Southern California Fertility

Check out all my latest quotes

2010-01-08T10:32:00.000-08:00

Check out all my latest media quotes at the RPMG Blog.

Thrombophilias and Unexplained Infertility

2009-12-15T10:08:00.001-08:00

Hereditary thrombophilias do not cause unexplained infertility. Read all about it: http://is.gd/5oM7M

Single Embryo Transfer Encouragement Program in USA Today

2009-12-05T16:53:00.000-08:00

On December 1st we launched our eSET Encouragement Program. The article explaining the program was outlined in USA Today.

The Pap Smear Guidelines and Fertility and Life & Style

2009-11-22T10:31:00.000-08:00

My opinion on the new Pap smear guidelines and the effect on fertility and my quotes in an article on Celine Dion's recent IVF disappointment are now on the Reproductive Partners blog. http://www.reproductivepartners.com/blog/

Fertility Drugs and Ovarian Cancer

2009-11-12T13:31:00.000-08:00

You can read about the latest study about fertility drugs and ovarian cancer at our Reproductive Partners blog.

All new posts will be at the Reproductive Partners blog.

Sex ratio in blastocyst transfer

2009-10-26T13:25:00.000-07:00

Do we see more boys then girls born as the result of blastocyst transfers. Check out the new RPMG blog.

By the way, in the future my posts will be at the RPMG blog.

Arthur L. Wisot, M. D.

RPMG and Dr. Wisot in ELLE

2009-10-20T18:52:00.000-07:00

Girl Crazy: Women Who Suffer from Gender Disappointment

Reproductive Partners was cited in an article in the November 2009 issue of ELLE magazine, “Girl Crazy: Women Who Suffer from Gender Disappointment.” The article profiles women whose lives are disrupted because they have not been able to have the girl child that they are craving. According to the author, they resort to a variety of techniques to try to achieve their elusive dream from folk remedies to IVF with preimplantation genetic screening (PGS), also know as preimplantation genetic diagnosis ((PDG) for chromosomes. The focus of the article was the degree of emotional impairment from which these women suffer rather than the procedure itself. The article profiles a physician whose practice is devoted to IVF/PGS for gender selection, although the technique is widely available, including at Reproductive Partners.

The article states, “Physicians at other clinics, including California’s topranked Reproductive Partners Medical Group, use PGD as a screening tool to identify embryos with defects, and—if pressed— will reveal the sex of embryos in conjunction with other findings. ‘We would transfer embryos of one sex or another if that is the patient’s preference,’ says Arthur Wisot, its executive director and a clinical professor of reproductive medicine at UCLA. ‘We would do it if they seem like reasonable people and no one is hurt by it. But we certainly don’t advertise it and promote it the way Steinberg does. The people he services are more on the fringe, and he’s just playing to their neuroses.’”

Actually Reproductive Partners offers IVF/PGS for family balancing and we do not need to be “pressed” to reveal the sex of embryos. It is just not the only focus of our practice. We mostly employ this technology to detect embryos with chromosomal abnormalities, when appropriate, and diseases caused by known gene abnormalities carried by one or both parents. In fact, the most recent recommendation from the American Society for Reproductive Medicine has reduced the number of reasons for doing PGS for chromosomes because of evidence that it does not improve live birth rates in patients with advanced maternal age, previous implantation failure, recurrent pregnancy loss and even those who have recurrent pregnancy loss from chromosomal abnormalities.

Reproductive Partners Commended By Redondo Beach City Council

2009-09-02T09:45:00.000-07:00

REPRODUCTIVE PARTNERS COMMENDED BY REDONDO BEACH CITY COUNCIL

Reproductive Partners Medical Group was awarded a Mayor’s Commendation at its September 1st City Council Meeting. The commendation, presented to Drs. David Meldrum, Arthur Wisot and Bill Yee by Mayor Michael Gin and City Councilman Steven Diels cited recognition of the practice “giving hope to many couples in our South Bay Community.”

Also attending was Councilman Diels’ wife, Elizabeth, and their eight-month-old son, Luke. In his remarks, Mayor Gin cited the fact that Reproductive Partners has been helping South Bay couples, like the Diels, achieve the dream of completing their family for over 24 years in their Redondo Beach location. The group has expanded to now include offices in Beverly Hills, Westminster and La Jolla.
The physicians at Reproductive Partners are responsible for over ten thousand births resulting from assisted reproductive technology. They offer comprehensive evaluation and practical treatment of all aspects of infertility care. Reproductive Partners is nationally recognized for their pioneering work in helping infertile couples.

Top Ten Misconceptions About Infertility Treatment

2009-08-20T10:49:00.000-07:00

When a couple is having difficulty conceiving, accurate information about all aspects of their fertility can actually help them conceive more quickly. That information can go beyond the usual medical information about the woman’s cycle, timing of intercourse and other issues related to maximizing their chance of conceiving. It can also include information to make them better consumers by knowing where to get the best care and what treatments make sense especially if they need assisted reproductive procedures such as IVF. Because “misconceptions” can lead to a “missed conception,” I wrote my latest book, “Conceptions & Misconceptions” (Hartley & Marks Publishers, Pt. Roberts, WA 2004). The top ten misconceptions about infertility treatment are:

1. . “Our goal is to become pregnant.” Actually the goal should be to have a healthy baby. A lot can happen between pregnancy and a healthy baby. Keep you eye on the real goal.
2. “Success is not everything; it’s the only thing.” The point is, when you are searching for a doctor or clinic to perform an assisted reproductive procedure, the success rate of that center is not the only factor to consider.
3. “Ethics, shmethics! All we want is a baby.” It might seem best to do anything you can to achieve your goal. However, following ethical principles may protect you from potential harm.
4. “More is better.” One might assume that if something is good, more of it would be better. This is a misconception when applied to assisted reproductive technology. Too much of a good thing can quickly get you into big trouble. The most critical example would be that placing too many embryos back into the uterus for one's age in in vitro fertilization can lead to a triplet (or more) pregnancy which may present potentially dangerous problems for mother and children.
5. “Don’t worry; this is a ‘simple’ procedure.” This is an easy misconception to explain because there is no such thing as a simple medical procedure.
6. "Don't put all your eggs in one basket." If you are going through assisted reproduction, you will want all your eggs "in one basket." Not only will you want them in one basket, you will want to make sure that it's your basket. That's a metaphor for making sure that there are no mistakes made with your eggs. Furthermore, you want to make sure that someone doesn't take them out of your basket and put them in someone else's without your knowledge or permission like happened in the U. C. Irvine fertility scandal.
7. “Let the doctor decide: he/she knows best.” There are many things about which the doctor knows best. But does this mean that you should leave all the decisions to the doctor without any input from you? Of course not.
8. “There is such a thing as a free lunch.” If it sounds too good to be true, it probably is. . Since the early days of assisted reproduction, the enthusiasm of some of its practitioners has led to a variety of advertising claims and marketing schemes. You need to be a careful consumer.
9. “Don’t worry. I’m sure our insurance covers this.” Wrong. Most people do not have infertility coverage.
10. “Trust me. I’m a doctor.” If you are considering the possibility of ART, you are going to need to put a great deal of trust in a team of physicians, scientists, and other medical personnel. We feel that the vast majority of teams doing this work are deserving of your trust. But unfortunately, you cannot rely on blind trust.

If you keep these misconceptions in mind when you seek fertility treatment you will be a better consumer, which will make you more likely to succeed.

Erectile Dysfunction and Infertility

2009-08-05T09:35:00.000-07:00

Studies have found that sexual dysfunction is present in about 20-25% of infertile couples. Clearly adequate sexual function will contribute to the success of fertility treatments, but more importantly, sexual dysfunction can be a source of stress and conflict within the couple’s relationship, and the stress in turn can reduce the chance of a successful outcome. Erectile dysfunction can be further worsened by performance anxiety and the pressure to time relations or a procedure to the woman’s ovulation.
Fortunately one of our physicians, Dr. Meldrum in Redondo Beach, CA, has developed an avid interest in this problem, and has developed a web site and written a book outlining the many things men can do to solve this problem. It turns out according to Dr. Meldrum’s research, that drugs such as Viagra should be the last resort.
Click on the following link to Dr. Meldrum’s web site, www.erectile-function.com, and you will learn about the physiology and biochemistry of erectile function so that you can start on the path toward a more pleasurable and fulfilling sexual relationship. Download his book, “Survival of the Firmest”, that will give you all the details.
If you prefer an in-person evaluation with Dr. Meldrum, you can schedule an appointment by calling 1-877-273-7763.

WFWW-Implantation Question

2009-07-29T10:26:00.000-07:00

Ask Dr. Wisot

Questions from the reproductivepartners.com bulletin board

Q. When does implantation take place in IVF?

I have had IVF with blastocysts (5 day old embryos) implanted. When the blastocyst is placed in the uterus what stops it from falling out? And when would implantation occur? Immediately? Also, what criteria are used to judge the quality of blastocysts?

A. Embryos are sticky and can adhere to the surface of the uterine lining before they actually implant, which helps prevent them from “falling out.” In addition, we now use a substance in the fluid used to transfer the embryos to make it the same viscosity as fluid in the uterine lining, which prevents migration of the embryos in IVF. That’s so-called “embryo glue,” although it is not really a glue. Despite these measures, the embryos can float around somewhat, and that's why we want activity restricted for 48 hours after an IVF embryo transfer.

Implantation is defined as the process by which an embryo attaches to the uterine wall and penetrates the surface and the circulatory system of the mother. It starts between six to ten days after ovulation in natural conceptions, or egg retrieval in IVF, no matter how and when the embryos reach the uterus. Usually the degree of development of the embryo will determine when the process will actually begin. Most of the time, implantation occurs silently. There are no consistent signs or symptoms associated with it except that it occasionally can result in some vaginal spotting or bleeding which may be mistaken for the start of the next menstrual period.

In IVF, blastocysts are generally graded on the stage of their general development on a one to six scale, and the specific development of what will become the fetus and the placenta on A-B-C scales (A being best). Blastocysts graded at 3AA or higher would generally be considered good quality blastocysts, although this grading level is not required to create a healthy pregnancy. Many healthy babies have been born from embryos which have only reached the stage before blastocyst (morula) after five days of development. Of course none of this is known in a pregnancy conceived by conventional means as we have no idea of what was happening to that embryo, although they would be going through much the same process.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern California

Do blastocysts like fresh air?

2009-07-22T16:53:00.000-07:00

WFWW-Do blastocysts like fresh air?

Embryos are very sensitive to their environment. Issues such as temperature, light and atmosphere are critical to proper embryo development and thus to a center’s success rates.

A study in the June 2009 issue of the journal “Fertility and Sterility” supports our decision at Reproductive Partners some time ago to use low oxygen incubators. In this study blastocysts were cultured in atmospheres with either 6% carbon dioxide (CO2) in air, the equivalent to 19% O2, a two-gas system; or 5% O2, 6% CO2, and 90% nitrogen (N2), a three-gas system.

Three hundred ninety six women, were randomized to 197 cultures with the three-gas system and 199 cultures with the two-gas system. The outcome with the three-gas system compared with the two-gas system showed a statistically significantly increased blastocyst rate (47.8% vs. 42.1%), mean number of blastocysts (3.8 vs. 3.3), and number of cryopreserved blastocysts (1.7 vs. 1.1). The mean number of transferred blastocysts was 1.2 versus 1.3. Culture with the three-gas system increased the relative birth rate by 10% compared with the two-gas system (42% vs. 32%, respectively), a statistically significant difference. The overall twin rate was 4.8%.
They concluded that blastocyst culture with low-oxygen (5%) versus high-oxygen (19%) concentration yielded a better blastocyst outcome and a marked improvement in birth rate.

WFWW-PGD for Single Gene Defects

2009-07-15T10:03:00.000-07:00

Wisdom from Wisot Wednesday

What Do Women at High Risk for Genetic Diseases Think of PGD?

PGD is an IVF technology that can detect chromosomal abnormalities in the embryos of women at high risk for anuploidy, as well as single gene defects in the those of couples who carry the gene for a serious disease. One problem in applying this technology is that it is not widely known that it exists.

A survey reported in the journal “Fertility and Sterility” examined women’s attitudes about the technology at a national conference for individuals and families affected by hereditary breast and ovarian cancer.

Of the women surveyed, only 32% had ever heard of PGD before taking the survey. None of the women surveyed had actually used PGD, and 44% believed they would not use it in the future. However, 57% of attendees believed that PGD was an acceptable option for high-risk individuals, and 74% believed that high-risk individuals should be given information about PGD.
I am sure that if groups carrying genes for other single gene defect diseases such as cystic fibrosis, muscular dystrophy and Huntington’s Disease were surveyed, we would find the same lack of awareness of the technology.
The authors concluded that health care professionals who serve cancer patients should consider incorporating information about PGD into patient education. Further research is needed to survey physicians and genetic counselors about their knowledge and opinions of PGD. The same conclusion probably applies to couples carrying other single gene diseases.

WFWW-Gender Selection

2009-07-07T18:29:00.000-07:00

Wisdom from Wisot Wednesdays

Can I do gender selection?

I have been an infertility patient with 2 successful frozen embryo transfers, one singleton and now a twin pregnancy, all 3 boys. I can't believe we are considering this already, but we've been throwing around the idea of trying again. I was wondering if I can do some procedure to do gender selection and look for any little girl embryos to transfer back.

There are two procedures you can take advantage of to try to increase your chances of a girl. One is sperm selection through a patented sperm selection technique called Microsort. This technique is 90% effective creating girl embryos; 70% success when boys are desired. It can be used with either intrauterine insemination or IVF depending on how many viable sperm of the desired sex are available after the separation process, as well as fertility issues in the intended parents.

If IVF is needed, as in your case, the process can be increased to virtually 100% accuracy by adding preimplantation genetic diagnosis (PGD) to select girl embryos. In addition to sorting the sperm to increase the number of girl embryos with Microsort, the embryos could be biopsied three days after retrieval and insemination. One cell is removed from the then six to eight cell embryos and sent to the genetics lab where from five to twelve chromosomes, including the sex chromosomes, will be examined. Chromosomally normal female embryos will be identified for transfer five days after retrieval.

There are some ethical issues related to this. First, Microsort is currently seeking FDA approval and their protocol requires that the procedure be performed for “family balancing.” That means a couple must have at least one child before seeking the procedure to balance with a child of the opposite sex. Second, if not enough sperm are available for insemination and IVF would be required for that reason only, the question of whether to do IVF, in others, just for sex selection raises an ethical dilemma since IVF is more risky, invasive and costly. If you want sex selection for whatever your situation, you will likely find differing answers among different doctors to all the ethical issues raised by sex selection.

WFWW-Progesterone Options for IVF

2009-06-30T19:54:00.000-07:00

WFWW-Progesterone Options for IVF

If you ask women who have gone through an IVF cycle which the part they consider as the most difficult, it would likely be the progesterone injections. Traditionally progesterone in oil has been used and consists of deep intramuscular injections of an oily substance. Since IVF became a clinical treatment thirty years ago, we have been searching for an effective, more acceptable alternative. As you may be aware Reproductive Partners in Los Angeles and Orange counties currently has an ongoing study comparing an FDA approved vaginal medication with a new subcutaneous, easier injection.
One of our sister Integramed practices has just reported in the journal Fertility & Sterility results of a study comparing intramuscular progesterone with a variety of vaginal preparations. Among patients using vaginal progesterone, there were no statistically significant differences in outcomes between the vaginal and IM progesterone treatment groups. There was a 50.0% pregnancy rate among patients treated with vaginal progesterone and a 51.5% rate among matched IM progesterone patients. The live birth rates were 47% in the IM versus 47.5% in the vaginal progesterone groups. There were no statistically significant differences in miscarriage rates between groups.
Our current study goes one step further by comparing the only vaginal progesterone approved by the FDA for pregnancy support, Endometrin, with a new easy subcutaneous injection. If you meet the inclusion criteria you can still join the study and be eligible for free progesterone medication and an honorarium. For more information, call your nearest Reproductive Partners office or (877) 273-7763.

Sex Ratio/Identical Twins in Blastocyst Transfer

2009-06-24T10:27:00.000-07:00

WFWW-Sex Ratio and Identical Twinning in Blastocyst Transfer

One of the most frequent questions I am asked is whether IVF treatment, and blastocyst transfer in particular, increase the number of offspring of one sex.

According to a compilation of four studies published in the June 2009 issue of Fertility & Sterility, a higher male-female ratio after Day 5 blastocyst transfer compared with Day 3 cleavage-stage ET was 1.29:1 in favor of male offspring. This is not high enough to recommend this as a sex selection technique, but will be somewhat reassuring to those wanting a male child.

The study also looked at the chance of identical twins (monoztgotic twinning-MZT) in Day 5 transfers which has been said to be increased over Day 3 transfers or natural conception. They reviewed the results of nine studies incorporating almost 41,000 cycles and found the risk of MZT after blastocyst transfer was significantly higher compared with cleavage-stage transfer by a factor of 3.04:1. MZT is not a desirable result as it can create a more risky pregnancy for the babies, especially if they are in the same amniotic sac.

Recurrent miscarriage question

2009-06-17T09:50:00.000-07:00

Wisdom from Wisot Wednesdays

With eight previous miscarriages what tests should I DEMAND?

Q. I have just lost my 8th baby due to early pregnancy loss. All losses have been at 11wks or earlier. The hardest part was there was a great heartbeat and a perfect looking baby. My OB/GYN said I was having a textbook perfect pregnancy. Of course I let my guard down, got excited and lost the baby almost 2 weeks later. The OB who did the D&C said she would have testing done on the placenta. What tests is she talking about? And more importantly we want to have a baby and are ready emotionally to try again, so what tests should I have done before we try again?
Kelly

A. I am so sorry to hear about your repeated losses. You can be sure that your enthusiasm had nothing to do with the loss. The test the doctor wanted to do on the placental tissue was probably to examine the chromosomes to see if the baby was normal or abnormal. That could provide clues on what is causing the problem and how to deal with it.

Once you recover from this miscarriage you might want to see an Ob/Gyn who treats recurrent miscarriage or a reproductive endocrinologist to review your history and see what tests are appropriate. Yours does not sound like the typical case and I really can't tell specifically which tests should be done from this information. Generally the tests will check the following issues:
• the chromosomes of both partners
• the quality of the woman’s eggs with hormone tests
• abnormalities of the uterus
• infection with an organism-ureaplasma
• progesterone levels/development of the uterine lining
• abnormal antibodies in the woman’s blood
• heredity blood clotting problems in the woman

By the way, when anyone approaches a doctor I would recommend that one not start the interaction by “demanding” that something be done. Start by listening to the doctor’s advice and then add any “request” you may have with the reason you want something done. The best doctor-patient relationship is one of mutual concern, cooperation and trust. If one does not feel that their doctor is concerned about their problem, not willing to reasonably cooperate or they do not trust the doctor, it is best to find another doctor.

Arthur L. Wisot, M. D.

2009-06-11T08:37:00.000-07:00

It has been a few months since I blogged on Redbook magazine's blog, The Infertility Diaries. In the feature, Wisdom from Wisot Wednesdays," I answered reader's questions. Since that blog no longer exists, I am going to resurrect WFWW on my blog. Here is the first entry. You can post new questions as comments to this message.

Wisdom from Wisot Wednesdays

When to perform an insemination?

Could you please give your opinion on what is the best time to perform an insemination (IUI) without any drugs in relation to the detection of the LH surge? Is it before or after detection of surge and please be specific with hours. There seems to be a lot of differing info on best times.

I usually recommend that a single insemination be done in a natural cycle the day after an LH surge is detected by an ovulation predictor kit. That’s because the surge usually precedes ovulation by 36 or more hours. You are detecting the surge sometime after it happened. Most women test once a day in the afternoon or evening, so they should be close to ovulation by the next morning. The egg has about 12-24 hours to be fertilized and the most sperm specimens can maintain good motility for 48 hours in the wash media, so the IUI does not have to be done at the exact time of ovulation. All the averages coincide the morning after the surge is detected, making it the most logical time to perform the IUI. Alternatives to using the urinary ovulation predictor kit to time intercourse or insemination are ultrasound or a variety of fertility monitors. In fact if at the time of the insemination, an ultrasound shows that the follicle is still present, we recommend doing a second insemination the next day as well.

Erectile Dysfunction and Infertility

2009-05-05T17:48:00.000-07:00

Studies show that sexual dysfunction is present in about 20-25% of infertile couples. Adequate sexual function can contribute to the success of fertility treatments, but more importantly, sexual dysfunction can be a source of stress and conflict within the couple’s relationship. The stress itself can reduce the chance of a successful outcome. Erectile dysfunction can be further worsened by performance anxiety and the pressure to time relations to the woman’s ovulation.

At Reproductive Partners we are concerned about your mental well-being and want you to maintain a strong relationship during and following your fertility treatments. That can help attain the highest possibility of success and strengthen your relationship during the challenges of pregnancy and rearing your family.

Dr. David Meldrum of Reproductive Partners has developed a web site and written a book outlining many simple things men can do to help solve this problem themselves. According to Dr. Meldrum’s research, drugs such as Viagra should be the last resort. The critical factor for adequate erections, nitric oxide (NO), is positively influenced by factors such as increasing physical activity, reducing excess weight and fat and sugar intake, and by ingesting specific foods and nutritional supplements that maximize NO production. Dr. Louis Ignarro, who received the Nobel Prize for the discovery of nitric oxide, and who first defined the role of NO in the erectile response, has written the forward for Dr. Meldrum’s book. He states “I have no doubt that this book will help millions of couples around the world by improving male sexual performance.” In fact Dr. Meldrum’s non-drug regimen is helping some men have better erectile performance than they have ever had, even when much younger.

Click on the following link to Dr. Meldrum’s web site, www.erectile-function.com, to learn about the physiology and biochemistry of erectile function so that you can start on the path toward a more pleasurable and fulfilling sexual relationship. At the website you may also download his book, “Survival of the Firmest” that provides all the details. Individual consultations are also available at the RPMG Redondo Beach office or by phone with Dr. Meldrum by calling (310) 318-3010 to schedule a telephone consultation.

IVF Costs - Third Cycle Free

2009-04-02T12:40:00.000-07:00

At Reproductive Partners Medical Group, we believe in success. Our expert physicians and staff have well over twenty years of experience and are dedicated to using our knowledge and expertise to maximize your chances to achieve your dream of having a baby.

Our financial program, called the SUCCESS PROGRAM is based on the philosophy that couples capable of getting pregnant with IVF usually do so within the first three cycles.

The Reproductive Partners SUCCESS PROGRAM is really very simple. If you pay our regular standard Global Rate for each of two complete IVF cycles at Reproductive Partners, transfer all embryos from those cycles, including frozen embryos, without achieving a viable12 week pregnancy your third IVF cycle at Reproductive Partners will be provided free for the same basic IVF procedures as in the first two cycles. Patients who have insurance coverage for IVF are not eligible.

There will be no age limits, no higher up-front fees as in money-back guarantee programs, no pre-payment for the second cycle until the first is completed, no mandatory procedures like hysteroscopy or IVIG injections and no arbitrary cancellations. If we determine that you are a candidate for and complete at least two cycles of IVF you may participate in the program. We expect our patients to succeed, and when success does not come quickly, we will go the extra mile for you.

Q&A

Q- How much time do I have to complete the three cycles?
A- You have 18 months from the start of birth control pills or Lupron in the first cycle, to the start of the third cycle.

Q- What about frozen embryos from the first two cycles?
A- All frozen embryos must be transferred without achieving a viable 12-week pregnancy before you will be eligible for the third cycle.

Q- In the third “free” cycle, what is covered and what is not?
A- All the same procedures that are covered in the Global Rate in your first two cycles are covered,

Here is a summary:

INCLUDED IN THE THIRD CYCLE -

BASIC PROCEDURES USED IN CONJUNCTION WITH IVF:
• Starting at the visit to begin birth control pills or Lupron:
• Ultrasound and estradiol monitoring of egg development
• Egg retrieval
• IVF laboratory work including preparation of sperm, identification of eggs, preparation of eggs for insemination, insemination of eggs, embryo incubation and monitoring and preparation for transfer
• ICSI (only if ICSI was paid for in the previous cycles)
• Assisted hatching
• Embryo transfer
• Progesterone level after transfer, ending with the first pregnancy test.

NOT INCLUDED IN ANY THIRD CYCLE -

IVF PRE-TREATMENT PROCEDURES:
• Consultations
• Pre-cycle lab work including infectious disease screening
• Semen testing
• Procedures such as trial transfer, hysteroscopy (if necessary)

POSSIBLE ADDITIONAL COSTS ASSOCIATED WITH IVF CYCLES:
• Anesthesia for retrieval
• Medications
• Surgical Sperm Retrieval
• Intracytoplasmic Sperm Injection (ICSI) (if not paid for in two previous cycles)
• Preimplantation Genetic Diagnosis (PGD)
• Cumulus co-culture
• Embryo freezing and storage or frozen embryo cycles
• In donor and surrogate cycles:
Administrative fees
Surrogate or donor recruitment, screening or remuneration costs
Pregnancy monitoring following the first pregnancy test

If a viable 12-week pregnancy is achieved within the first two cycles, including the use of frozen embryos, couples will not be entitled to a free third cycle. If three cycles are necessary, all must be completed in an 18-month period and only same procedures and category of cycle will be provided without charge. Other additional costs enumerated above are not provided without additional charge. All fees for each “paid” cycle must be paid in advance.

Infertility Success Story

2009-03-20T10:21:00.000-07:00

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.

Wisdom from Wisot Wednesdays - The Final Round

2009-03-19T10:43:00.000-07:00

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.

Wisdom from Wisot Wednesdays, Round 20!

2009-03-19T10:39:00.000-07:00

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.

Wisdom from Wisot Wednesdays, Round 19!

2009-03-19T10:35:00.000-07:00

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.

Wisdom from Wisot Wednesdays Round 18!

2009-03-19T10:29:00.000-07:00

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.

First Time IUI without Meds or Ultrasound

2009-03-12T10:21:00.000-07:00

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

The Basic Infertility Evaluation

2009-03-10T13:23:00.000-07:00

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.

Stricter rules on fertility industry debated

2009-03-06T13:27:00.000-08:00

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."

IVF Success Rates

2009-03-02T12:31:00.000-08:00

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.

Wisdom from Wisot Wednesdays, Round 17!

2009-02-25T16:25:00.000-08:00

Reprint from Redbook’s Fertility Diaries

Hello, everyone, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. We've got so much in store this week: Four great questions, an answer to last week's pop quiz ("What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck?"), and a question from Dr. Wisot to all of you! If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: We've been trying for two years and never once had a positive pregnancy test. Recently we went through extensive testing — I am completely healthy/normal however, we were diagnosed with male factor infertility. He's seen a urologist and received a clean bill of health. We've been to an RE and were told that given his SA, we should "Do not pass go, go straight to IVF/ICSI." I've come to terms with the path ahead of us, however despite my RE's frequent reassurance that "It only takes one!", I feel like I need another opinion on his stats to fully understand our chances of a successful pregnancy: SA #1 (WHO Methodology) Total Count: 208 million A - 0% B - 15% C - 4% D - 81% Total Motility - 31 million Kruger Morphology Normal - 3% Head Defects - 44% Acrosomal - 5% Neck Defects - 31% Tail Defects - 17% SA #2 (WHO Methodology) Total Count: 98.9 million A - 0% B - 21% C - 18% D - 61% Total Motility - 20.8 million Kruger Morphology Normal - 1% Head Defects - 44% Acrosomal - 3% Neck Defects - 28% Tail Defects - 24% His counts are high, but the motility and morphology numbers freak me out. Should we be concerned with chromosomal abnormalities or possible DNA fragmentation? As our start date to cycle approaches, I worry that there simply won't be enough "quality" sperm to choose from. Can you help me understand what criteria the lab technicians look for when selecting sperm for ICSI? Thank you.

Answer: Fertility treatment works best when we are correcting a problem, if that's possible. Here the problem is the motility and morphology. If they don't move well, they have much less chance of reaching the egg. If they are misshapen, they have much less chance of penetrating the egg. Fortunately, the speed and shape have nothing to do with the chromsome makeup of the sperm. So IVF with ICSI is a treatment that can overcome this problem. If you are young, you could try some IUIs, but I would usually not recommend spending too much time before moving on.

Question #2: Due to my husband's cancer treatments, he is unable to have children (based on a semen analysis in 2000). When I started my IF treatments in 2007 (no birth control since 2000), we did not do another semen analysis and used donor sperm. I'm now considering IVF (15 failed IUIs, medicated and not). Can we consider utilizing my husband's sperm? What's the minimum an RE will want to see in order to use his sperm?

Answer: The minimum number of viable sperm needed is equal to the number of eggs you produce. That's easy. The bigger question is whether the chemotherapy drugs may have damaged the sperm beyond their numbers, ability to swim and their shape. You should consult with his cancer doctor to get information on exactly what and how much of the drugs he received and what potential damage they could have caused beyond the obvious.

Question #3: Hi, Dr. Wisot! A few weeks ago, in your answer to my questions about embryo defragmentation, you mentioned looking at strategies to improve egg (or embryo) quality. What are some of the strategies you've used in situations with low ovarian reserve, lots of fragmentation in the embryos? Thanks for your thoughts!

Answer: Unfortunately I can not get into the details of prescribing and protocols here. Each fertility center has its ways of dealing with poor embryo quality. In the lab, procedures like co-culture, assisted hatching and defragmentation may be used. There can be modifications to the stimulation protocol. You may want to get an opinion from your doctor about what strategies he/she would suggest and then get a second opinion from another outstanding center. This is a difficult issue to resolve and it can't always be fixed.

Question #4: Hi. Some background: I have a small prolactenoma that I take Parlodel for. Have had regular prolactin levels for one year now and have been TTC since April 08. Husband's sperm is normal, he is 34, I am 30. My question: Ever since going off the pill I have had a very short luteal phase. My doctor thinks I am ovulating due to OPKs thermal shift. But luteal phase is 2 - 6 days. My doctor says that is not a concern; do you agree? I have an HSG scheduled for this week and if clear, the doctor suggests Clomid. Thanks for your thoughts!

Answer: You need to get into this more deeply than following your cycles with a temperature chart. You do fit the definition of a luteal phase defect just by the length of your luteal phase. I would guess that you are not seeing a reproductive endocrinologist/fertility specialist. Clomid is one way to overcome this problem, but your cycles need to be monitored by ultrasound following your egg development, confirming the egg's release and progesterone monitoring in the luteal phase.
Before I get to last week's quiz answer, I would like to get your perspective on the reproductive aspects of the Octo-Mom situation. Has it affected your confidence in the specialty as a whole? Do you think we should legislate how many embryos may be transferred? I'd love to hear what you think. Next week, I'll share my perspective.

Pop quiz answer:

Last week's question was, "What are the three reasons that it seems like the conception rate is 100% on prom night in the back of the pick-up truck," while so many women struggle to have a child.

1. The girls are usually in the late teens, which biologically is the optimal age group for reproduction. (Please, don’t shoot the messenger.) Today, between education and careers, many women are putting off their childbearing until they are biologically more mature.

2. The guys are also at a peak of sorts. Most of the time they look at the post-prom hours with great anticipation. In fact, they frequently practice so they will give a stellar performance. They can regenerate their counts more quickly than their more mature counterparts. The increased, er, practice time improves motility and decreases DNA fragmentation so they are primed to perform magnificently from a reproductive point of view.

3. This is where the back of the pick-up truck comes in. Couples who are engaged in fertility treatment have sex, make love, have intercourse, or whatever you want to call it. In the back of the pick-up our two prom goers and have hot, steamy sex like two rabbits going at it, with similar results. There is no stress and the level of excitement improves the semen specimen further. The stress comes about two weeks later when she misses her period.

The point of all this is that one cannot expect fertility treatment to match the efficacy of this method. I’ve even had patients borrow a pick-up to try to regain their lost youth. But, believe me, it doesn’t work. What may help if you are not already at the point of IVF is to try to regain that spark that brought the two of you together and don't let the quest for a baby get in the way of what you once had. If you are having IUIs, try it the old-fashioned way after your IUI. Even if it is the IUI that ends up getting you pregnant, at least you’ll have had some fun trying.

Wisdom from Wisot Wednesdays, Round 16!

2009-02-25T16:22:00.000-08:00

Reprint from Redbook’s Fertility Diaries

Hi, and welcome back to our weekly Q&A with top fertility expert Dr. Arthur Wisot. It was a short week and we've got just two questions. If you've got a question for Dr. Wisot, just leave it in the comments section and we'll get to it next week. And now, for the disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: With all your knowledge, do you find any belief in the Jonas Method?

Answer: No. It's really hard even for me to figure out how it's supposed to work but seems to be a method of timing that's more rooted in astrology than science. If one is reading infertility blogs, chances are that it's beyond the point of just a timing issue. Besides if timing was so critical, why does it seem that conception occurs 100% of the time on prom night in the back of a pick-up truck? Prom night is not timed to the cycle. There are at least three reasons girls get pregnant on prom night. Any guesses?

Question #2: (Subject: Botched IUI) We are trying to conceive with donor sperm. At the time of the botched IUI, we had planned to do an insemination at home (our attempt at a hail mary after 10 cycles of non-medicated IUI and our doctor suggesting that we stay the course) and two IUIs at the doctors office. My spouse had an urgent work trip come up the day before my LH surge so we decided to skip the at home insem because the tank is heavy and process sounded cumbersome with just one person. I went in for my IUI as usual and instructed them to send the remaining ICI preparations back for storage. A week later I received confirmation of the two vials being put in storage, except they had one IUI and one ICI. Despite my repeated clarification that there were two different types of sperm in the tank, they inserted unwashed sperm directly into my uterus. I ended up with an awful infection, which made my HSG two weeks later brutally painful. What, if any, lasting effects could this have on my fertility? We have obviously left this clinic and have found a wonderful RE who knows what she is doing! Thank you for any insight you might have.

Answer: The reason for the violent reaction to unwashed sperm is the presence of a substance in semen called prostaglandin. It can cause labor-like contractions of the uterus. There should not be any long-term medical consequences from this. Although semen is usually sterile, the donor could have an infection or the collection technique could contaminate the specimen with bacteria, causing the infection. Infection can cause damage to the fallopian tubes, although quick treatment will usually prevent that.

Wisdom from Wisot Wednesdays, Round 15!

2009-02-25T16:01:00.000-08:00

Reprint from Redbook’s Fertility Diaries

Hello, all, and welcome back to our weekly Q&A with fertility expert Dr. Arthur Wisot. It's been a busy week for Dr. Wisot, between the Today Show and your bounty of questions! Before we get started, the doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: Dr. Wisot, how long can embryos be frozen and then successfully thawed/transfered? I have seven frozen embryos from 1994! We transfered five, resulting in twins and froze the rest. I am 40 now and have a feeling my eggs aren't like they were at 25. Thank you.

Answer: Theoretically, forever. We have had frozen embryos create healthy pregnancies up to 14 years after they were frozen. Apparently they do not get freezer-burn. But don't forget that not all may survive the freeze-thaw.

Question #2: Dr. Wisot, first, thanks. You're awesome. Second, my husband and I are both 36, and we've been trying to conceive for about a year. So far everything is super great (HSG, semen analysis, hormone levels, general health). We've done two cycles of Clomid with insemination, resulting in two and four follicles, but zero pregnancies. Much as I want a biological kid, I'm not interested in IVF (partly because of the money, partly because it seems to send couples to Stress Town — a place I'd rather not go). So, my question is, how many IUIs should we try before we know it won't take? Any other fertility meds I should look into? Tests? Anything else?

Answer: Thank you. The rule is that if a treatment has a good chance of working, it will work in three tries. After that the chance of success drops. So the sequence you are looking at is another cycle of Clomid with IUI, then there are some options. If you are really opposed to doing IVF you might want to consider a laproscopy to see if you have some endometriosis that can be treated. An alternative is to have a repeat HSG, but this time have them put in an oil-based dye which can deal with some immunologic issues and increases the chances that future treatment might be successful. And that next treatment would be injectable drugs with insemination.

Question #3: Dr. Wisot, could you give us a description from the RE perspective of fertility as it relates to a woman's age? (e.g., at 20 years old the average woman is very fertile and pregnancy is usually achieved within X months; at 45/50 the average woman probably will not be able to get pregnant, and points in between. Also, is there one age that really indicates a tipping point? 35 usually seems to be cited. Is there a big difference between 34 and 36 years old in the fertility world, for example? Sometimes you state "if you are young, I would advise XYZ". What is "young" from the RE perspective and what is "old"?) I have always wondered. Thanks so much! I hope you know how much we appreciate your answering our questions!

Answer: That appreciation keeps me going. Age is the most important factor determining success in reproduction. What you are referring to is the "fecundity rate" at various ages. I can't remember the exact monthly rates by age, but in the 20's it would be in the low 20%, 15% in the mid 30's, rapidly declining starting at about age 38, and by 45 would be less than 1%. You can probably search for exact figures. When I say "young," I usually mean under 35. I can't tell you if there is a big difference between 34 and 36 because it's an individual thing; significant for some, not for others. Bottom line: Whenever possible, reproduce early.

Question #4: Dr. Wisot, thank you for taking the time to answer questions. I am 38 years old and have a 5-year-old son who was conceived with Clomid and timed intercourse (first cycle). Been trying for over four years for #2. Multiple Clomid/IUI cycles and one non-medicated pregnancy (miscarried at 12 weeks) during that time. Had a laparoscopy before moving to injectables and discovered pelvic adhesions, so IVF seemed to be only route as the surgeon did not think adhesions could be cleared. FSH went from 6 to close to 9 in less than a year and antral follicle count last time we checked was very low (2 -3). To top it off, I have a unicornuate uterus with only one ovary and tube. With an FSH close to 9 and a low antral follicle count and only one ovary, would you recommend IVF? I am thinking it would not make a lot of sense but would appreciate your thoughts. Thanks.

Answer: I probably would recommend IVF, as time here is a major issue. Remember success in reproduction is about quality, not quantity, although quantity helps. With a single horn uterus we would be considering a single embryo transfer for you to avoid twins, so in IVF they would need to push for the best embryo quality possible.

Question #5: Hi, Dr. Wisot. Thank you so much for your time. You encouraged me to see an RE (Wisdom from Wisot, Round 9, Question 1), and we did, and we're now doing our first medicated IUI (today, in fact). I'm just wondering if you can tell me whether the protocol sounds typical to you. I took 100 mg of Clomid on cycle days (CD) 5-9, we had an ultrasound on CD 13, and today is CD 15. I did an HCG trigger on CD 13, and I'm supposed to do supplemental HCG injections on CD 16 and CD 19. Is that normal? What is the purpose of the last two HCG shots? Will that affect a home pregnancy test (I will be traveling, so I can't get a blood test at the clinic)? BTW, we did a saline contract sonogram for the spotting and it was fine — is the HCG meant to counteract the spotting? Also, is it possible I could have ovulated on CD 13 before the HCG shot (or before today, at least), since CD 15 is rather late in my cycle, or does the Clomid delay ovulation?

Answer: I'm so happy to hear that you were helped. Supplemental hCG injections is one alternative to supplement progesterone in the second half of the cycle as it prolongs the life of the structure that produces progesterone. The hCG can remain in your system for nine days so it could create a false positive pregnancy test for that length of time after the last injection.

Question #6: Thank you for your time. I am 38, G6 P3, (G2P2 unassisted prior to 37-year-old hubby). We've been trying for more children for five years. We had two unmedicated misscarriages (low progesterone assumed to be the cause). Then one unmedicated successful pregnancy (still rather low progesterone with supplements). We have done IUI four times with Clomid 150mg resulting with 3-4 follicles size 16-24 each time. Always followed with labs and ultrasound each time. Hubby has low motility and quantity 20-30 mil. We thought our chance with IUI would be wonderful. Is there a chance male progesterone could be effecting our chance at successful pregnancy? Any suggestions to improve our chance with hubby's lazy sperm :) Thank you.

Answer: First of all for the others, G means number of pregnancies (gravida); P means number of deliveries (para). I don't know what you mean by "male progesterone." There is no such thing. But low motility could be the reason that IUI has not worked. A urologist might be able to determine the cause of the sperm issues and recommend treatment. Or, you could move on to IVF with ICSI to overcome the sperm issues.

Question #7: Hi. I will be doing IVF and was prescribed gonal-f. My RE was initially going to prescibe the follistim pen but I had two unused vials of gonal-f from a different RE when we did IUI's, so he changed to gonal-f so I could use what we had at home, even though I said that I will use what he felt was most effective. Is there a difference between gonal-f and the follistim pen other than how it is administered? Are they equally effective? My RE says that they are essentially the same medication but I have found a study that said that IVF with gonal-f has poorer pregnancy results. Our infertility issue is endometriosis if that has anything to do with it. Thanks.

Answer: Most doctors consider Gonal-F and Follistim to be equivalent drugs. Apparently that one study has not been definitive enough to convince doctors to use Follistim universally. Endometriosis has nothing to do with the selection of stimulation drugs.

Question #8: Hello, Dr. Wisot. Thank you for taking your time. I am 30 years old and my partner is 34. I conceived but unfortunately it turned out it was a blighted ovum pregnancy in we are trying to conceive for the second time is it possible to have a second blighted ovum pregnancy twice?

Answer: The reason for most miscarriages is some variant of a blighted ovum, which is merely the failure to develop a fetus. At age 30, the incidence of miscarriage is about 20-25% of early diagnosed pregnancies, so the chance of this happening again is 20-25%. But look at it this way: You have a 75-80% chance of not having this happen again.

Question #9: Hi, I have a question about morphology. We are starting our second round of IVF with a new clinic. In our first IVF, and in all of the semen analysis they did in the tsting phase, I was told my husband's count, motility, and morphology were fine. He's 38, I'm 40. I had five eggs (poor quality) and all five fertilized without ICSI (this was October 2008). ICSI was never brought up even as a possibility based on the sperm testing. Now with this new place, they did another semen analysis, and they are telling me that his morphology is 3% and normal is 4% on the Kruger scale, and that if the semen on the day of retreival is the same, they will do ICSI. We have to pay for everything out of pocket, and ICSI would add another $3k that we weren't expecting. I've done some reasearch, and found many anecdotal discussions about the Kruger scale being too strict, and so I was wondering about your opinion. Aside from the money factor, I also hesitate to do ICSI, as I've read that there might be a small increase in possible birth defects. Is it possible that in five months, my husband's sperm would change that much to make ICSI necessary? I want to tell them not to do it, based on our history, but I don't want to be stubborn if it is really needed. Can the lab wait to see if they fertilize before performing ICSI, or does it have to be decided ahead of time? Also, is there anything he can do in the next 3-4 weeks before the retreival to improve his morphology? (vitamins, diet, etc.). He usually has a glass of wine every night, but stopped that last week, and he does drink a lot of caffeinated coffee and tea, could that affect it? Thanks for your thoughts on this!

Answer: Most doctors use the strict morphology as one criteria for recommending ICSI because sperm which are misshapen are much less likely to be able to penetrate the egg. You can compare the current sperm count to the last one, but based on the current one, ICSI would usually be recommended. It's not a decision you can go back and re-do. If the eggs do not fertilize, so-called "rescue ICSI" on the day after retrieval does not usually work well and the cycle is ruined. In a few weeks, lifestyle changes and vitamins will not result in a significant change.

Fertility Specialist Comments on the Nadya Suleman Octuplets

2009-02-17T13:28:00.000-08:00

By Arthur L. Wisot, M. D.

Every few years we are treated to a fertility misadventure that makes for great water-cooler discussion. But it also brings out a knee-jerk response that we need to regulate an entire specialty because of the actions of one ethically misguided physician.

Keep in mind that we know only one fact about the current situation: Nadya Suleman delivered octuplets. All the rest about her life and the doctor who reportedly performed the IVF procedure on her are the subject of anecdotal statements. However, there are mechanisms in place to deal with the questions about her ability to raise her 14 children and the alleged actions of Dr. Michael Kamrava. The Department of Social Services can evaluate her questionable suitability as a mother of 14, some of whom are reportedly disabled. The Medical Board had said they will review the doctor’s actions and if the Standard of Practice has been violated and there has been a potentially disastrous outcome, they can discipline the doctor. There is no need to impose arbitrary restrictions on an entire specialty because of one doctor’s actions. The fact that a recent LA Times article reported that another woman, Rosalind Saxton, wound up going to Dr. Kamrava after three other doctors turned her down, telling her to lose weight first, is testament to the fact that many fertility groups do have patient selection criteria and are acting responsibly.

Fertility is one of the most highly self-regulated of specialties. The Fertility Clinic Success Rate and Certification Act of 1992 requires all IVF centers to report their success rates to the CDC. Those rates, along with the average number of embryos transferred, are posted on the Internet and are available to the public. You cannot find success rates of individual doctors, practices or institutions in most other specialties. The problem is that there is no penalty for not reporting; those practices are just listed as non-reporters. Non-reporters usually say that they do not like the mandated format. That means that the standard format does not present their results in the best light or, more likely, their success rates may not measure up to national averages and they do not want their stats to be audited. Until reporting is truly mandatory, consumers should choose not to patronize non-reporting clinics. Surprisingly, Dr. Kamrava does report. His poor success rates were available to any consumer who bothered to look and should have been a red flag.

It’s true that some European countries have restrictions on the number of embryos that may be transferred. But those same countries follow the Golden Rule: the one with the gold rules. IVF is covered in their national health systems. I would personally have no objection to mandate all centers follow the guidelines, if there was universal insurance or government coverage for fertility treatments in the U.S. In fact, a small number of enlightened insurance companies are now covering IVF and contracting only with selected groups which follow the guidelines and have low high-order multiple pregnancy rates. Insurance coverage would take some of the pressure off patients to demand more embryos be transferred in an attempt to have quicker success because of financial pressures.

So let’s not throw out the baby with the bathwater. We can maintain our reproductive freedom. Informed consumers can do at least as much research when selecting a fertility clinic as they would when purchasing a refrigerator. What’s needed to reduce the occurrence of multiple pregnancies resulting from fertility treatment is a combination of physicians’ responsibility to follow guidelines, educating patients not to push for more drugs and embryos hoping to make this largely uninsured treatment work faster, and society to provide insurance benefits for infertility to reduce the financial pressure on the patients to demand unsafe measures in order to achieve a quick pregnancy, disregarding the dangers involved. Finally, state medical boards can and should hold those physicians who violate guidelines and cause a reproductive nightmare accountable for their actions.

Dr. Wisot is a fertility specialist with Reproductive Partners Medical Group in Southern California and author of “Conceptions & Misconceptions” the informed consumer’s guide through the maze of in vitro fertilization (IVF) and other assisted reproduction techniques.

Octuplets' mom was hoping for 'just one more girl'

2009-02-02T10:54:00.000-08:00

Octuplets' mom was hoping for 'just one more girl,' grandmother says
Nadya Suleman, a 33-year-old mother of twins, octuplets and 4 other young children, loves being around kids and was not seeking fame or financial gain, her friends and family say.
By Jessica Garrison and Kimi Yoshino

Reprint from Los Angeles Times Article featured on January 31, 2009

Nadya Suleman's goal in life was to be a mother, her friends and family said. That is why, even with a brood of six, including 2-year-old twins, she decided to have more embryos transferred in hopes, her mother said Friday, of getting "just one more girl."

"And look what happened. Octuplets. Dear God," Angela Suleman said four days after her 33-year-old daughter became the second person in the U.S. ever to give birth to eight babies at once.

Suleman stressed that her daughter "is not evil, but she is obsessed with children. She loves children, she is very good with children, but obviously she overdid herself."

Angela Suleman said all the children are from the same sperm donor, but she did not identify him. Her daughter is divorced, but Suleman said the ex-husband was not the father.

Suleman said she is caring for her six grandchildren while their mother is in the hospital recovering. She said she had few details about how the octuplets were conceived and did not know the identity of the doctor or the clinic that transferred the frozen embryos into her daughter's uterus. Suleman said it was not Kaiser Permanente, where the babies were born.

Fertility experts have raised concerns about the number of embryos implanted and whether the procedure was within medical guidelines.

"I cannot see circumstances where any reasonable physician would transfer [so many] embryos into a woman under the age of 35 under any circumstance," said Arthur Wisot, a fertility doctor in Redondo Beach and the author of "Conceptions and Misconceptions."

Doctors probably could not deny treatment to a woman simply because she already has children, he said. However, he added, they should have taken steps to make sure she did not have so many babies at once.

"I certainly think you can talk to her about it if you feel like she's making a decision that's not in her best interest or the interest of her children," Wisot said. "You can send her for psychological evaluation, but I honestly don't know if you can say, 'No, I won't take care of you because you have too many children.' "

Dr. Geeta Swamy, an assistant professor of obstetrics and gynecology at Duke University, told The Times this week that the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists advise doctors "to curb these higher-order multiple gestations," she said. "But it really is still up to the individual physician. There aren't any laws or legal ramifications to it."

The California Medical Board, which investigates doctors, and the California Department of Public Health, which licenses clinics and hospitals, said no doctors or facilities are currently being investigated regarding the births. It is also unlikely that the Los Angeles County Department of Children and Family Services would get involved unless it receives a complaint of child abuse or neglect.

Allison Frickert, a friend of Nadya Suleman, said the mother was not seeking potential fame or financial benefit. "There was no overriding situation, other than having more children to love," she said.

"Her whole life, she couldn't wait to be a mom," Frickert said. "That was her No. 1 goal."

Friends and family also reported that Nadya Suleman worked as a psychiatric technician until she was injured on the job. Then she began having children and enrolled in school.

She graduated from Cal State Fullerton in 2006 with a bachelor of science degree in child and adolescent development, school officials said. She returned to pursue a master's in counseling, but last attended in the spring of 2008.

By juggling school and six children, Frickert said, Nadya Suleman proved to be "a lot more capable than the average person in handling stress."

She and her children live with her mother in a 1,550-square-foot home in Whittier, and her father has been working in Iraq as a translator to help support the family.

In 2008, Angela Suleman filed for bankruptcy, claiming nearly $1 million in liabilities mostly due to a bad housing investment, her bankruptcy attorney said. Suleman said Friday that she had withdrawn the filing and paid her debts.

As the media camped outside the house, Angela Suleman said in a telephone interview that she could not explain her daughter's decision.

Nadya Suleman has always loved children, her mother said. Then she sighed. "I wish she would have become a kindergarten teacher."

jessica.garrison@latimes.com

kimi.yoshino@latimes.com

Times staff writers Alan Zarembo, Tony Barboza, Corina Knoll, Richard Winton, Garrett Therolf, Janet Lundblad and Scott Wilson contributed to this article.

Wisdom from Wisot Wednesdays, Round 14! - Reprint from Redbook’s Fertility Diaries

2009-01-29T14:51:00.000-08:00

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.

Diet, Lifestyle and Male Fertility

2009-01-29T14:40:00.000-08:00

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

Age and Ovarian Reserve: Predictors of Fertility Treatment Success

2009-01-27T12:01:00.000-08:00

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.

Wisdom from Wisot - Redbook Magazine Fertility Q & A

2009-01-27T11:43:00.000-08:00

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.

Tubal Disease, Hydrosalpinges and Infertility

2009-01-19T15:27:00.000-08:00

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

2009-01-19T15:14:00.000-08:00

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.

Fertility Q & A - Redbook's Fertility Diaries

2009-01-12T12:19:00.000-08:00

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.

Reproductive Partners Participates in New IVF Progesterone Delivery System Study

2009-01-12T12:06:00.000-08:00

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.

The Infertility Diaries

2008-11-06T10:11:00.000-08:00

I am now the on-call fertility expert for Redbook blog, The Infertility Diaries. View posts and answers to key infertility questions every Wednesday, at Wisdom from Wisot Wednesdays.

Fertility After Forty

2008-11-04T13:27:00.000-08:00

More than 15 percent of couples in the reproductive age group in the U.S. have difficulty conceiving a child. The tendency to delay childbearing in order to pursue an education and career has meant that more women in their late 30s and early 40s are attempting conception for the first time. Studies have demonstrated that almost 50% of women over the age of 40 will experience infertility. Because fertility in women decreases with advancing age, prompt evaluation and aggressive treatment are critical in infertile women close to or over the age of 40.

Numerous demographic studies suggest a consistent decline in fecundity (the chance to conceive in any given month) with increasing age. The average 25 year old woman who is trying to conceive may have a 25% per month chance of conceiving if all fertility factors are optimal. Compare this with the 5% per month chance for conception of the average 40 year old woman. This age associated decline in live births is due largely to abnormalities in the egg. The meiotic spindle, which helps the chromosomes segregate for cell division, exhibits abnormalities in chromosome alignment. This high rate of abnormal chromosome distribution is the major factor that can explain a lower rate of successful pregnancies in older women. In addition to decreasing fecundity, older women experience an increasing incidence of miscarriage. Women over age 40 have approximately a one in three chance of having a miscarriage in any given pregnancy. In addition, at age 40 one in sixty live births is genetically abnormal.

With this in mind, it seems reasonable to promptly evaluate women over 40 who are concerned about fertility. Before starting an evaluation, however, it is important to discuss some of the special considerations for the woman over 40 trying to conceive. These include general health issues, since women over 40 are more likely to have medical problems including diabetes, hypertension, heart disease, all of which can complicate a pregnancy. Therefore, we recommend that an over 40-year-old woman contemplating a pregnancy have a thorough medical evaluation, including a mammogram. The increased incidence of genetic abnormalities in infants born to women over age 40 and the recommendation for prenatal genetic diagnosis should also be discussed.

Patient Evaluation

The usual trial period of one year of attempting conception prior to an infertility evaluation is not appropriate for women who are close to forty years old.

A basic infertility evaluation is indicated for any couple who have been attempting conception for six months if the woman is approaching 40. First, an infertility history should include how long the couple has been trying to conceive, method of timing and the frequency of intercourse, as well as questions regarding menstrual regularity, premenstrual symptoms, and any prior pregnancies. Factors suggesting problems with the patient’s fallopian tubes, such as a history of sexually transmitted diseases, IUD use, or pelvic infection, should be noted, as well as any previous cervical procedures such as cryotherapy or conization. In addition, the patient should be asked about early menopausal symptoms.

Laboratory and other tests should include:

• A semen analysis for the patient's partner.
• Evaluation of ovulation: basal body temperature charts, a midluteal serum progesterone level, a urine luteinizing hormone ( L H ) t e s t using an ovulation predictor kit, or ultrasound monitoring of follicular development.
• An evaluation of the patient’s fallopian tubes and uterine cavity with a hysterosalpingogram.
• Evaluation of ovarian reserve (see below) Ovarian Reserve

Studies suggest that a woman's chronologic age and her ovarian reserve are independent predictors of fertility. Ovarian reserve describes a woman’s reproductive potential with respect to egg quantity and quality.

Perhaps the best method we have readily available to measure ovarian reserve is a cycle day 2 or 3 blood FSH (Follicle Stimulating Hormone) level and an estradiol (estrogen) level. This measurement may be very important in evaluating how aggressively to treat women approaching the age of 40 and also to give that woman a realistic idea of her chance for a successful pregnancy. The levels of FSH that are considered in the normal range are dependent on the lab where the test is performed. With modern techniques for measuring FSH, generally, a level of less than 10 is good, 10-14 borderline, and 15+ suggests a very low chance for successful pregnancy with fertility treatment with a woman’s own eggs. A single elevated FSH level predicts a poor prognosis even when subsequent FSH levels are normal. In women with a normal FSH, a Clomiphene
Challenge Test may provide more information about a patient’s ovarian reserve than a day 3 FSH level. Blood testing is done on day 3 for FSH & estradiol, clomiphene 100 mg day is taken on days 5-9, and a blood test for FSH level is taken on day 10. Elevation of either FSH level (day 3 or day 10) is a poor prognostic sign. Also a cycle day 3 estradiol level above 70 may suggest a lower chance for success. In a general infertility population an abnormal clomiphene challenge test predicts that a successful pregnancy will be achieved only about five percent of the time. Risk factors for early loss of ovarian reserve include smoking, family history of early menopause, shortening menstrual cycle interval and previous ovarian surgery.

The basic evaluation can be performed over a period of one month in women approaching 40 years of age, rather than spreading it over a number of cycles. Any abnormalities that are uncovered in the basic evaluation should be corrected promptly. If the evaluation is normal, or if abnormalities have been corrected and the patient still does not conceive in a short period of time, aggressive therapy is indicated. It may be difficult to convince a couple that has been trying to conceive for only six months that a very aggressive approach such as IVF may be necessary. Similarly, use of controlled ovarian hyperstimulation (COH) with gonadotropins (injectable fertility drugs) combined with intrauterine insemination (IUI) may be unacceptable to some couples. Knowledge of the patient’s blood FSH level may help to convince the couple that an aggressive approach is needed.

Treatment

Treatment options for age-related infertility include controlled ovarian hyperstimulation with intrauterine insemination (COH-IUI), IVF, and ultimately in nothing else works, egg donation. COH-IUI and IVF help by increasing the chance to conceive in any given cycle. They cannot improve egg/embryo quality. COH-IUI involves taking gonadotropins to increase the number of mature eggs released in a given cycle and the placement of washed sperm into the uterine cavity at the time of ovulation. This treatment has fair success in women forty and older, with pregnancy rates of 10 percent per cycle in a 2004 study. For couples with tubal disease, endometriosis, or sperm abnormalities, as well as couples with unexplained infertility who want to accelerate their chance for pregnancy, IVF is an appropriate option. Per-cycle pregnancy rates with IVF are higher than from COH-IUI, but do decline significantly with increasing age.

Egg Donation

Egg donation has become an accepted and successful technique to achieve pregnancy in older women. Studies show that average delivery rate of over 50 % per cycle can be expected in recipients who are aged 40 and older. This treatment is the only treatment available to improve egg/embryo quality in older women. Egg donation involves preparing the recipient’s uterus with estrogen and progesterone to create an optimal bed for implantation. The egg donor undergoes hormonal stimulation to produce multiple eggs. The eggs are retrieved with a minor procedure and fertilized with sperm from the recipient’s partner. Fertilized embryos are then placed into the recipient’s uterus.

Egg donation offers couples a number of advantages over adoption. First, the sperm is obtained from the patient’s husband, and therefore the child is genetically related to him.
Second, since the pregnancy develops inside the patient herself, she has control over such factors as nutrition, smoking, drinking or taking recreational drugs during the pregnancy, control she would not have in the case of adoption.

Finally, the woman experiences the positive feelings of pregnancy and delivery and is able to breast-feed. These are all important experiences in establishing positive feelings toward the infant. For the present, egg donation is the best medical option for women over the age of 40 who have repeatedly failed other fertility therapies, as well as for women with elevated FSH levels. Adoption is a wonderful alternative for women who do not wish to use a biological ortion.

Recommendations

One approach to therapy for the infertile woman aged 40 and over who has a normal evaluation is to first consider one or two cycles of COH-IUI. This will give the patient a chance of conceiving and also allows the physician to evaluate ovarian response for a future IVF cycle. In addition, it helps the patient get used to the idea of a more aggressive, "higher-tech" approach. For the patient who desires the highest chance for pregnancy with her own eggs, IVF is a more successful treatment per cycle.

If the patient does not conceive with COH-IUI, IVF is a next possible step. If her ovarian response is suboptimal, her embryo quality is very poor, or she does not conceive with IVF cycles using her own eggs, egg donation or adoption may be considered. For a patient with an FSH level of 10 to 12, it may be best to direct her promptly to an IVF cycle with her understanding that the chance for a successful pregnancy is reduced. Patients with a day 3 FSH greater than 14 might best be offered egg donation as the first-line option.

Summary

Some women seeking to conceive after the age of 40 have little difficulty in achieving a pregnancy. For those who do not, however, prompt evaluation and aggressive treatment are critical. The serum FSH level, along with the patient’s comfort level with aggressive treatment can help to guide the treatment. Egg donation offers hope to women who can not achieve a pregnancy using other treatments with their own eggs.

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.

Clomid—Moodiness and Multiples

2008-11-04T12:13:00.000-08:00

Clomid is an anti-estrogen drug used to stimulate the ovaries to produce mature eggs, and it's often the first choice for women who don't ovulate regularly. "Lots of people feel lousy on Clomid. We get a lot of complaints about feeling moody and out of sorts," says Dr. Arthur Wisot, MD, F.A.C.O.G., executive director of Reproductive Partners Medical Group, which has offices throughout Southern California, and author of Conceptions & Misconceptions: The Informed Consumer's Guide Through the Maze of In Vitro Fertilization and Other Assisted Reproduction Techniques. Most women only take Clomid for a few weeks and weather the emotional storms. But one of Clomid's most notable side effects is permanent! "The biggest side effect is multiple births," says Wisot.
Read more ….

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.

The Stress of Fertility Treatment

2008-10-08T14:52:00.000-07:00

The stress, strain, and feelings connected with infertility and its treatment are universal and not to be taken lightly. Even before a couple visits a specialist, the worry often begins. For any couple, just making that first appointment with a specialist is stressful. To the couple, the fact that they need to see a specialist may mean they truly may have a problem and worse, may be incapable of having a biological child. It also means going to a new doctor and a new office. It may take a while to get the courage to make an appointment, which adds to the stress. They experience the feeling that time is passing and everyone else seems to be getting pregnant. People are asking when they will have children, and there is no easy answer for that painful question.

The first phase of infertility treatment consists of probing questions about their sexual practices, diagnostic tests including blood tests, ultrasound examinations, semen analyses, and sometimes even surgery or painful "procedures." None of this is pleasant. Appointments are disruptive to people's schedules, and because it's not often covered by insurance, may be a financial burden. It also means more time passing without a pregnancy while it seems there are pregnant women everywhere. The specialist cannot start treatment without the diagnostic testing, but all the couple wants is to start their family.

Normally the doctor will explain what the treatment choices are, and the chances of success with each one. He or she will explain side effects of drugs and possible risks, such as a multiple pregnancy. There are just so many decisions to be made. Many couples have to self-inject hormones to stimulate the woman's ovaries, which is very challenging to people who, like many, hate needles. Then there are more appointments, more stress and more financial burdens. If the couple has to go on to IVF, there will be some complicated decisions about how many embryos to transfer and what to do with the others.

When treatment cycles end in disappointing news (no pregnancy or a pregnancy that fails), the negative effect can be overwhelming. Couples search for ways to cope, and ask the question "why is this happening to us?" There may not be an answer, certainly not a satisfying one and many people unfairly blame themselves and their own stress. Although there is

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.

Legal Considerations for Those Who Want to Conceive

2008-09-23T09:34:00.000-07:00

That’s the gist of a recent talk I heard on “Legal and Ethical Dilemmas in ART Today.” The speaker was Susan L. Crockin, Esq., who is very experienced in reproductive law and authors the “Legally Speaking” column in the American Society of reproductive Medicine newsletter.

Using case illustrations, her main point was that unless one is in a legally binding relationship such as a marriage, it is advisable to have the relationship between the individuals involved in the procreation clearly defined. When people enter into these relationships to try to create a child they assume that things will go well and sometimes they do not. Situations which may raise a red flag include unmarried couples, those using surrogates or a known egg donor, single women using a known sperm donor, same-sex couples who have not been able to enter a legally-binding relationship, especially if one member of the couple is providing the eggs or sperm and the other is the carrier or has no biological relationship to the child.

Many situations have led Reproductive Partners to require a legal contract. It’s most commonly required when a surrogate or egg donor is used. But in other instances a fertility center may be unaware of the nature of the relationship between partners attempting to conceive. And this recommendation is valid regardless of the method used to conceive the child, whether it’s by natural conception or IVF with ICSI and PGD. One situation in which Ms. Crockin thought a contract was mandatory is when people of different states are involved (i.e. a couple in California using an egg donor from Colorado and a surrogate from Arkansas). In this instance the contract should indicate which state’s law applies.

To me this recommendation makes sense: After all one should not enter into an investment or buy real estate with an individual with whom one does not have a legal relationship without a contract. But sometimes we do not apply the same common sense principles to our personal lives that we do to business.

Reproducer, beware.

Arthur L. Wisot, M. D.

Reproductive Partners Medical Group, Inc.

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.

Embryo Donation Works

2008-09-03T14:13:00.000-07:00

An email I recently received from a patient demonstrates how embryos created from successful IVF cycles that have been sitting in our facility for years can help create families for other unsuccessful patients.

The email was from a couple who had tried multiple IVF cycles without success and although she was relatively young we were never able to achieve success. Although we tested everything, we never found a reason for the repeated failures. This added to the frustration of the repeated failures.

On the other hand I had a couple who tried IVF because of secondary infertility and at the same time was struggling with the problem of what to do with a number of frozen embryos they had in storage. For ethical reasons they did not want to discard them and did not want more children. I brought up the concept of embryo donation and this option appealed to them especially since the recipient couple was planning to move out of the area.

Needless to say, the transfer was successful and all parties are thrilled. The previously unsuccessful couple has the child they had been longing for. The couple with the extra embryos are happy their disposition of their embryos resulted in them achieving their potential for life and that they got to give something back in return for their good fortune. And I am happy that I was able to help both couples.

Embryo donation works. I only wish more couples with unwanted frozen embryos sitting in freezers throughout the country would consider this option.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
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.

Court Backs Fertility Treatment Time Off

2008-08-13T10:57:00.000-07:00

As though it were not difficult enough dealing with the shots and emotional ups-and-downs associated with fertility treatments, one aspect of fertility treatment might just be getting easier. Taking time off from work may be one of the most stressful aspects of fertility treatment. As reported in the August 13, 2008 issue of the Wall Street Journal, a Federal Appeals Court three-judge panel in Chicago found that women who need time off from work for infertility treatment may invoke the Pregnancy Discrimination Act as potential protection against adverse action.

This ruling only currently applies in Indiana, Illinois and Wisconsin but an expected appeal for a rehearing by the employer to the full 11-judge panel may trigger a Supreme Court petition.

“Conceptions & Misconceptions” a “book by two fertility specialists” is listed in the article as a resource. The two fertility specialists are Dr. Meldrum and me.

Credits –

Dr. Wisot Discusses Clomid

2008-07-30T09:13:00.000-07:00

As a consultant on fertility issues for the Choice Mom community, choicemoms.org, I am frequently asked questions about treatment options for single women who are attempting to achieve pregnancy without a partner.

Q. What to do if my lining is thin on clomiphene (Clomid)?

One recent query sent to me by Choice Moms liaison Mikki Morrissette was about a woman whose RE clinic reported that her uterine lining was affected by taking Clomid, which had barely reached 6mm for her previous IUI. He recommended that she take injections [one option: Follistim]. She wasn't sure if the RE was erring on the side of too much intervention. She was concerned about the greater likelihood of having twins. And she was afraid that she would miss her next cycle while she waited to take the "training" required for the injections.

A. Success rates are not reported for this type of treatment so except for the doctor's pride this would not be recommended for the reason of increased success rates. I think most REs will actually try the most conservative treatments first. Of course there will always be someone who rushes patients into the highest level of treatment right away. But, as I point out in my book, Conceptions & Misconceptions," the treatment has to make sense and even a lay person can get a sense of what's appropriate. If there is a question, one can always get a second opinion.

The risk of multiples is increased over Clomid. That is true, but if the injectables are used judiciously the risk can be reduced, especially the risk of the higher order multiple pregnancies like triplets and above.

The injection training can be done in a few minutes and not really a reason for delaying a cycle.

But there is another alternative that you can ask for and do it in this cycle. If you use estrogen for five days after the last Clomid it may adequately thicken the endometrium and if it doesn't you can go to injectables next cycle.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center

Credits –

Brad and Angelina: Meet Louise Brown

2008-07-25T07:12:00.000-07:00

In an exclusive article just released in Us Weekly magazine it was disclosed that two of the world’s biggest celebrities and movie stars conceived their recently-delivered twins by in vitro fertilization (IVF). Coincidentally, this article was published 30 years to the week of the very first IVF birth (Louise Brown on July 25, 1978).

I am pleased that Us Weekly chose Reproductive Partners Medical Group, Inc. to be their source of background information on this important story. Here is an excerpt from the story as released on their website. For the full story, please see the August 4, 2008 issue of Us Weekly.

Forget Mother Nature – Us Weekly reports in its new issue, on newsstands now, that Angelina Jolie and Brad Pitt turned to fertility treatments to quickly conceive twins Knox and Vivienne. “They conceived through in vitro fertilization," a well-placed source within their camp tells Us. "They both desperately wanted more babies soon."

The chance of having fraternal twins at Angelina's age (33) naturally is under 1 percent; with in vitro, the chances are 25 percent. Says Dr. Arthur Wisot of L.A.'s Reproductive Medical Group (who did not treat the couple), "We live in an era of reproductive freedom, so anybody can do anything they want within legal limits."

The actress chose the procedure (which can cost around $12,000 a pop) so "she wouldn't have to deal with the stress of trying to get pregnant," the source tells Us. "She could just knock it out."

Indeed, Jolie has spoken about her goal to do just that. "If we're going to have 10 kids, we'd like to raise them while we're young," she told Elle U.K. last year. Brad Pitt turns 45 on December 18.

A source adds: "They were too impatient."

Knox and Vivienne – born in Nice, France on July 12 – join the couple's adopted brood of Maddox, 6, Pax, 4, Zahara, 3.

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.

Excerpts from the ReproductivePartners.com Infertility Bulletin Board

2008-07-15T14:31:00.000-07:00

Ask Dr. Wisot -

When to perform an insemination?

Q. Could you please give your opinion on what is the best time to perform an insemination (IUI) without any drugs in relation to the detection of the LH surge? Is it before or after detection of surge and please be specific with hours. There seems to be a lot of differing info on best times.

A. I usually recommend that a single insemination be done in a natural cycle the day after an LH surge is detected by an ovulation predictor kit. That’s because the surge usually precedes ovulation by 36 or more hours. You are detecting the surge sometime after it happened. Most women test once a day in the afternoon or evening, so they should be close to ovulation by the next morning. The egg has about 12-24 hours to be fertilized and the most sperm specimens can maintain good motility for 48 hours in the wash media, so the IUI does not have to be done at the exact time of ovulation. All the averages coincide the morning after the surge is detected, making it the most logical time to perform the IUI. Alternatives to using the urinary ovulation predictor kit to time intercourse or insemination are ultrasound or a variety of fertility monitors. At the time of the insemination an ultrasound can be performed and if ovulation has not occurred, the insemination can be repeated, insuring that it will be done as close to ovulation as possible.

With eight previous miscarriages what tests should I DEMAND?

Q. I have just lost my 8th baby due to early pregnancy loss. All losses have been at 11wks or earlier. The hardest part was there was a great heartbeat and a perfect looking baby. My OB/GYN said I was having a textbook perfect pregnancy. Of course I let my guard down, got excited and lost the baby almost 2 weeks later. The OB who did the D&C said she would have testing done on the placenta. What tests is she talking about? And more importantly we want to have a baby and are ready emotionally to try again, so what tests should I have done before we try again?

A. I am so sorry to hear about your repeated losses. You can be sure that your enthusiasm had nothing to do with the loss. The test the doctor wanted to do on the placental tissue was probably to examine the chromosomes to see if the baby was normal or abnormal. That could provide clues on what is causing the problem and how to deal with it.

Once you recover from this miscarriage you might want to see an Ob/Gyn who treats recurrent miscarriage or a reproductive endocrinologist to review your history and see what tests are appropriate. Yours does not sound like the typical case and I really can't tell specifically which tests should be done from this information. Generally the tests will check the following issues:

· The chromosomes of both partners

· The quality of the woman’s eggs with hormone tests

· Abnormalities of the uterus

· Infection with an organism-ureaplasma

· Progesterone levels/development of the uterine lining

· Abnormal antibodies in the woman’s blood

· Heredity blood clotting problems in the woman

By the way, when anyone approaches a doctor I would recommend that one not start the interaction by “demanding” that something be done. Start by listening to the doctor’s advice and then add any “request” you may have with the reason you want something done. The best doctor-patient relationship is one of mutual concern, cooperation and trust. If one does not feel that their doctor is concerned about their problem, not willing to reasonably cooperate or they do not trust the doctor, it is best to find another doctor.

Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
Southern California Fertility Center

Credits –

Male Infertility: Intracytoplasmic Sperm Injection (ICSI)

2008-06-20T15:12:00.000-07:00

Background

Male infertility accounts for the reason for the problem in approximately 40% of the 2.3 million couples experiencing infertility in the US. Traditionally, couples with severe male factor had three options: using donor sperm, adopting or electing not to have children. The plight of men with severe sperm problems having their own biological children was a strong force in the development of new approaches.

Treatment of male infertility often depends on the specific cause of the infertility and can include surgery, medical treatment and if those are not effective, microinsemination techniques. Microinsemination is laboratory assisted fertilization of an egg. Intracytoplasmic sperm injection (ICSI), a specialized form of microinsemination, was first developed by reproductive medical specialists in Belgium to help couples overcome male infertility problems associated with an inability of sperm to fertilize an egg. Since then, ICSI has been successfully used to treat many types of male infertility and is helping more couples realize their dream of having their own biological children even in the most severe cases of male infertility. Today, the technique is no longer considered experimental and is among our routine services.

The ART of Parenthood

There are several Assisted Reproductive Technologies (ART) that have been developed to assist couples in having children. Among them are: in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), egg donation, cryopreservation with subsequent thawing and transfer of embryos, and a growing number of microscopic techniques such as ICSI and most recently, preimplantation genetic diadnosis (PGD). These microscopic procedures are the most demanding and exacting part of ART.

Male Infertility & ICSI

Fertilization of the egg by ICSI, getting one sperm into one egg, is the starting point for embryo development. For many years the only approach available for fertilizing an egg in ART procedures was to imitate what occurs in fertile couples, incubating the egg with sperm. This approach is successful in fertilizing approximately 75% of eggs in men with normal sperm parameters. Microinsemination techniques were developed to improve the likelihood of fertilization in men whose sperm parameters are markedly abnormal. Male infertility can be associated with the production of low numbers of sperm, sperm that do not “swim” properly or do not swim at all, and sperm that are abnormal in shape. Abnormally shaped sperm have reduced ability to penetrate the egg.

Non-ICSI insemination can be a difficult process in men with abnormal sperm parameters for two reasons: the sperm must first reach the egg and then penetrate the egg. They may not have adequate numbers, motility or normal morphology to have a good chance of their sperm accomplishing these two tasks. ICSI overcomes these deficiencies by injecting a single sperm into an individual egg. ICSI makes a low number of sperm, “poor sperm motility” and “poor sperm morphology” no longer barriers to couples who seek to have their own biological children.

In some men, the tubes known as the vas deferens that transfer sperm from the testis are blocked or missing through a congenital abnormality, an accident, a disease or an irreversable vasectomy. In such situations, sperm may be obtained by a surgeon from the epididymis, the site where sperm are stored through a process called percutaneous epididymal sperm aspiration (PESA). In men with other severe problems, sperm can be obtained by testicular biopsy (TESE). ICSI makes it possible to use epididymal or testicular sperm to achieve a pregnancy. There is also the situation where, for unknown reasons, a man’s sperm does not penetrate the woman’s egg, even though the number, shape and motility of the sperm all appear normal. ICSI is also appropriate treatment in these situations.

ICSI - The Technique

ICSI requires only one sperm per egg to be effective. ICSI is a simple and elegant way to transfer that sperm directly into the egg. Using a microscope, the embryologist gently draws one sperm into a pipette. The tip of the pipette is then guided into the waiting egg. The egg is held steady at the end of another glass pipette. Then with a steady and measured forward motion, the sharpened tip of the sperm-containing pipette is inserted into the egg. Reversing the process that pulled the sperm into the pipette, the embryologist now ejects the sperm into the egg. And finally, the sharpened tip of the empty pipette is removed from the egg. After picking up the sperm, the entire ICSI technique takes the embryologist less than ten minutes.

ICSI - Does it damage the egg?

ICSI procedures are routinely done successfully without damaging the egg in most cases.

This is not surprising to embryologists for several reasons. First, the egg is many times larger than the pipette that is used to penetrate its surface. Second, the human egg is encased in a tough, elastic membrane that usually doesn’t crack, shatter or crumble.

Finally and most important, Mother Nature lends a hand: the egg has the ability to rapidly repair the small hole in its membrane made by the pipette.

ICSI - Are there any side effects?

Despite widespread use and acceptance, ICSI is still a relatively new procedure. Children born as the result of ICSI are still very young and have not yet reached an age to reproduce. Genetic reproductive abnormalities in the father can be passed on to male offspring. Currently there are reports of a small increase in minor birth defects and congenital abnormalities in babies born through ICSI. This is not surprising since it is usually being performed in couples in which the man has very abnormal sperm. In addition ICSI bypasses an important natural process of sperm penetration.

Theoretically, this could permit the transfer of certain conditions that have a genetic basis. Where a genetic basis for male infertility is suspected or known, the couple may also find it helpful to speak with a genetic counselor before choosing to use ICSI, as well as have genetic testing for abnormal chromosomes or microdeletion in the male (Y) chromsome.

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.