Wisdom from Wisot Wednesdays, Round 15!

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.

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

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.