is your opinion of this procedure, and can you point me to any resources that I can use to research this further?
Also, do you know of any resources where I can find out about IVF studies being conducted that might pay for some/all of the procedure/drugs—a centralized website where the studies are registered or listed? Thank you so much!
Answer: Now this is a technical question. Very sophisticated; you've done your homework. The reason you can't find much on it is that there is really not a good study showing that it's effective. There is a retrospective study suggesting a benefit [Keltz, et al (Fertility and Sterility) F&S 2006; 86:321], and there is one randomized study with frozen embryos showing a benefit (Nagy ZP, et al F&S 2005; 84:1606)but these are not at the highest level of evidence. Fragments can occur when the cells divide and it's a sign of poorer embryo quality. Our embryologists do fragment removal in selected cases, but your question has inspired one of my partners when I mentioned it to him to look further into the issue so you did some good with your question. The real effort for your doctor should be to try strategies to try to improve your embryo quality if it has not already been done.
To your second question, there is no central resource which has IVF studies currently being conducted which offer some compensation for the study patients. You can call around to centers in your area and ask them if they are doing one. We are currently doing the study I mentioned in previous posts and it's a great one to join as it's an easier delivery method of progesterone and you get compensated for filling out the forms and help medical science.
And last but not least, a follow-up. Last week, Dr. Wisot asked a potential egg donor what she guessed might be the most frequent complication of egg donation. Here's her (very funny) answer, and Dr. Wisot's response:
Reader: I appreciate that Dr. Wisot assigned me homework during my winter break lol. I'll take a guess and assume that the most common complications for egg donors are pain and infection. If I'm incorrect, don't hold it against me—I'm a History major, not Pre-Med :)
Dr. Wisot: It's a good guess, but not correct. The correct answer: pregnancy in the donor. Although we instruct donors not to have relations from the start of the fertility drugs until their period after the cycle, apparently not all of them know what that means. Or maybe we should be talking to their significant others. You will make a fine history major.
Hello, all, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. LOTS of great questions this week, and, at the end, a follow-up to a question posed by the doctor last week. 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: Hello, Dr. Wisot. I am almost 36 years old, and I have tried Clomid and done 3.5 IUI's with injectibles, all unsuccessful (the half was one that was stopped because of too many cysts). I also had a large fibroid removed and laproscopy surgery to remove some cysts and scar tissue. I would like to try IVF, however my insurance doesn't cover any of it so it will be a real hardship financially, but I feel we need to try now before I get too old. My RE stated my issue is low ovarian reserve, my FSH level was 7 but my Estradiol levels have been pretty high. My question is, can you give some advice on what FSH levels, Estradiol & Progesterone levels would be okay for IVF and what levels aren't really worth trying? We will only have one shot at IVF and will go into debt for that one shot.
Answer: For IVF at 36, I would like to see a Day 3 FSH of under 10; probably not above 13. Estrogen levels should be under 80; ideally under 40, as a high baseline estradiol can also be a sign of ovarian reserve issues. Progesterone is not an issue because your progesterone will likely be supplemented during an IVF cycle. Another way of looking at ovarian reserve is the count of early (antral) follicles on Day 2-3. Ask your doctor to put this all in perspective for you regarding your chances.
Question #2: Dr. Wisot, I'm 35 years old, will turn 36 in March. I've been TTC since Oct '07 with all negative pregnancy tests. I am officially unexplained infertility. I've had 3 cycles of Femara with timed intercourse, and am on my 2nd cycle of Clomid and IUI. I've been a good responder to both Femara and Clomid. I had 4 follicles (10, 12, 13, 15mm) during my mid-cycle ultrasound on my first IUI. How many IUIs should I continue to have? And if we decide to go with IVF, what are the pros and cons of minimal stimulation IVF? Religiously, we are not certain we can go with the standard IVF. Thank you.
Answer: Generally in infertility, if a treatment is to have a good chance of working it will occur in three tries. I am seeing more couples with unexplained moving to IVF rather than injectable fertility drugs with IUI after Clomid fails because you have more control over multiple pregnancy and if three cycles of injectable fertility drugs fail, you will be facing IVF anyway. We have reduced our stimulation in recent years as we are transferring fewer embryos and in fact doing more elective single embryo transfers (SET) to avoid multiples. I don't know how you define "minimal," but your most cost-effective approach is to get pregnant in the first cycle so you need to create enough eggs to try to make that happen.
Question #3: We conceived our daughter our second month on Clomid (Month 1: 50 mg, no ovulation; Month 2: 100 mg, our daughter). I am nursing her and she is 14 months old. When she was 6 months old, I tried Clomid because we have always wanted our kids close in age (my periods hadn't returned with the breastfeeding, but we induced with provera and did Clomid 100 mg). The result was a late ovulation (Day 20) with only an 8-day luteal phase. We decided to wait to try Clomid again until she was nursing less.
However, the next month I was thrilled to ovulate on my own (albeit late–Day 28–with only a 7-day luteal phase). I have PCOS and considered that remarkable! The following month (no meds) it took me 50 days to ovulate, but my luteal phase was 13 days.
Hopeful that the ovulations and sufficient luteal phase meant increased fertility for me, we went back to the doctor and did another round of Clomid 100 mg. No dice; mid-cycle scan didn't look good and I never ovulated. We tried Clomid 100 mg again the next month and I had one 19mm follicle at my mid-cycle scan, but never ovulated it.
I’m confused. My body appeared to respond better without Clomid than with it. How did my body respond better to Clomid (at 6 months) when my daughter was breastfeeding significantly more? Since I had ovulated on my own and my luteal phase became sufficient, does this mean my daughter's breastfeeding is not the interfering factor? What would you suggest we do in order to get pregnant? I am 30. Thank you so much for taking our questions! It is greatly appreciated! Have a great day!
Answer: Understanding the benefits of nursing, how about waiting until you stop completely before you use hormonal means to try to conceive? Nursing increases prolactin levels which causes poor progesterone levels and a shortened luteal phase which happened to you with the Clomid. Also what about the exposure of your daughter to the Clomid? I usually tell my patients to stop nursing before using any hormonal treatment methods. I can't explain why you are having better cycles without the Clomid but at age 30 I would not use it anyway until you wean completely.
Question #4: In June 2005 I was diagnosed with PCOS and began taking Clomid to induce ovulation so I could get pregnant. To determine if I was ovulating, my doctor had me get my progesterone level checked at CD23. I only ovulated during two of the nine cycles I took Clomid (luckily, the last cycle my gyn was willing to prescribe it, I got pregnant). Recently a friend told me there is an increased risk of ovarian cancer with taking Clomid for more than three cycles. Is there any truth to this? Would I be further increasing my chances of cancer if I were to try Clomid again?
Answer: No. That has been shown to not be true. It actually applied to all fertility drugs, but women who ever conceived had the average risk. Then they found that many of the women who never conceived had a genetic reason for the infertility which is the same as the gene for early breast and ovarian cancer. The example of this was Gilda Radner, who described in her book, It's Always Something, her embryo transfer by my partner, Dr. David Meldrum (he's the sandy-haired Protestant) and then sadly developed ovarian cancer. Her efforts led to the discovery of the BCRA-1 and 2 gene which now can be tested for. To make a long story short—you have conceived, so, "Never mind."
Question #5: Dr Wisot, thank you for taking the time to answer our questions. I probably will be asked to wean my daughter before beginning a new round of IVF. What is the reason for weaning? Is it the drugs in the breastmilk? Hormone fluctuations or uterine contractions that can occur with nursing? If ovulation (monitored by basal temps and cervical mucus) and menses are occurring regularly while I still breastfeed, can I assume normal fertility has returned? Thanks again for your insight.
Answer: This must be, "I Am Breastfeeding and Want to Get Pregnant Week." It's as I explained above; it can cause a luteal phase defect and you don't want the drugs to cross over to the baby.
Question #6: Hi. I wanted to get your opinion on embryo defragmentation as a technique to help embryo quality. On my first (unsuccessful) IVF I had three day-3 embryos transferred and they were all poor quality with lots of fragmentation. I had never heard of embryo defragmentation before, and I'm having a hard time finding any information on it. From what I understand it's a manual process done only by highly skilled labs (mine doesn't do it). But I can not find any stats, risks, indications, or other information on the internet about it, and I've only found a few IVF clinics across the country who seem to perform it based on their websites. What is your opinion of this procedure, and can you point me to any resources that I can use to research this further?
Also, do you know of any resources where I can find out about IVF studies being conducted that might pay for some/all of the procedure/drugs—a centralized website where the studies are registered or listed? Thank you so much!
Answer: Now this is a technical question. Very sophisticated; you've done your homework. The reason you can't find much on it is that there is really not a good study showing that it's effective. There is a retrospective study suggesting a benefit [Keltz, et al (Fertility and Sterility) F&S 2006; 86:321], and there is one randomized study with frozen embryos showing a benefit (Nagy ZP, et al F&S 2005; 84:1606)but these are not at the highest level of evidence. Fragments can occur when the cells divide and it's a sign of poorer embryo quality. Our embryologists do fragment removal in selected cases, but your question has inspired one of my partners when I mentioned it to him to look further into the issue so you did some good with your question. The real effort for your doctor should be to try strategies to try to improve your embryo quality if it has not already been done.
To your second question, there is no central resource which has IVF studies currently being conducted which offer some compensation for the study patients. You can call around to centers in your area and ask them if they are doing one. We are currently doing the study I mentioned in previous posts and it's a great one to join as it's an easier delivery method of progesterone and you get compensated for filling out the forms and help medical science.
And last but not least, a follow-up. Last week, Dr. Wisot asked a potential egg donor what she guessed might be the most frequent complication of egg donation. Here's her (very funny) answer, and Dr. Wisot's response:
Reader: I appreciate that Dr. Wisot assigned me homework during my winter break lol. I'll take a guess and assume that the most common complications for egg donors are pain and infection. If I'm incorrect, don't hold it against me—I'm a History major, not Pre-Med :)
Dr. Wisot: It's a good guess, but not correct. The correct answer: pregnancy in the donor. Although we instruct donors not to have relations from the start of the fertility drugs until their period after the cycle, apparently not all of them know what that means. Or maybe we should be talking to their significant others. You will make a fine history major.
Monday, January 19, 2009
Tubal Disease, Hydrosalpinges and Infertility
Approximately 25% of female infertility is due to blockage of the fallopian tubes. The fallopian tubes are very delicate structures that are responsible for picking up the egg and providing the site for fertilization and early embryo development. The tube is narrowest at the inner portion that joins the uterus and then widens in the outer portion that has ¬ne projections called ¬mbria. The ¬mbria are responsible for picking up the egg. The cells lining the tube produce secretions that nourish the egg and embryo. The tubes can frequently be damaged by infections (e.g., chlamydia, gonnorrhea) or other pelvic conditions such as endometriosis or even severe appendicitis. Scar tissue and blockage can occur at either the inner or outer portion or in both of those regions. If blockage occurs at the outer portion, tubal secretions will not be able to drain out of the end of the tube and can be retained in the tube (hydrosalpinx). If the tube is open at the uterine end, those embryotoxic secretions can drain back into the uterus, impairing implantation or result in the miscarriage of an implanted pregnancy.
There are two di erent approaches to treating infertility that results from tubal damage. If there is mild damage, surgical repair can be attempted. If there is severe damage, the results of surgery are frequently poor and IVF (in vitro fertilization) is recommended to bypass the damaged fallopian tubes. The success rate of surgical treatment of a tube that has become a hydrosalpinx is usually very low.
The IVF process includes 4 steps designed to bypass the fallopian tubes:
1. Stimulation of the ovaries with fertility drugs to produce multiple eggs (ovulation induction.)
2. Retrieval of eggs from the ovary. This is performed by placing a needle through the upper vagina into the ovary under ultrasound guidance using deep sedation or spinal analgesia.
3. The eggs are then fertilized with the partner’s sperm.
4. The resulting embryos are allowed to develop in the laboratory for 3-5 days and are then transferred into the uterus.
It would seem that the ability to bypass the tube with IVF makes this the ideal treatment for tubal damage. Careful analysis of the results of this treatment have shown a low rate of success if a hydrosalpinx is present. One of the ¬rst studies showing this e ect was published as early as 1994 by a group from Sweden that found only a 6.6% IVF success rate in the presence of hydrosalpinx compared to 18.2% with tubal disease and no hydrosalpinx.
A paper in January of 1998 showed only four deliveries in women with a hydrosalpinx who had undergone 47 IFV cycles (8.5%.) As a controlled group, there were 97 patients who had tubal disease, but did not have a hydrosalpinx. In this group, there were 44 deliveries in 145 embryo transfers (30.3%.) This striking difference in the success rate seems to confi¬rm the negative effect of the hydrosalpinx. The suspected mechanism of this effect is that the fluid that builds up within the fallopian tube flows backward into the uterus. This fluid can be toxic to the embryos and can have a negative effect on the uterine lining. It stands to reason that the negative effect would be eliminated by preventing the fluid from flowing back into the uterus. Thus, we recommend that laparoscopic surgery or hysteroscopic with Essure plugs be performed on all patients with a hydrosalpinx which communicate with the uterus prior to IVF. Depending on the extent of the tubal damage, we recommend either blocking the tube with cautery or Essure, or removing the damaged tubes.
Twelve women with a hydrosalpinx who had not conceived with previous IVF attempts in that 1998 study had surgery performed. Of 16 subsequent IVF attempts 6 (37.5%) deliveries resulted. Subsequently surgery was performed by the same group on an additional 25 women who had a hydrosalpinx, but had never been through IVF before. Their 29 IVF cycles following the surgery resulted in 15 deliveries (51.7%.) This is very convincing data that surgically treating hydrosalpinx prior to IVF overcomes the negative effect.
The negative effect of hydrosalpinx has been confirmed by the vast majority of the many studies evaluating this issue. This is a very important ¬finding as it may explain why some women with a hydrosalpinx have failed to conceive despite good IVF cycles. Careful consideration should therefore be given to surgically correcting hydrosalpinges prior to attempting any IVF cycle.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
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 infertility treatments please visit www.reproductivepartners.com.
Fertility Q & A - Redbook's Fertility Diaries
Wisdom from Wisot Wednesdays, Round 12! - Reprint from Redbook's Fertility Diaries
January 14, 2009 at 10:00 AM by Cheryl | 3 comments
Hello! Sorry I've been MIA. My Hunky Husband and I took a little vacation. But I'm back just in time for our weekly Q&A with top fertility expert Dr. Arthur Wisot. I love how the questions seem to take on a theme each week. Today's hot topic: egg donation. 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: Hi. I am 34 and have been trying for almost two years. I have done two IUIs with injectables and got pregnant both times, but miscarried. I just did my first IVF. I was on the pill for a month (I get a lot of cysts on my ovaries, they needed to disappear before IVF) then did the flare protocol, using 300 Gonal F, 225 Menopur, and 10 units Lupron. I got 5 follicles but only one had an egg, and that was immature and did not fertilize. I have mild to moderate endometriosis (90% removed in September) and some of it has already returned to my ovaries. FSH 7, AMH around 1. My questions: Since this cycle was a spectacular failure, do you think I should move to donor eggs? Or, do you think the fact I got pregnant from two out of two IUIs is encouraging and I should try once more with a different protocol? Thanks so much.
Answer: I really can't give a good opinion without all the information. But this strikes me as a situation which we see often in women with severe endometriosis. Between the damage the endometriosis does and the surgery to remove it, one may be left with few early follicles capable of stimulation. But with the normal FSH and your response in the two IUI cycles I would guess that the eggs you produce may be good. Maybe IUI is a better treatment for awhile before jumping into another IVF. Sometimes pretreatment before IVF with Lupron for three months or birth control pills with letrozole for two cycles may deal with some of the bad effects of the endometriosis. It's not so much about how many eggs you can make, but to make the best of the few you do make. All the follicles contain eggs and I do not understand why they only retrieved one. That can and does happen but it's more about the maturity of the follicles and the adequacy of the dose of hCG than about endometriosis. Depending on your tolerance for more of this, I would not yet be running to egg donation. But if you are tired of all this and want a quick fix, egg donation might be the way to go.
Question #2: Hi. I'm not actually dealing with infertility, but I'm very interested in your thoughts regarding the risks and benefits of becoming an egg donor. I'm currently a college student, very healthy, and recently became curious about the process. I really like the idea of helping a deserving couple become parents. However, I'd like to know a bit more about the donating process and what the risks and benefits are. Thank you.
Answer: Sounds like you would make a good egg donor. Most of the risks are related to the egg retrieval in which a needle is passed through the vaginal wall into the ovary. Stick a needle in someone and you can cause bleeding, introduce infection or injure some adjacent organ. The other major issue is overstimulation of the ovaries which can vary from a nuisance to a serious medical condition. Fortunately both of these occur very infrequently. We have a 13-page informed consent that the donor has to read and sign that outlines the entire process and risks. The process involves birth control pills, fertility drug injections, ultrasounds, and blood tests and then the egg retrieval under sedation or anesthesia. The most frequent complication of egg donation is...well maybe I'll let you all guess and tell you next week. Post your guess.
Question #3: And one logistical question: I am a So. Cal. girl and was intrigued by Dr. Wisot's post about participation in a national study. Should we just call his offices in the South Bay to try and participate?
Answer: Just call our toll free number (877) 273-7763 and they can have you make a consultation appointment at your nearest Reproductive Partners office in Los Angeles and Orange Counties. We are definitely looking for subjects. You can check out this link to more information about the study.
January 14, 2009 at 10:00 AM by Cheryl | 3 comments
Hello! Sorry I've been MIA. My Hunky Husband and I took a little vacation. But I'm back just in time for our weekly Q&A with top fertility expert Dr. Arthur Wisot. I love how the questions seem to take on a theme each week. Today's hot topic: egg donation. 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: Hi. I am 34 and have been trying for almost two years. I have done two IUIs with injectables and got pregnant both times, but miscarried. I just did my first IVF. I was on the pill for a month (I get a lot of cysts on my ovaries, they needed to disappear before IVF) then did the flare protocol, using 300 Gonal F, 225 Menopur, and 10 units Lupron. I got 5 follicles but only one had an egg, and that was immature and did not fertilize. I have mild to moderate endometriosis (90% removed in September) and some of it has already returned to my ovaries. FSH 7, AMH around 1. My questions: Since this cycle was a spectacular failure, do you think I should move to donor eggs? Or, do you think the fact I got pregnant from two out of two IUIs is encouraging and I should try once more with a different protocol? Thanks so much.
Answer: I really can't give a good opinion without all the information. But this strikes me as a situation which we see often in women with severe endometriosis. Between the damage the endometriosis does and the surgery to remove it, one may be left with few early follicles capable of stimulation. But with the normal FSH and your response in the two IUI cycles I would guess that the eggs you produce may be good. Maybe IUI is a better treatment for awhile before jumping into another IVF. Sometimes pretreatment before IVF with Lupron for three months or birth control pills with letrozole for two cycles may deal with some of the bad effects of the endometriosis. It's not so much about how many eggs you can make, but to make the best of the few you do make. All the follicles contain eggs and I do not understand why they only retrieved one. That can and does happen but it's more about the maturity of the follicles and the adequacy of the dose of hCG than about endometriosis. Depending on your tolerance for more of this, I would not yet be running to egg donation. But if you are tired of all this and want a quick fix, egg donation might be the way to go.
Question #2: Hi. I'm not actually dealing with infertility, but I'm very interested in your thoughts regarding the risks and benefits of becoming an egg donor. I'm currently a college student, very healthy, and recently became curious about the process. I really like the idea of helping a deserving couple become parents. However, I'd like to know a bit more about the donating process and what the risks and benefits are. Thank you.
Answer: Sounds like you would make a good egg donor. Most of the risks are related to the egg retrieval in which a needle is passed through the vaginal wall into the ovary. Stick a needle in someone and you can cause bleeding, introduce infection or injure some adjacent organ. The other major issue is overstimulation of the ovaries which can vary from a nuisance to a serious medical condition. Fortunately both of these occur very infrequently. We have a 13-page informed consent that the donor has to read and sign that outlines the entire process and risks. The process involves birth control pills, fertility drug injections, ultrasounds, and blood tests and then the egg retrieval under sedation or anesthesia. The most frequent complication of egg donation is...well maybe I'll let you all guess and tell you next week. Post your guess.
Question #3: And one logistical question: I am a So. Cal. girl and was intrigued by Dr. Wisot's post about participation in a national study. Should we just call his offices in the South Bay to try and participate?
Answer: Just call our toll free number (877) 273-7763 and they can have you make a consultation appointment at your nearest Reproductive Partners office in Los Angeles and Orange Counties. We are definitely looking for subjects. You can check out this link to more information about the study.
Monday, January 12, 2009
Fertility Q & A - Redbook's Fertility Diaries
Wisdom from Wisot Wednesdays, Reprint from Redbook's Fertility Diaries
January 7, 2009 at 10:00 AM by Cheryl | 6 comments
It's the post you've been waiting for, dear readers: the weekly Q&A with top fertility expert Dr. Arthur Wisot (who's featured in this week's Life & Style, talking about Lance Armstrong's super sperm. Pick up a copy when you buy your Redbook!) Before the questions, 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, I am 30 and my husband is 28. We have been trying to conceive for 4 years. We have both been through all the testing except the post coital test. I was diagnosed with PCOS but have since lost 50 lbs and taken Clomid numerous times. We have been through 3 rounds of IUI with Clomid that my RE felt progressed perfectly but still no pregnancy. My insurance does not cover IVF so we have put that idea on hold. Since our last IUI my husband has lost 60 lbs (and still going) under a doctor's care and I have been working on getting in better shape. We are considering trying IUI again before working on the financials for IVF since we are both much healthier. Is this a good idea or should we just move on? Thank you for your input.
Answer: You are doing great things for both your fertility and your general health. One of the best things a PCOSer (Polycystic Ovarian Syndrome) can do is lose even 5% of their body weight. You have done much more. Another measure to enhance your chances with Clomid would be to ask your doctor to put you on metformin to combat the insulin resistance associated with PCOS. Also ask your doctor to monitor your cycles with ultrasound to make sure the Clomid is being effective (if he/she is not already doing that). With the weight loss, metformin, and monitoring, I would be inclined to try a few more cycles of Clomid with IUI while you get your bodies and finances in shape for IVF.
Question #2: What are your thoughts on the use of alternative medicines or treatments such as acupuncture to assist with fertility treatments? My friend mentioned that she sees an acupunturist and that he told her he can do acupuncture that can assist with infertility treatment.
Answer: Acupuncture has been shown to improve the success rates of IVF. You will see all sorts of claims for acupuncture and herbs. I think it is fine as an adjunct to your fertility treatment, but not a substitute. When I wrote my last book I did a lot of research on acupuncture and herbs and found out that you need to be very careful with herbs because of a great variation in purity. You need to get a good prescription from a doctor of Chinese medicine and obtain them from reliable sources. Mind-Body Connection programs have also been shown to enhance the effects of fertility treatments. Especially if you are feeling stressed (and who going through this isn't?), stress may be playing a role and stress reduction techniques like these may help.
Question #3: My husband and I are both 32 years old. I have PCOS. My RE has me on Clomid (100 mg) to help me ovulate (I wasn't ovulating before) and now for the first time in my life I'm getting a period every month. My husband's first semen analysis came up normal. I've been on the Clomid for six months now, though, and no babies. I'm scheduled for an HSG next month - I've heard that an HSG sometimes raises the chances of conception. Is this true? If so, do you have any percentages? Also, my GP says that I am probably not conceiving because I'm overweight. She first suggested Metformin to help me with that, but then looked at my chart, told me that she couldn't prescribe Metformin because my "liver numbers are elevated" because of being overweight. So should I even be TTC if I have something wrong with my liver? My RE knows about it and isn't advising against it.
Answer: Overweight leading to liver problems? If that isn't a signal to get serious about your weight I don't know what is. That's where I would start. The HSG (tubal dye test) can improve pregnancy rates over the next six months, especially if they inject an oil-based dye after they show your tubes are open. One of my partners (David Meldrum, M.D.) showed that back in the 1980's. I can not tell you how much that will affect your chances because of all the other problems. By the time one gets to six months of Clomid, one can start to experience some of its negative effects like thinning of the lining of the uterus and reduction in cervical mucus. I would ask your doctor if you should take some time off from Clomid, lose the weight, get your liver in good shape and then restart trying the the HSG, metformin and Clomid.
Question #4: I will be 38 and my husband will be 33 soon. I was diagnosed with PCOS and had HSG, laparascopy. Everything was ok. I am taking metformin 500 mg daily. We have been trying to conceive since 2005. First we tried clomid and it didn't work. I have gone through three IUI's with injectables.(not consecutive, cannot afford it) First was unsuccessful as was the last one this past month. The second IUI succeeded, yet ended in miscarriage at 8 weeks. We can't afford to try again until in abouth three months. Is that to long to wait considering my age? Should we do more tests? My husband had a semen analysis in 2005 and everything was fine.I also want to mention that I am about 100 pounds overweight. I want to try and get healthier during the time we raise the money for the IUI, but i know i wont't lose all the weight in a few months and i don't want to lose more time. What do you reccomend?
Answer: Is there a PCOS epidemic this week? It sounds like you have three months to lose as much weight as you can. You've got to get serious about this. It may mean the difference between success and another failed cycle. If you have been trying since 2005, I would be looking at going beyond IUI and consider IVF after you get yourself in better shape. Unless you can't tolerate more, 500 mg is a fairly low dose of metformin. If IVF is out of the question for you, set a goal to lose 30 pounds in the next three months, ask your doctor if it might help to increase the metformin dose and then do another cycle of injectables with IUI. Like the women above, you can do a lot to help yourself.
January 7, 2009 at 10:00 AM by Cheryl | 6 comments
It's the post you've been waiting for, dear readers: the weekly Q&A with top fertility expert Dr. Arthur Wisot (who's featured in this week's Life & Style, talking about Lance Armstrong's super sperm. Pick up a copy when you buy your Redbook!) Before the questions, 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, I am 30 and my husband is 28. We have been trying to conceive for 4 years. We have both been through all the testing except the post coital test. I was diagnosed with PCOS but have since lost 50 lbs and taken Clomid numerous times. We have been through 3 rounds of IUI with Clomid that my RE felt progressed perfectly but still no pregnancy. My insurance does not cover IVF so we have put that idea on hold. Since our last IUI my husband has lost 60 lbs (and still going) under a doctor's care and I have been working on getting in better shape. We are considering trying IUI again before working on the financials for IVF since we are both much healthier. Is this a good idea or should we just move on? Thank you for your input.
Answer: You are doing great things for both your fertility and your general health. One of the best things a PCOSer (Polycystic Ovarian Syndrome) can do is lose even 5% of their body weight. You have done much more. Another measure to enhance your chances with Clomid would be to ask your doctor to put you on metformin to combat the insulin resistance associated with PCOS. Also ask your doctor to monitor your cycles with ultrasound to make sure the Clomid is being effective (if he/she is not already doing that). With the weight loss, metformin, and monitoring, I would be inclined to try a few more cycles of Clomid with IUI while you get your bodies and finances in shape for IVF.
Question #2: What are your thoughts on the use of alternative medicines or treatments such as acupuncture to assist with fertility treatments? My friend mentioned that she sees an acupunturist and that he told her he can do acupuncture that can assist with infertility treatment.
Answer: Acupuncture has been shown to improve the success rates of IVF. You will see all sorts of claims for acupuncture and herbs. I think it is fine as an adjunct to your fertility treatment, but not a substitute. When I wrote my last book I did a lot of research on acupuncture and herbs and found out that you need to be very careful with herbs because of a great variation in purity. You need to get a good prescription from a doctor of Chinese medicine and obtain them from reliable sources. Mind-Body Connection programs have also been shown to enhance the effects of fertility treatments. Especially if you are feeling stressed (and who going through this isn't?), stress may be playing a role and stress reduction techniques like these may help.
Question #3: My husband and I are both 32 years old. I have PCOS. My RE has me on Clomid (100 mg) to help me ovulate (I wasn't ovulating before) and now for the first time in my life I'm getting a period every month. My husband's first semen analysis came up normal. I've been on the Clomid for six months now, though, and no babies. I'm scheduled for an HSG next month - I've heard that an HSG sometimes raises the chances of conception. Is this true? If so, do you have any percentages? Also, my GP says that I am probably not conceiving because I'm overweight. She first suggested Metformin to help me with that, but then looked at my chart, told me that she couldn't prescribe Metformin because my "liver numbers are elevated" because of being overweight. So should I even be TTC if I have something wrong with my liver? My RE knows about it and isn't advising against it.
Answer: Overweight leading to liver problems? If that isn't a signal to get serious about your weight I don't know what is. That's where I would start. The HSG (tubal dye test) can improve pregnancy rates over the next six months, especially if they inject an oil-based dye after they show your tubes are open. One of my partners (David Meldrum, M.D.) showed that back in the 1980's. I can not tell you how much that will affect your chances because of all the other problems. By the time one gets to six months of Clomid, one can start to experience some of its negative effects like thinning of the lining of the uterus and reduction in cervical mucus. I would ask your doctor if you should take some time off from Clomid, lose the weight, get your liver in good shape and then restart trying the the HSG, metformin and Clomid.
Question #4: I will be 38 and my husband will be 33 soon. I was diagnosed with PCOS and had HSG, laparascopy. Everything was ok. I am taking metformin 500 mg daily. We have been trying to conceive since 2005. First we tried clomid and it didn't work. I have gone through three IUI's with injectables.(not consecutive, cannot afford it) First was unsuccessful as was the last one this past month. The second IUI succeeded, yet ended in miscarriage at 8 weeks. We can't afford to try again until in abouth three months. Is that to long to wait considering my age? Should we do more tests? My husband had a semen analysis in 2005 and everything was fine.I also want to mention that I am about 100 pounds overweight. I want to try and get healthier during the time we raise the money for the IUI, but i know i wont't lose all the weight in a few months and i don't want to lose more time. What do you reccomend?
Answer: Is there a PCOS epidemic this week? It sounds like you have three months to lose as much weight as you can. You've got to get serious about this. It may mean the difference between success and another failed cycle. If you have been trying since 2005, I would be looking at going beyond IUI and consider IVF after you get yourself in better shape. Unless you can't tolerate more, 500 mg is a fairly low dose of metformin. If IVF is out of the question for you, set a goal to lose 30 pounds in the next three months, ask your doctor if it might help to increase the metformin dose and then do another cycle of injectables with IUI. Like the women above, you can do a lot to help yourself.
Reproductive Partners Participates in New IVF Progesterone Delivery System Study
Southern California fertility center participates in a national study to explore new IVF progesterone delivery systems replacing intramuscular injections.
Los Angeles, CA January 2009 - Reproductive Partners Medical Group a leading Southern California fertility center esteemed for their excellent IVF success rates and national reputation was recently selected as a participant in a national, multi-center study exploring new progesterone delivery systems to replace intramuscular injections. Patients going through in vitro fertilization (IVF) often describe the progesterone injections as the most difficult and painful part of the IVF cycle. For more than 30 years doctors have been seeking effective alternatives to these painful injections.
The study compares an FDA-approved vaginal progesterone, Endometrin, with a new formulation which is administered subcutaneously, similar to the relatively painless fertility drug injections. Patients will be randomized to receive either the vaginal or subcutaneous progesterone until the pregnancy test and then until about 10 weeks of pregnancy. In case of unacceptable side effects the patient will be offered an alternative medication. Side effects are usually local reactions and mild.
Benefits to patients include free progesterone medications as well as a $1,500 honorarium for participating and completing the study questionnaires.
Participating patients will be IVF candidates, including those undergoing ICSI, Blastocyst and PGD, who are age 18-42 who have had less than three prior IVF cycles and an FSH less than 15IU/L and estradiol less than 80 pg/mL. Other exclusion criteria exist.
For more information, please visit www.reproductivepartners.com or call Reproductive Partners Medical Group at (877) 273-7763.
Los Angeles, CA January 2009 - Reproductive Partners Medical Group a leading Southern California fertility center esteemed for their excellent IVF success rates and national reputation was recently selected as a participant in a national, multi-center study exploring new progesterone delivery systems to replace intramuscular injections. Patients going through in vitro fertilization (IVF) often describe the progesterone injections as the most difficult and painful part of the IVF cycle. For more than 30 years doctors have been seeking effective alternatives to these painful injections.
The study compares an FDA-approved vaginal progesterone, Endometrin, with a new formulation which is administered subcutaneously, similar to the relatively painless fertility drug injections. Patients will be randomized to receive either the vaginal or subcutaneous progesterone until the pregnancy test and then until about 10 weeks of pregnancy. In case of unacceptable side effects the patient will be offered an alternative medication. Side effects are usually local reactions and mild.
Benefits to patients include free progesterone medications as well as a $1,500 honorarium for participating and completing the study questionnaires.
Participating patients will be IVF candidates, including those undergoing ICSI, Blastocyst and PGD, who are age 18-42 who have had less than three prior IVF cycles and an FSH less than 15IU/L and estradiol less than 80 pg/mL. Other exclusion criteria exist.
For more information, please visit www.reproductivepartners.com or call Reproductive Partners Medical Group at (877) 273-7763.
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