This message appeared on the Success Stories section of the RPMG Bulletin Board and I wanted to share it with everybody:
My miracle twin boys are healthy, happy, energetic and almost 4 years old now. Thanks so much to all the Doctors at RPMG. I would like to especially thank the amazing doctors on my team: Dr. Wisot, Dr. Yee and Dr. Meldrum.
My story:
I found RPMG through a RESOLVE support group. This little purple flyer in a doctors office caught my eye, and changed my life.....It was for a support group, for an Organization called RESOLVE - the NATIONAL INFERTILITY ASSOCIATION ( a Non-Profit Organization). The women in the support group had so much information, I was taking lots of notes....they highly recommended RPMG and Dr. Wisot, IVF and acupuncture.
I was a complete rookie, didn't know anything about IUI's, IVF's, I don't know!. The entire staff at RPMG educated me. I soon became a support group leader for RESOLVE and I have referred over 50 patients to RPMG! Almost all of them have children now, thanks to RPMG. There are so many miracle stories from our little support group. I would highly recommend finding one in your neighborhood. Please email with any questions -about RPMG and my wonderful experience with them. My Email: Lisag@sbsdevelop.com.....I also have children's clothing line on the internet: www.wombmates.com - clothing for twins.... Last year, my friend and I bought lunch for the doctors at the Redondo Beach office as a thank you. My girlfriend and I cried, we were so happy...She too is another miracle success story from RPMG.
Friday, March 20, 2009
Thursday, March 19, 2009
Wisdom from Wisot Wednesdays - The Final Round
Reprint from Redbook’s Fertility Diaries
Yes, it's true: I'm sad to say that this is the final installment of Wisdom from Wisot Wednesdays and the Infertility Diaries. You'll still be able to access the archives of past blogs, and everyone's favorite fertility expert, Dr. Arthur Wisot, will continue to take questions at the Reproductive Partners bulletin board (though the questions and answers will have to be a bit shorter over there). It seems only fitting that we're winding down with just one last question. But first, the doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answer is below, in bold. Baby dust to everyone.
Question: Hello, Dr. Wisot. I'm 31 years old and my husband is 35 years old. I have been trying to carry for 10 years already. I was diagnosed with PCOS and endometrial hyperplasia. I was treated with the hyperplasia and was put on Metformin for the PCOS. I started seeing an infertility specialist and he put me on a combination of Clomid and Dexamethasone. After the 4th cycle I was able to get pregnant but ended up to be a blighted ovum pregnancy, so I am going back for another cycle. My concern is that if I had hyperplasia, isn't it risky to let so much time go by for the hyperplasia to come back? Should I be considering other procedures to have done? I know that I can't afford IVF, but do you recommend something else that's less expensive? I was told by my OB-Gyn that I had to get pregnant soon because I've had the hyperplasia come back two years in a row. Please advise, and thank you.
Answer: I don't know what you mean by "so much time." If they start another cycle and get you to ovulate in a matter of a couple of months, it would be unlikely for the hyperplasia (increased growth in the lining of the uterus) to return in that period of time. The hyperplasia is caused by estrogen stimulation without any progesterone effect on the endometrium. So they could try to get you to ovulate again soon or give you monthly progesterone to try to prevent the hyperplasia from coming back while they are waiting to get you started again. Sometimes that hyperplasia can be relentless, so I hope they will get you right back into treatment; usually there is no reason to wait.
I have enjoyed answering all your great questions over the past few months. I wish you all a quick resolution to your infertility.
Yes, it's true: I'm sad to say that this is the final installment of Wisdom from Wisot Wednesdays and the Infertility Diaries. You'll still be able to access the archives of past blogs, and everyone's favorite fertility expert, Dr. Arthur Wisot, will continue to take questions at the Reproductive Partners bulletin board (though the questions and answers will have to be a bit shorter over there). It seems only fitting that we're winding down with just one last question. But first, the doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answer is below, in bold. Baby dust to everyone.
Question: Hello, Dr. Wisot. I'm 31 years old and my husband is 35 years old. I have been trying to carry for 10 years already. I was diagnosed with PCOS and endometrial hyperplasia. I was treated with the hyperplasia and was put on Metformin for the PCOS. I started seeing an infertility specialist and he put me on a combination of Clomid and Dexamethasone. After the 4th cycle I was able to get pregnant but ended up to be a blighted ovum pregnancy, so I am going back for another cycle. My concern is that if I had hyperplasia, isn't it risky to let so much time go by for the hyperplasia to come back? Should I be considering other procedures to have done? I know that I can't afford IVF, but do you recommend something else that's less expensive? I was told by my OB-Gyn that I had to get pregnant soon because I've had the hyperplasia come back two years in a row. Please advise, and thank you.
Answer: I don't know what you mean by "so much time." If they start another cycle and get you to ovulate in a matter of a couple of months, it would be unlikely for the hyperplasia (increased growth in the lining of the uterus) to return in that period of time. The hyperplasia is caused by estrogen stimulation without any progesterone effect on the endometrium. So they could try to get you to ovulate again soon or give you monthly progesterone to try to prevent the hyperplasia from coming back while they are waiting to get you started again. Sometimes that hyperplasia can be relentless, so I hope they will get you right back into treatment; usually there is no reason to wait.
I have enjoyed answering all your great questions over the past few months. I wish you all a quick resolution to your infertility.
Wisdom from Wisot Wednesdays, Round 20!
Reprint from Redbook’s Fertility Diaries
Welcome back to our weekly Q&A with all-around great guy and fertility expert Dr. Arthur Wisot. If you've got a question for Dr. Wisot, just leave it in the Comments section. The doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:
Question #1: Hi, Dr. Wisot. My husband and I are dealing with male factor infertility. Our RE referred us to an urologist who we saw last week. My husband's numbers are pretty low: count 0.3; motility 33%; and morphology 0. When we saw our RE a few weeks ago, the impression that we got was that hopefully (but don't get your hopes too high up), the urologist will be able to find some viable sperm for IVF-ICSI. But the urologist seemed much more encouraging. He is doing blood work - hormones and genetics - but he told us to have two specimens frozen while we wait for the results. He told us that most likely we will be ready for IVF-ICSI in the next few months with two frozen reserves. We got two totally different impressions from the two doctors and I just wanted to get your opinion. Have you seen men with such low numbers have success with ICSI? Thanks.
Answer: All you need for ICSI is the same number of viable sperm that you have eggs. If his count is 300,000 with 33% motility (indicating viability) then you could produce 100,000 eggs and there would be enough sperm. Apparently your husband does produce sperm, so even if they could not get ejaculated sperm on the day of retrieval and the two backups fail, they could always resort to testicular biopsy (TESE). It sounds to me from what you write that you will be OK.
Question #2: I have been off the pill for two years, but only TTC one year. At the end of last October, I had emergency surgery to remove an ectopic pregnancy. They were able to save the ovary and tube, but results from last month's HSG showed that the tube on that side is blocked (although other side looks great), so I would have a 50/50 chance each month, except for the fact that my cycles are quiet irregular, averaging about 1 cycle every two months (going something like a couple of months of normal cycles, skip a month, skip three months). My gynecologist has given me the go ahead to start trying again and suggested seeing an RE if I don't get pregnant within the year, but with the one working tube and irregular cycle combination, I am wondering if I should consider seeing one sooner (my husband and I are both 31).
Answer: You have already had an ectopic pregnancy and now are faced with trying to conceive with irregular cycles and a blocked tube which means that you are going to have far fewer chances to conceive naturally. You also have fewer ovulations in a year than someone who has cycles every month and only those that occur on the good side count. In addition, tracking your ovulation will be difficult. With those odds I would recommend seeing an RE now. Your gynecologist is not in a hurry but I’ll bet you are.
Question #3: Hi, Dr Wisot. I'm 37 years old, trying to conceive two years, with unexplained infertility. We currently have a healthy 3 year old and did not have any problems with conception at that time. Have done two IUI's with Clomid, took one month off and became pregnant on our own, but miscarried after never seeing a heartbeat. My past few cycles I have had bleeding with BM's starting the days after ovulation, lasting about four days. Then two days later I start spotting until my cycle begins. I have not been back to my fertility specialist since last year, but was wondering if I my progesterone levels might be too low. What would be the symptoms of low progesterone? Thank you.
Answer: The signs of low progesterone include shorter luteal phases (the phase after ovulation) and abnormal bleeding in the second half of the cycle. Clomid can increase progesterone levels and lengthen the luteal phase. So I would suggest you go back to the fertility specialist and get this evaluated and treated, if needed.
Question #4: Hello, Dr. Wisot. I'm 26 and my husband is 36, and we have been trying to concieve for 19 months now. I had PCOS but was given Clomid. But instead of a positive pregnancy test, I have been having regular periods for two months and this is the third month. I want to know if there is any chance for me because this will be my last month — or do you advise I go another month because I if I stop Clomid, I don't know if I'll still get my period. Thank you.
Answer: I don’t know what dose you are on. In general women with PCOS (Polycystic Ovarian Syndrome) can benefit from metformin, a medication to reduce insulin resistance, in addition to an ovulation inducing drug like Clomid. Women taking Clomid for problems like no ovulation or infrequent ovulation can take the drugs for more than three months, or switch to another drug. I hope your Clomid cycles were monitored with ultrasound and an ovulation predictor kit to help time your attempts to conceive accurately and that they have made sure there are no other problems in addition to your lack of ovulation. If you feel you are not making progress, consider switching to a reproductive endocrinologist, or if you are already seeing one, get a second opinion.
Question #5: Hi, Dr. Wisot. I'm 36 years old, trying to conceive for 17 months without success. We have unexplained infertility. We've had three IUIs with Clomid, with BFN (big fat negative). The RE is suggesting either a laproscopy to rule out endometriosis (I have no symptoms other than infertility) then IUI, or straight to IVF. Due to religious reasons, IVF is ruled out for us. Should I have the lap and then try IUI again with injectibles? Thank you.
Answer: If you have ruled out IVF, you need to do everything to try to make conventional treatment work. Laparoscopy to rule out and/or treat endometriosis and flush debris out of the pelvis can be helpful. After that you can go back to a couple of cycles of Clomid or move on to injectable drugs with IUI to try to maximize your chances.
Welcome back to our weekly Q&A with all-around great guy and fertility expert Dr. Arthur Wisot. If you've got a question for Dr. Wisot, just leave it in the Comments section. The doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:
Question #1: Hi, Dr. Wisot. My husband and I are dealing with male factor infertility. Our RE referred us to an urologist who we saw last week. My husband's numbers are pretty low: count 0.3; motility 33%; and morphology 0. When we saw our RE a few weeks ago, the impression that we got was that hopefully (but don't get your hopes too high up), the urologist will be able to find some viable sperm for IVF-ICSI. But the urologist seemed much more encouraging. He is doing blood work - hormones and genetics - but he told us to have two specimens frozen while we wait for the results. He told us that most likely we will be ready for IVF-ICSI in the next few months with two frozen reserves. We got two totally different impressions from the two doctors and I just wanted to get your opinion. Have you seen men with such low numbers have success with ICSI? Thanks.
Answer: All you need for ICSI is the same number of viable sperm that you have eggs. If his count is 300,000 with 33% motility (indicating viability) then you could produce 100,000 eggs and there would be enough sperm. Apparently your husband does produce sperm, so even if they could not get ejaculated sperm on the day of retrieval and the two backups fail, they could always resort to testicular biopsy (TESE). It sounds to me from what you write that you will be OK.
Question #2: I have been off the pill for two years, but only TTC one year. At the end of last October, I had emergency surgery to remove an ectopic pregnancy. They were able to save the ovary and tube, but results from last month's HSG showed that the tube on that side is blocked (although other side looks great), so I would have a 50/50 chance each month, except for the fact that my cycles are quiet irregular, averaging about 1 cycle every two months (going something like a couple of months of normal cycles, skip a month, skip three months). My gynecologist has given me the go ahead to start trying again and suggested seeing an RE if I don't get pregnant within the year, but with the one working tube and irregular cycle combination, I am wondering if I should consider seeing one sooner (my husband and I are both 31).
Answer: You have already had an ectopic pregnancy and now are faced with trying to conceive with irregular cycles and a blocked tube which means that you are going to have far fewer chances to conceive naturally. You also have fewer ovulations in a year than someone who has cycles every month and only those that occur on the good side count. In addition, tracking your ovulation will be difficult. With those odds I would recommend seeing an RE now. Your gynecologist is not in a hurry but I’ll bet you are.
Question #3: Hi, Dr Wisot. I'm 37 years old, trying to conceive two years, with unexplained infertility. We currently have a healthy 3 year old and did not have any problems with conception at that time. Have done two IUI's with Clomid, took one month off and became pregnant on our own, but miscarried after never seeing a heartbeat. My past few cycles I have had bleeding with BM's starting the days after ovulation, lasting about four days. Then two days later I start spotting until my cycle begins. I have not been back to my fertility specialist since last year, but was wondering if I my progesterone levels might be too low. What would be the symptoms of low progesterone? Thank you.
Answer: The signs of low progesterone include shorter luteal phases (the phase after ovulation) and abnormal bleeding in the second half of the cycle. Clomid can increase progesterone levels and lengthen the luteal phase. So I would suggest you go back to the fertility specialist and get this evaluated and treated, if needed.
Question #4: Hello, Dr. Wisot. I'm 26 and my husband is 36, and we have been trying to concieve for 19 months now. I had PCOS but was given Clomid. But instead of a positive pregnancy test, I have been having regular periods for two months and this is the third month. I want to know if there is any chance for me because this will be my last month — or do you advise I go another month because I if I stop Clomid, I don't know if I'll still get my period. Thank you.
Answer: I don’t know what dose you are on. In general women with PCOS (Polycystic Ovarian Syndrome) can benefit from metformin, a medication to reduce insulin resistance, in addition to an ovulation inducing drug like Clomid. Women taking Clomid for problems like no ovulation or infrequent ovulation can take the drugs for more than three months, or switch to another drug. I hope your Clomid cycles were monitored with ultrasound and an ovulation predictor kit to help time your attempts to conceive accurately and that they have made sure there are no other problems in addition to your lack of ovulation. If you feel you are not making progress, consider switching to a reproductive endocrinologist, or if you are already seeing one, get a second opinion.
Question #5: Hi, Dr. Wisot. I'm 36 years old, trying to conceive for 17 months without success. We have unexplained infertility. We've had three IUIs with Clomid, with BFN (big fat negative). The RE is suggesting either a laproscopy to rule out endometriosis (I have no symptoms other than infertility) then IUI, or straight to IVF. Due to religious reasons, IVF is ruled out for us. Should I have the lap and then try IUI again with injectibles? Thank you.
Answer: If you have ruled out IVF, you need to do everything to try to make conventional treatment work. Laparoscopy to rule out and/or treat endometriosis and flush debris out of the pelvis can be helpful. After that you can go back to a couple of cycles of Clomid or move on to injectable drugs with IUI to try to maximize your chances.
Wisdom from Wisot Wednesdays, Round 19!
Reprint from Redbook’s Fertility Diaries
Hello, hello, and welcome back to our weekly Q&A with tippy-top fertility expert Dr. Arthur Wisot. If you've got a question for Dr. Wisot, just leave it in the Comments section. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:
Question #1: Dr. Wisot, I have hypothalmic annovulation and my doctor has started me on high doses of Repronex on my last two cycles (both which ended in negative pregnancy test). I responded great, but my doses were like 250units for the first 5-6 days, then 150units for the last 3 days. Followed by IUI. Do you think too high of doses can cause poor egg quality? Should we start at a lower dose?
Answer: The dose needed is dependent on the exact cause of the lack of ovulation. If it's really hypothalamic (the hormones from the hypothalamus are dysfunctional), lower doses of pure FSH will usually work. Pure FSH drugs have no LH; the body manufactures it itself so you don't need extra LH. Repronex has both FSH and LH and the higher doses of LH can affect egg quality. If the problem is hypogondotropic (the body does not produce FSH or LH) then both are needed and in fairly high doses. But based on two cycles you can not assume that this is an egg quality issue. Even at a young age, all this can do is restore you to normal fertility for your age and that would give you a monthly fecundity rate (the rate at which women conceive per cycle at a given age) that would probably give you less than a 50% chance of conceiving in two cycles. It may need more time.
Question #2: Hi, Dr. Wisot. I am writing in reference to this week's #2 question about a husband taking Clomid that increased his sperm count "from 1.5 to 3 million in 12 weeks." Is Clomid often used to increase sperm count? I had asked you a question via this site a few months ago. I am 32, DH 38 diagnosed with male factor: low count. Of 3 sperm analyses his counts were: 2.92, 4.7, 7.1. We are currently in the middle of our 2WW with IVF/ICSI #1 (I'm a nervous wreck!), but in the meantime...would this be an option for us? For him to try the Clomid thing to increase his count? This would be so much more affordable for us. Again, thank you so much...for all that you do! Your shared knowledge and expertise is so greatly appreciated!
Answer: I am not an expert in male fertility so I turned to Dr. Jacob Rajfer, Professor of Urology at the UCLA School of Medicine, who is a male fertility expert extraordinaire. He says that Clomid may be used primarily in men who have both low counts and low testosterone levels. "Clomid is used to increase the testosterone levels within the testicle. This supposedly is "beneficial" for speramatogenesis (making sperm). Since each sperm takes about 70 days to form and then it takes about 12 or so days for it to transit from the testicle to the outside, Clomid should be used for a minimum of 3 months and preferably for 6 months, which includes two full spermatogenic cycles." But let's hope the IVF worked so you will not be confronted with this issue. If it doesn't, ask your doctor if this would be an appropriate course of treatment for your husband.
Hello, hello, and welcome back to our weekly Q&A with tippy-top fertility expert Dr. Arthur Wisot. If you've got a question for Dr. Wisot, just leave it in the Comments section. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:
Question #1: Dr. Wisot, I have hypothalmic annovulation and my doctor has started me on high doses of Repronex on my last two cycles (both which ended in negative pregnancy test). I responded great, but my doses were like 250units for the first 5-6 days, then 150units for the last 3 days. Followed by IUI. Do you think too high of doses can cause poor egg quality? Should we start at a lower dose?
Answer: The dose needed is dependent on the exact cause of the lack of ovulation. If it's really hypothalamic (the hormones from the hypothalamus are dysfunctional), lower doses of pure FSH will usually work. Pure FSH drugs have no LH; the body manufactures it itself so you don't need extra LH. Repronex has both FSH and LH and the higher doses of LH can affect egg quality. If the problem is hypogondotropic (the body does not produce FSH or LH) then both are needed and in fairly high doses. But based on two cycles you can not assume that this is an egg quality issue. Even at a young age, all this can do is restore you to normal fertility for your age and that would give you a monthly fecundity rate (the rate at which women conceive per cycle at a given age) that would probably give you less than a 50% chance of conceiving in two cycles. It may need more time.
Question #2: Hi, Dr. Wisot. I am writing in reference to this week's #2 question about a husband taking Clomid that increased his sperm count "from 1.5 to 3 million in 12 weeks." Is Clomid often used to increase sperm count? I had asked you a question via this site a few months ago. I am 32, DH 38 diagnosed with male factor: low count. Of 3 sperm analyses his counts were: 2.92, 4.7, 7.1. We are currently in the middle of our 2WW with IVF/ICSI #1 (I'm a nervous wreck!), but in the meantime...would this be an option for us? For him to try the Clomid thing to increase his count? This would be so much more affordable for us. Again, thank you so much...for all that you do! Your shared knowledge and expertise is so greatly appreciated!
Answer: I am not an expert in male fertility so I turned to Dr. Jacob Rajfer, Professor of Urology at the UCLA School of Medicine, who is a male fertility expert extraordinaire. He says that Clomid may be used primarily in men who have both low counts and low testosterone levels. "Clomid is used to increase the testosterone levels within the testicle. This supposedly is "beneficial" for speramatogenesis (making sperm). Since each sperm takes about 70 days to form and then it takes about 12 or so days for it to transit from the testicle to the outside, Clomid should be used for a minimum of 3 months and preferably for 6 months, which includes two full spermatogenic cycles." But let's hope the IVF worked so you will not be confronted with this issue. If it doesn't, ask your doctor if this would be an appropriate course of treatment for your husband.
Wisdom from Wisot Wednesdays Round 18!
Reprint from Redbook’s Fertility Diaries
Hello again, and thanks for your patience! Our favorite fertility expert Dr. Arthur Wisot is back to answer your questions, plus share his thoughts on the Octo-Mom situation. If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:
Question #1: Dr Wisot. I have developed a peritubular cyst from my last cycle with repronex. I am having surgery this week to remove the cyst, but also do "ovarian drilling" to help refresh my ovaries. Do you think this is safe?
Answer: Ovarian drilling in the U.S has been largely abandoned because we have such good medications and IVF as a backup. It involves burning small holes on the thickened surface of the ovary in patients with polycystic ovaries. The main concerns about the procedure is that it may create adhesions to the ovary, creating an additional problem. I asked my new colleague, Dr. Andy Huang, how many he saw in his recently completed training in reproductive endocrinology. His answer was that he has never seen one.
Question #2: Dr. Wisot, once more thank you so much for your time and for all this invaluable information. It is very much appreciated. I am one of those super-lucky women who got and stayed pregnant — recently delivering a full term baby: My husband (who is now 41) and I (I'm 33) were trying to conceive for 3 years. The diagnosis was male factor (hypogonadotropic hypogonadism), though I also have Hashimoto's and possibly other autoimmune issues (positive ANA's) that may have contributed to infertility. We were finally gearing up for IVF with ICSI, but in the mean time my husband was on Clomid to see if it would boost his sperm count a bit ( I remained unmedicated). The sperm count went from 1.5 to 3 million in 12 weeks, and just as we were thinking "it's still abysmal" I got pregnant (!?!?). I just had my baby 3 weeks ago. My question is the following: As I approach my 6-week postpartum appointment with my OB, I know I'm going to get the "contraception talk." I know that I'd like to have a second child one day. Ideally I'd like to wait a bit, but beggars can't be choosers, plus neither my eggs nor my husband's sperm are getting any younger. It just feels so counterintuitive to use contraception: The chances me of getting pregnant (esp. while I'm breastfeeding) still seem close to nil, but why not maximize whatever little chances we have? On the other hand, I know that if we hit the jackpot again and the unimaginable happens and I get pregnant within the next 6 months or so, my chances of miscarriage or preterm labor are greatly increased. I know what an OB's take on this is (use contraception!) but I was wondering what an RE would have to say — especially given my history. I was also wondering: Generally, given my and my husband's history and age, how long after the pregnancy should we wait before proceeding to IVF for #2?
Answer: I think your instincts are correct. But I hope your doctor will not be giving you the contraception talk in this situation. If you don’t mind having your children close together you can throw caution to the wind. I am not aware that one increases the chances of miscarriage or premature labor by having your pregnancies close together unless you have an individual risk factor. Your husband’s age is not a critical issue; success in reproduction is more related to the woman’s age. So enjoy this baby, play around and when you are serious about wanting another get started with treatment again.
Question #3: Dr. Wisot, I am 29, diagnosed with unexplained IF (FSH 3). I am in the middle of my first IVF cycle. They removed 20 eggs. I was feeling great about the process until I learned that only 7 were mature. Of the 7, 5 fertilized and 3 made it to embryos — which were transferred back yesterday (varying grades). I am pretty shocked/upset by the fact that only 7 of the 20 were mature. My RE does not schedule follow through appointments until after the beta. I was just wondering what causes just a low rate of mature eggs. Does this mean I have egg quality issues? Is there anything that can be done to help eggs mature better? Thank you so much for your time.
Answer: This is one of the reasons that having a large number of eggs may not necessarily be a good thing. It may result in triggering early because of rising estrogen levels when many of the eggs may be immature. It is not a reflection of poor egg quality. The way to try to get better egg maturity is that if a new cycle is required to use a less aggressive stimulation protocol. Hopefully one or two of the three transferred will work.
Question #4: Hi, Dr. Wisot. Thank you for taking the time to answer these questions. Mine has to do with when is the appropriate time to test? We are doing our second medicated (150mg Clomid) with FSP-IUI. The doctor I am seeing has his patients do progesterone gel starting two days after the procedure through the 14th day after. They then tell me to test on that 14th day and if it's negative to stop the progesterone so I can get my period. My question is that in talking to other women, the length of time they are told to wait before testing varies from 12 to 17 or 18 days. What is the rationale behind what the number of days it takes before testing? When I asked the office about it they told me that if I didn't have a positive by 14dpiui I wouldn't get one... is that true? I have a hard time believing this because my cycle has always been 30 or 31 days and if I follow their instructions I'm testing at cd28. I do have a second question related to this: if we do get a negative on that 14th day but in fact it's too early to get a positive hpt result will stopping the progesterone gel cause a miscarriage?
Answer: Our rationale for our testing 16 days after ovulation/retrieval is that a blood test at that time is predictive of a successful outcome if the level is above 100. Tests before that may show pregnancy hormone in the blood or urine at the 14 days after ovulation as your doctor has requested. Keep in mind that urine tests can be unreliable. But it probably does not matter much in your case because most doctors don't use progesterone in addition to the Clomid, as the Clomid usually raises progesterone to adequate levels. So if you were pregnant, didn’t get a positive test and stopped the progesterone, it probably would not change anything. The length of your cycle is irrelevant; it’s the number of days after ovulation that counts.
Question #5: Hi, Dr. Wisot. We had our first IUI cycle in January and to our surprise we were pregnant! First beta was 18, then 79, then 954. At 6 weeks we had our first ob ultrasound and the baby was in my tube! Needless to say we were devastated. This was on a Monday, we were given a shot of methotrexate and on Thursday at 3 a.m. we rushed to the hospital in horrible pain and ended up having emergency surgery. My doctor was able to save my tube and he checked for any scar tissue and endometriosis and I didn't have any. I know that once you have one ectopic you have a higher risk of having another; my question is then is it safe to try another IUI cycle since I don't have any scarring and we conceived on our first try or do you recommend going right to IVF? Mind you we are self-pay as our insurance does not cover infertility. Thanks.
Answer: Ectopics suck. The risk of a recurrent ectopic is usually quoted at 10%. But you can fine tune that for you by getting a hysterosalpingogram and checking if your tubes are normal or may have some subtle abnormalities. If they look perfectly normal you would be on the lower risk side. Subtle abnormalities would put you on the higher side and you may want to use IVF although that does not eliminate the possibility of an ectopic; just significantly reduces it.
Question #6: Hi, Dr. Wisot. I am one of the lucky ones — I got pg my first try at IVF. At the time I was a healthy 34-year-old with no fertility troubles. My husband, however, had had cancer, so we ended up doing TSE with a nationally known specialist. We are trying again, and although I am 3 1/2 yrs older, my doctors are not changing my protocol (and I trust them, so that's not my question). My question is this: What other sorts of behavioral changes might improve our odds? I believe that there was a peer-reviewed study that indicated that acupuncture increased implantation and that caffeine has been linked to miscarriage in a minority of cases. I would be willing to hang upside down from a meat-hook for the entire two-week wait if I thought it would help. Our procedure is very costly (we have to relocate with a toddler to NYC) and due to the severity of my husband's IF, we may only have one or two more cycles that we can try. I'd sure love to give my little boy a sibling. Is there anything that you recommend, even from the perspective of a placebo effect? And if you do recommend acupuncture, what do I ask the acupuncturist to do, exactly? Thanks!
Answer: The two alternative methods that seem to improve success rates with IVF are acupuncture and Mind-Body programs. Find an acupuncturist who is trained and experienced in fertility issues and he/she will know what to do. Lifestyle issues usually include stopping smoking, recreational drugs, alcohol and caffeine and while in cycle limit exercise to a moderate recreational level and check any herbal medications with your doctor. I don’t know why you would need to relocate to New York to have IVF as there are now good groups in almost every section of the country.
Question #7: Hi, Dr. Wisot. What do you think of doing a "mock" cycle before a real egg donor cycle? I am researching clinics and one of them requires me to do a mock cycle before I get on the waiting list. They want to see if their drug protocol for getting my uterus ready works on me before they start an actual cycle. Is this really necessary? I have been through so much treatment already, the idea of spending a month stuffing myself with Lupron, estrogen, and progesterone doesn't really appeal. Plus, it will delay things by quite a bit. Also, one thing I've learned from treatment is that my body will not always respond to the same protocol the same way. What are your thoughts on the necessity of a mock cycle? Thanks.
Answer: I think the mock cycle is very important and recommend it to every recipient. The way the uterus responds in other cycles does not necessarily predict how it will on Lupron, estrogen and progesterone. When one is spending all the time and money on a donor egg cycle it is terrible to have to freeze all the embryos if the endometrial response is not adequate and doing that reduces the chance of success. The time it takes can be minimized by doing it just before the actual cycle and staying on Lupron until the real cycle begins. So you only need to do the BCPs and Lupron once.
Regarding Octo-Mom Feedback
Thank you to those of you who took the time to give me your thoughts. It's gratifying to see that people involved in this process understand the issues so well. Now here are my thoughts.
Every few years we are treated to a fertility misadventure that makes for great water-cooler discussion. But it also brings out a knee-jerk response that we need to regulate an entire specialty because of the actions of one ethically misguided physician.
Keep in mind that we know only one fact about the current situation: Nadya Suleman delivered octuplets. All the rest about her life and the doctor who reportedly performed the IVF procedure on her are the subject of anecdotal statements. However, there are mechanisms in place to deal with the questions about her ability to raise her 14 children and the alleged actions of Dr. Michael Kamrava. The Department of Social Services can evaluate her questionable suitability as a mother of 14, some of whom are reportedly disabled. The Medical Board had said they will review the doctor’s actions and if the Standard of Practice has been violated and there has been a potentially disastrous outcome, they can discipline the doctor. There is no need to impose arbitrary restrictions on an entire specialty because of one doctor’s actions. The fact that a recent LA Times article reported that another woman, Rosalind Saxton, wound up going to Dr. Kamrava after three other doctors turned her down, telling her to lose weight first, is testament to the fact that many fertility groups do have patient selection criteria and are acting responsibly.
Fertility is one of the most highly self-regulated of specialties. The Fertility Clinic Success Rate and Certification Act of 1992 requires all IVF centers to report their success rates to the CDC. Those rates, along with the average number of embryos transferred, are posted on the Internet and are available to the public. You cannot find success rates of individual doctors, practices or institutions in most other specialties. The problem is that there is no penalty for not reporting; those practices are just listed as non-reporters. Non-reporters usually say that they do not like the mandated format. That means that the standard format does not present their results in the best light or, more likely, their success rates may not measure up to national averages and they do not want their stats to be audited. Until reporting is truly mandatory, consumers should choose not to patronize non-reporting clinics. Surprisingly, Dr. Kamrava does report. His poor success rates were available to any consumer who bothered to look and should have been a red flag.
It’s true that some European countries have restrictions on the number of embryos that may be transferred. But in those countries, IVF is covered in their national health systems. I would personally have no objection to mandate all centers follow the guidelines, if there was universal insurance or government coverage for fertility treatments in the U.S. In fact, a small number of enlightened insurance companies are now covering IVF and contracting only with selected groups which follow the guidelines and have low high-order multiple pregnancy rates. Insurance coverage would take some of the pressure off patients to demand more embryos be transferred in an attempt to have quicker success because of financial pressures.
So let’s not throw out the babies with the bathwater. We can maintain our reproductive freedom. Informed consumers can do at least as much research when selecting a fertility clinic as they would when purchasing a refrigerator. Reducing the occurrence of multiple pregnancies resulting from fertility treatment relies on a combination of things: on the physicians' responsibility follow guidelines and to educate patients not to push for more drugs and embryos in the hopes of making expensive treatments work faster; on our society to provide insurance benefits for infertility, which will reduce the financial pressure on the patients who demand unsafe measures in order to achieve a quick pregnancy, regardless of the dangers involved; and on state medical boards who can and should hold those physicians who violate guidelines and cause a reproductive nightmare accountable for their actions.
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.
Thursday, March 12, 2009
First Time IUI without Meds or Ultrasound
Excerpt from the 03-12-09 Reproductive Partners Medical Group Bulletin Board
Q. I am 36 yrs old and my husband and I are going in for our first IUI in a matter of days after discovering that our fertility problems were related to his low motility. Being that this is my first time, I have been doing some of my own research so as to try to make it happen! My doctor's office does not use ultrasound to detect and I am not using any fertility meds. So, given that, I have some questions...I want to know how long my husband should abstain from ejaculation before going in with his specimen - is it about 3-5 days? What's best?
A. We usually recommend a 2-4 day interval. A shorter interval helps motility so I usually recommend on the short side when motility is the issue.
Q. Most importantly, I want to know when I should be going in for the IUI - I am only using ovulation strips to detect my LH surge and my doctor's office says to come in the day of the surge, however I have been reading that maybe it is best to come in the day AFTER the surge??? What would you recommend if there is no ultrasound to detect the follicle and it is all natural - no meds?
A. Since the surge occurs 36-44 hours before ovulation we feel the next day makes to most sense.
Q. And using the OPK, can you test first thing in the morning, even if the directions say to wait??
A. The early morning is not the best. We recommend midday to afternoon since most surges occur in the late morning.
Q. Also, how long does the sperm last when washed? Does it have the same lifespan as it would without or is it shorter?
A. Actually often longer. We can see good motility in some men 48 hours later.
Q. Thank you for taking the time to answer all my questions! I appreciate your help to time things as close as possible...My doctors office also only does one treatment vs. a 2nd day follow up, so I want to time it the best I can!!!
A. Good luck.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Redondo Beach, California
Q. I am 36 yrs old and my husband and I are going in for our first IUI in a matter of days after discovering that our fertility problems were related to his low motility. Being that this is my first time, I have been doing some of my own research so as to try to make it happen! My doctor's office does not use ultrasound to detect and I am not using any fertility meds. So, given that, I have some questions...I want to know how long my husband should abstain from ejaculation before going in with his specimen - is it about 3-5 days? What's best?
A. We usually recommend a 2-4 day interval. A shorter interval helps motility so I usually recommend on the short side when motility is the issue.
Q. Most importantly, I want to know when I should be going in for the IUI - I am only using ovulation strips to detect my LH surge and my doctor's office says to come in the day of the surge, however I have been reading that maybe it is best to come in the day AFTER the surge??? What would you recommend if there is no ultrasound to detect the follicle and it is all natural - no meds?
A. Since the surge occurs 36-44 hours before ovulation we feel the next day makes to most sense.
Q. And using the OPK, can you test first thing in the morning, even if the directions say to wait??
A. The early morning is not the best. We recommend midday to afternoon since most surges occur in the late morning.
Q. Also, how long does the sperm last when washed? Does it have the same lifespan as it would without or is it shorter?
A. Actually often longer. We can see good motility in some men 48 hours later.
Q. Thank you for taking the time to answer all my questions! I appreciate your help to time things as close as possible...My doctors office also only does one treatment vs. a 2nd day follow up, so I want to time it the best I can!!!
A. Good luck.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Redondo Beach, California
Tuesday, March 10, 2009
The Basic Infertility Evaluation
The basic elements of an infertility evaluation target ovarian function, tubal and uterine anatomy, ability of the sperm to reach the fallopian tube and male factor.
Improvements in diagnosis and treatment technology are changing the medical experience and chance of success for couples experiencing infertility. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve the couple’s ultimate goal, a healthy baby. Since women are often starting their families at later ages, the initial infertility evaluation in the female has evolved to focus more on ovarian function as an indicator of fertility potential. However, assessments of all the other factors are still important parts of the evaluation.
Following a history and physical examination, the initial tests used to assess the major causes of infertility are:
• Day 2 or 3 FSH (Follicle Stimulating Hormone) and estradiol (estrogen)
• Hysterosalpinogram (tubal dye test) and/or Sonohysterogram (ultrasound)
• Ultrasound to document the time of ovulation
• Post coital test to see if sperm can penetrate the cervical mucus
• Mid-luteal phase progesterone level
• Semen analysis
In the majority of cases this information is enough to indicate the appropriate initial treatment plan. Today laparoscopy is not routinely indicated, because it has the risks of surgery and does not usually change the initial treatment plan. It may be recommended in specific cases if there is suspected endometriosis or tubal disease based on the history, physical findings, ultrasounds or if there are other specific gynecologic reasons to perform this procedure.
When to Test for Infertility
Evaluation of infertility is warranted for a couple when the female partner is older than 35 and has been trying to conceive for 6 months without success. It is also indicated if the female partner is 35 years of age or less after the couple has been trying to conceive for one year. Immediate evaluation and treatment of infertility is warranted in cases of known problems such as anovulation, tubal occlusion, or severe male factor infertility. We also must be aggressive in evaluating and treat women 40 years and greater because of the increased potential for significant loss of ovarian reserve in this age group.
Day 2 or 3 FSH and Estradiol
These hormone levels are drawn on the second or third day of full menstrual flow. The purpose is to evaluate ovarian reserve. Diminished ovarian reserve may be suspected by elevation in either the FSH or the estradiol. An antral (early) follicle count can be used to further clarify the patient’s ovarian reserve. The ovarian reserve essentially tells us whether it is worthwhile to offer treatment to the patient using her own eggs.
The FSH levels will vary somewhat by the endocrine lab and the assay used. Unfortunately the prognosis is based on the highest, but not necessarily the most recent, FSH level. It is advisable to obtain an opinion and possible further testing from an infertility specialist for those patients with abnormal levels, especially those under age 38.
Day 3 FSH Level in relation to Ovarian Reserve*
Ovarian Reserve FSH Levels
Good < 10
Mild Decrease 10-12
Moderate Decrease 12-15
Severe Decrease > 15
*assumes simultaneous D-3 estradiol is <80pg/ml
Hysterosalpingogram & Sonohysterogram
The hysterosalpingogram (HSG) is still the best and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. In addition, a sonohysterogram (ultrasound after saline is placed in the uterus through a catheter) is a relatively non-invasive way of evaluating the uterine cavity alone if intrauterine pathology is suspected, but does not give you any information about tubal patency. Both tests can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps. But, only the HSG can evaluate tubal abnormalities such as occlustions or hydrosalpinges. Abnormalities on an HSG or sonohysterogram may warrant further evaluation with laparoscopy and or hysteroscopy.
Ultrasound
The proper development of the follicle, which contains the egg, and the timing of its release are critical to the evaluation of infertility. Ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.
Post coital test
Once the timing of ovulation is determined accurately, the next step is to asscess if the sperm can penetrate the cervical mucus. When ultrasound and the urine LH kit pinpoint the timing, the couple is instructed to have intercourse and come in the next morning, at which time a microscopic examination of the cervical mucus will show if there is dequate penetration of the sperm.
Midluteal Progesterone
Menstrual cycle regularity and premenstrual symptoms are reliable medical history indicating the probability of ovulation. However, some women ovulate but fail to produce adequate quantities of progesterone (luteal phase deficiency) following ovulation. The clinical tests for ovulation (e.g. temperature chart, positive ovulation predictor kit) are not sufficient to diagnose luteal phase deficiency. We recommend obtaining a progesterone level approximately 8 days after detection of the LH surge.
Semen Analysis
It is important to perform this test early in the infertility evaluation since in at least 40% of couples experiencing infertility the sperm quality will be a factor. The test will identify a potential male factor by checking the semen volume, sperm concentration, motility and morphology (appearance) in a semen sample.
With this streamlined work up, which can be completed within one menstrual cycle, a couple can be efficiently evaluated, specific major causes of infertility identified, and treatment options considered. As with all medical testing, an infertility evaluation must be tailored to each patient’s situation.
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available fertility treatments please visit www.reproductivepartners.com.
Improvements in diagnosis and treatment technology are changing the medical experience and chance of success for couples experiencing infertility. The efficiency and accuracy of the infertility work up is a key factor in developing the appropriate treatment plan to achieve the couple’s ultimate goal, a healthy baby. Since women are often starting their families at later ages, the initial infertility evaluation in the female has evolved to focus more on ovarian function as an indicator of fertility potential. However, assessments of all the other factors are still important parts of the evaluation.
Following a history and physical examination, the initial tests used to assess the major causes of infertility are:
• Day 2 or 3 FSH (Follicle Stimulating Hormone) and estradiol (estrogen)
• Hysterosalpinogram (tubal dye test) and/or Sonohysterogram (ultrasound)
• Ultrasound to document the time of ovulation
• Post coital test to see if sperm can penetrate the cervical mucus
• Mid-luteal phase progesterone level
• Semen analysis
In the majority of cases this information is enough to indicate the appropriate initial treatment plan. Today laparoscopy is not routinely indicated, because it has the risks of surgery and does not usually change the initial treatment plan. It may be recommended in specific cases if there is suspected endometriosis or tubal disease based on the history, physical findings, ultrasounds or if there are other specific gynecologic reasons to perform this procedure.
When to Test for Infertility
Evaluation of infertility is warranted for a couple when the female partner is older than 35 and has been trying to conceive for 6 months without success. It is also indicated if the female partner is 35 years of age or less after the couple has been trying to conceive for one year. Immediate evaluation and treatment of infertility is warranted in cases of known problems such as anovulation, tubal occlusion, or severe male factor infertility. We also must be aggressive in evaluating and treat women 40 years and greater because of the increased potential for significant loss of ovarian reserve in this age group.
Day 2 or 3 FSH and Estradiol
These hormone levels are drawn on the second or third day of full menstrual flow. The purpose is to evaluate ovarian reserve. Diminished ovarian reserve may be suspected by elevation in either the FSH or the estradiol. An antral (early) follicle count can be used to further clarify the patient’s ovarian reserve. The ovarian reserve essentially tells us whether it is worthwhile to offer treatment to the patient using her own eggs.
The FSH levels will vary somewhat by the endocrine lab and the assay used. Unfortunately the prognosis is based on the highest, but not necessarily the most recent, FSH level. It is advisable to obtain an opinion and possible further testing from an infertility specialist for those patients with abnormal levels, especially those under age 38.
Day 3 FSH Level in relation to Ovarian Reserve*
Ovarian Reserve FSH Levels
Good < 10
Mild Decrease 10-12
Moderate Decrease 12-15
Severe Decrease > 15
*assumes simultaneous D-3 estradiol is <80pg/ml
Hysterosalpingogram & Sonohysterogram
The hysterosalpingogram (HSG) is still the best and least invasive method of evaluating the inside of uterine cavity and patency of the fallopian tubes. In addition, a sonohysterogram (ultrasound after saline is placed in the uterus through a catheter) is a relatively non-invasive way of evaluating the uterine cavity alone if intrauterine pathology is suspected, but does not give you any information about tubal patency. Both tests can uncover uterine abnormalities such as intracavitary adhesions, fibroids or polyps. But, only the HSG can evaluate tubal abnormalities such as occlustions or hydrosalpinges. Abnormalities on an HSG or sonohysterogram may warrant further evaluation with laparoscopy and or hysteroscopy.
Ultrasound
The proper development of the follicle, which contains the egg, and the timing of its release are critical to the evaluation of infertility. Ultrasound is a safe, painless and non-invasive way of evaluating this factor and timing subsequent tests.
Post coital test
Once the timing of ovulation is determined accurately, the next step is to asscess if the sperm can penetrate the cervical mucus. When ultrasound and the urine LH kit pinpoint the timing, the couple is instructed to have intercourse and come in the next morning, at which time a microscopic examination of the cervical mucus will show if there is dequate penetration of the sperm.
Midluteal Progesterone
Menstrual cycle regularity and premenstrual symptoms are reliable medical history indicating the probability of ovulation. However, some women ovulate but fail to produce adequate quantities of progesterone (luteal phase deficiency) following ovulation. The clinical tests for ovulation (e.g. temperature chart, positive ovulation predictor kit) are not sufficient to diagnose luteal phase deficiency. We recommend obtaining a progesterone level approximately 8 days after detection of the LH surge.
Semen Analysis
It is important to perform this test early in the infertility evaluation since in at least 40% of couples experiencing infertility the sperm quality will be a factor. The test will identify a potential male factor by checking the semen volume, sperm concentration, motility and morphology (appearance) in a semen sample.
With this streamlined work up, which can be completed within one menstrual cycle, a couple can be efficiently evaluated, specific major causes of infertility identified, and treatment options considered. As with all medical testing, an infertility evaluation must be tailored to each patient’s situation.
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available fertility treatments please visit www.reproductivepartners.com.
Friday, March 6, 2009
Stricter rules on fertility industry debated
Some doctors worry that octuplet mom Nadya Suleman's case may be used as a pretense to pass laws limiting abortion rights. Others fear a confusing patchwork of regulations.
By Kimi Yoshino and Jessica Garrison
March 6, 2009
Octuplet mom Nadya Suleman already had six children after five successful in vitro fertilization treatments, but one big dilemma kept gnawing at her: What was she supposed to do with her six frozen embryos?
"Those were my children," Suleman told NBC. "I couldn't live with the fact that if I had never used them . . . that I didn't allow these little embryos to live or give them an opportunity to grow." Now, anti-abortion groups in Georgia are using Suleman's story as a rallying call to enact stricter rules to govern the $3-billion fertility industry, which has some doctors worrying that the octuplets may be used as a pretense to pass laws restricting abortion rights.
Two other states, California and Missouri, are offering laws that critics say might create a confusing patchwork of regulations.
The Missouri bill seeks to adopt industry standards as law. The California law gives the state Medical Board oversight of fertility clinics.
But the Georgia bill, called the Ethical Treatment of Human Embryos Act, defines an embryo as a "biological human being" and prohibits the destruction of frozen embryos -- wading into a loaded debate over abortion rights and embryonic stem cells.
It is backed by the Georgia Right to Life organization and drafted by lawyers from the Bioethics Defense Fund, an anti-abortion, anti-stem-cell group.
The bill would set limits on the number of embryos that can be transferred to a woman to two or three. In Suleman's case, she said six embryos were transferred, far above the number recommended for a 33-year-old woman using younger eggs. With fewer embryos, the chances of multiple births decreases, along with the need for selective reduction.
"I want to make sure what happened in California doesn't happen in Georgia," said state Sen. Ralph Hudgens, a Republican from Hull, Ga. "There is nothing in this law to limit abortions. I can't believe that people are reading that into it."
The additional provisions, though, particularly the section that prohibits the destruction of embryos, has alarmed doctors and fertility industry groups. Louisiana is the only state with a similar law that prohibits discarding human embryos. The president of Georgia Right to Life issued a statement saying the bill would protect embryos as "living human beings and not property."
"The Georgia bill uses the octuplets as an excuse to pass an extreme anti-abortion measure introduced and promoted by and for Georgia Right to Life," said Sean Tipton, a spokesman for the American Society for Reproductive Medicine."
Dr. Arthur Wisot, a Redondo Beach-based fertility specialist, agreed, saying it could "set fertility treatment back to the Dark Ages."
On Thursday, lawmakers sent the bill to a subcommittee for further review. If a compromise isn't reached and it doesn't move out of committee by Monday afternoon, the bill will be held up until next year, though Hudgens said it is far from dead.
Unless the industry is careful, the country could end up with a mishmash of policies that forces patients to doctor shop from state to state in search of laws most favorable to their needs, said Jesse Reynolds, policy analyst for the Center for Genetics and Society. The group called this week for congressional hearings, noting that federal oversight is the best solution.
"I firmly believe that we can rein in the fertility business," Reynolds said. "It's a $3-billion industry that's completely outside of regulatory control. Bring it in, draw lines that we can agree on, while protective [of] reproductive rights and further encouraging reproductive health and reproductive justice."
The industry has long claimed that its voluntary guidelines are adequate. Doctors frequently cite their own efforts to decrease occurrences of high-order, multiple births.
In 1997, the percentage of in vitro fertilization procedures resulting in triplets or higher was 13.7%. By 2007, and by its own self-regulation, the industry average was down to less than 2%, said Dr. Robert Schaaf, the Missouri Republican who introduced legislation to make industry standards into state law.
Schaaf said that although the American Society for Reproductive Medicine standards have resulted in more success and less danger, laws are still needed.
"What if a woman says, 'I want to implant 10 embryos in there?' "Schaaf said.”I think it is within the realm of the state to make sure that doctors don't participate in things that are harmful to people. . . . To purposefully get pregnant with eight babies, is that something that should be a right? I would argue no."
By Kimi Yoshino and Jessica Garrison
March 6, 2009
Octuplet mom Nadya Suleman already had six children after five successful in vitro fertilization treatments, but one big dilemma kept gnawing at her: What was she supposed to do with her six frozen embryos?
"Those were my children," Suleman told NBC. "I couldn't live with the fact that if I had never used them . . . that I didn't allow these little embryos to live or give them an opportunity to grow." Now, anti-abortion groups in Georgia are using Suleman's story as a rallying call to enact stricter rules to govern the $3-billion fertility industry, which has some doctors worrying that the octuplets may be used as a pretense to pass laws restricting abortion rights.
Two other states, California and Missouri, are offering laws that critics say might create a confusing patchwork of regulations.
The Missouri bill seeks to adopt industry standards as law. The California law gives the state Medical Board oversight of fertility clinics.
But the Georgia bill, called the Ethical Treatment of Human Embryos Act, defines an embryo as a "biological human being" and prohibits the destruction of frozen embryos -- wading into a loaded debate over abortion rights and embryonic stem cells.
It is backed by the Georgia Right to Life organization and drafted by lawyers from the Bioethics Defense Fund, an anti-abortion, anti-stem-cell group.
The bill would set limits on the number of embryos that can be transferred to a woman to two or three. In Suleman's case, she said six embryos were transferred, far above the number recommended for a 33-year-old woman using younger eggs. With fewer embryos, the chances of multiple births decreases, along with the need for selective reduction.
"I want to make sure what happened in California doesn't happen in Georgia," said state Sen. Ralph Hudgens, a Republican from Hull, Ga. "There is nothing in this law to limit abortions. I can't believe that people are reading that into it."
The additional provisions, though, particularly the section that prohibits the destruction of embryos, has alarmed doctors and fertility industry groups. Louisiana is the only state with a similar law that prohibits discarding human embryos. The president of Georgia Right to Life issued a statement saying the bill would protect embryos as "living human beings and not property."
"The Georgia bill uses the octuplets as an excuse to pass an extreme anti-abortion measure introduced and promoted by and for Georgia Right to Life," said Sean Tipton, a spokesman for the American Society for Reproductive Medicine."
Dr. Arthur Wisot, a Redondo Beach-based fertility specialist, agreed, saying it could "set fertility treatment back to the Dark Ages."
On Thursday, lawmakers sent the bill to a subcommittee for further review. If a compromise isn't reached and it doesn't move out of committee by Monday afternoon, the bill will be held up until next year, though Hudgens said it is far from dead.
Unless the industry is careful, the country could end up with a mishmash of policies that forces patients to doctor shop from state to state in search of laws most favorable to their needs, said Jesse Reynolds, policy analyst for the Center for Genetics and Society. The group called this week for congressional hearings, noting that federal oversight is the best solution.
"I firmly believe that we can rein in the fertility business," Reynolds said. "It's a $3-billion industry that's completely outside of regulatory control. Bring it in, draw lines that we can agree on, while protective [of] reproductive rights and further encouraging reproductive health and reproductive justice."
The industry has long claimed that its voluntary guidelines are adequate. Doctors frequently cite their own efforts to decrease occurrences of high-order, multiple births.
In 1997, the percentage of in vitro fertilization procedures resulting in triplets or higher was 13.7%. By 2007, and by its own self-regulation, the industry average was down to less than 2%, said Dr. Robert Schaaf, the Missouri Republican who introduced legislation to make industry standards into state law.
Schaaf said that although the American Society for Reproductive Medicine standards have resulted in more success and less danger, laws are still needed.
"What if a woman says, 'I want to implant 10 embryos in there?' "Schaaf said.”I think it is within the realm of the state to make sure that doctors don't participate in things that are harmful to people. . . . To purposefully get pregnant with eight babies, is that something that should be a right? I would argue no."
Monday, March 2, 2009
IVF Success Rates
RPMG Announces 2008 Preliminary Results
Reproductive Partners Medical Group, Inc. has published its 2008 preliminary results on their website, reproductivepartners.com. When all the babies conceived in 2008 have been born, these results will be reported officially to the Society for Assisted Reproductive Technology (SART). The 2008 results from the Los Angeles and Orange County offices showed success rates of 63% (age under 35) 50% (ages 35-37) and 40% (ages 38-40) based on clinical pregnancies per retrieval. Cycles using egg donors had a success rate of 65% based on clinical pregnancies per embryo transfer. Complete reports for prior years as well as the results of all other centers reported can be found at the sart.org website.
Because the type and age of patients treated may vary from program to program, the comparison of cycle statistics is complicated. Couples should be aware of differences among programs as well as differences in specific characteristics when reviewing the data. There are a number of factors to keep in mind when reviewing data.
Only annual data should be quoted since short-term trends are unreliable. Outcomes should be reported only in terms of live births per cycle (clinical pregnancies for the last reporting year), retrieval or transfer. Success rates reported in the SART Data Registry format cannot be compared to programs which do not report to SART, since non-reporters may utilize formats designed to inflate their success rates.
In order to get a long-term view of our results we present a cumulative report of the last five years as well as 2008, the latest reporting year, on our website reproductive partners.com.
Reproductive Partners Medical Group, Inc. has published its 2008 preliminary results on their website, reproductivepartners.com. When all the babies conceived in 2008 have been born, these results will be reported officially to the Society for Assisted Reproductive Technology (SART). The 2008 results from the Los Angeles and Orange County offices showed success rates of 63% (age under 35) 50% (ages 35-37) and 40% (ages 38-40) based on clinical pregnancies per retrieval. Cycles using egg donors had a success rate of 65% based on clinical pregnancies per embryo transfer. Complete reports for prior years as well as the results of all other centers reported can be found at the sart.org website.
Because the type and age of patients treated may vary from program to program, the comparison of cycle statistics is complicated. Couples should be aware of differences among programs as well as differences in specific characteristics when reviewing the data. There are a number of factors to keep in mind when reviewing data.
Only annual data should be quoted since short-term trends are unreliable. Outcomes should be reported only in terms of live births per cycle (clinical pregnancies for the last reporting year), retrieval or transfer. Success rates reported in the SART Data Registry format cannot be compared to programs which do not report to SART, since non-reporters may utilize formats designed to inflate their success rates.
In order to get a long-term view of our results we present a cumulative report of the last five years as well as 2008, the latest reporting year, on our website reproductive partners.com.
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