Top Ten Misconceptions About Infertility Treatment

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.

Tubal Disease, Hydrosalpinges and Infertility

Approximately 25% of female infertility is due to blockage of the fallopian tubes. The fallopian tubes are very delicate structures that are responsible for picking up the egg and providing the site for fertilization and early embryo development. The tube is narrowest at the inner portion that joins the uterus and then widens in the outer portion that has ¬ne projections called ¬mbria. The ¬mbria are responsible for picking up the egg. The cells lining the tube produce secretions that nourish the egg and embryo. The tubes can frequently be damaged by infections (e.g., chlamydia, gonnorrhea) or other pelvic conditions such as endometriosis or even severe appendicitis. Scar tissue and blockage can occur at either the inner or outer portion or in both of those regions. If blockage occurs at the outer portion, tubal secretions will not be able to drain out of the end of the tube and can be retained in the tube (hydrosalpinx). If the tube is open at the uterine end, those embryotoxic secretions can drain back into the uterus, impairing implantation or result in the miscarriage of an implanted pregnancy.

There are two di erent approaches to treating infertility that results from tubal damage. If there is mild damage, surgical repair can be attempted. If there is severe damage, the results of surgery are frequently poor and IVF (in vitro fertilization) is recommended to bypass the damaged fallopian tubes. The success rate of surgical treatment of a tube that has become a hydrosalpinx is usually very low.

The IVF process includes 4 steps designed to bypass the fallopian tubes:

1. Stimulation of the ovaries with fertility drugs to produce multiple eggs (ovulation induction.)
2. Retrieval of eggs from the ovary. This is performed by placing a needle through the upper vagina into the ovary under ultrasound guidance using deep sedation or spinal analgesia.
3. The eggs are then fertilized with the partner’s sperm.
4. The resulting embryos are allowed to develop in the laboratory for 3-5 days and are then transferred into the uterus.

It would seem that the ability to bypass the tube with IVF makes this the ideal treatment for tubal damage. Careful analysis of the results of this treatment have shown a low rate of success if a hydrosalpinx is present. One of the ¬rst studies showing this e ect was published as early as 1994 by a group from Sweden that found only a 6.6% IVF success rate in the presence of hydrosalpinx compared to 18.2% with tubal disease and no hydrosalpinx.

A paper in January of 1998 showed only four deliveries in women with a hydrosalpinx who had undergone 47 IFV cycles (8.5%.) As a controlled group, there were 97 patients who had tubal disease, but did not have a hydrosalpinx. In this group, there were 44 deliveries in 145 embryo transfers (30.3%.) This striking difference in the success rate seems to confi¬rm the negative effect of the hydrosalpinx. The suspected mechanism of this effect is that the fluid that builds up within the fallopian tube flows backward into the uterus. This fluid can be toxic to the embryos and can have a negative effect on the uterine lining. It stands to reason that the negative effect would be eliminated by preventing the fluid from flowing back into the uterus. Thus, we recommend that laparoscopic surgery or hysteroscopic with Essure plugs be performed on all patients with a hydrosalpinx which communicate with the uterus prior to IVF. Depending on the extent of the tubal damage, we recommend either blocking the tube with cautery or Essure, or removing the damaged tubes.

Twelve women with a hydrosalpinx who had not conceived with previous IVF attempts in that 1998 study had surgery performed. Of 16 subsequent IVF attempts 6 (37.5%) deliveries resulted. Subsequently surgery was performed by the same group on an additional 25 women who had a hydrosalpinx, but had never been through IVF before. Their 29 IVF cycles following the surgery resulted in 15 deliveries (51.7%.) This is very convincing data that surgically treating hydrosalpinx prior to IVF overcomes the negative effect.

The negative effect of hydrosalpinx has been confirmed by the vast majority of the many studies evaluating this issue. This is a very important ¬finding as it may explain why some women with a hydrosalpinx have failed to conceive despite good IVF cycles. Careful consideration should therefore be given to surgically correcting hydrosalpinges prior to attempting any IVF cycle.


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

Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.

Fertility Q & A - Redbook's Fertility Diaries

Wisdom from Wisot Wednesdays, Round 12! - Reprint from Redbook's Fertility Diaries
January 14, 2009 at 10:00 AM by Cheryl | 3 comments


Hello! Sorry I've been MIA. My Hunky Husband and I took a little vacation. But I'm back just in time for our weekly Q&A with top fertility expert Dr. Arthur Wisot. I love how the questions seem to take on a theme each week. Today's hot topic: egg donation. Before we get started, the doctor's disclaimer: "My answers to questions on this blog do not constitute medical advice, but are merely meant to create an educational forum for consumers. It is always best to discuss these issues with your health care provider." The good doctor's answers are below, in bold:

Question #1: Hi. I am 34 and have been trying for almost two years. I have done two IUIs with injectables and got pregnant both times, but miscarried. I just did my first IVF. I was on the pill for a month (I get a lot of cysts on my ovaries, they needed to disappear before IVF) then did the flare protocol, using 300 Gonal F, 225 Menopur, and 10 units Lupron. I got 5 follicles but only one had an egg, and that was immature and did not fertilize. I have mild to moderate endometriosis (90% removed in September) and some of it has already returned to my ovaries. FSH 7, AMH around 1. My questions: Since this cycle was a spectacular failure, do you think I should move to donor eggs? Or, do you think the fact I got pregnant from two out of two IUIs is encouraging and I should try once more with a different protocol? Thanks so much.

Answer: I really can't give a good opinion without all the information. But this strikes me as a situation which we see often in women with severe endometriosis. Between the damage the endometriosis does and the surgery to remove it, one may be left with few early follicles capable of stimulation. But with the normal FSH and your response in the two IUI cycles I would guess that the eggs you produce may be good. Maybe IUI is a better treatment for awhile before jumping into another IVF. Sometimes pretreatment before IVF with Lupron for three months or birth control pills with letrozole for two cycles may deal with some of the bad effects of the endometriosis. It's not so much about how many eggs you can make, but to make the best of the few you do make. All the follicles contain eggs and I do not understand why they only retrieved one. That can and does happen but it's more about the maturity of the follicles and the adequacy of the dose of hCG than about endometriosis. Depending on your tolerance for more of this, I would not yet be running to egg donation. But if you are tired of all this and want a quick fix, egg donation might be the way to go.

Question #2: Hi. I'm not actually dealing with infertility, but I'm very interested in your thoughts regarding the risks and benefits of becoming an egg donor. I'm currently a college student, very healthy, and recently became curious about the process. I really like the idea of helping a deserving couple become parents. However, I'd like to know a bit more about the donating process and what the risks and benefits are. Thank you.

Answer: Sounds like you would make a good egg donor. Most of the risks are related to the egg retrieval in which a needle is passed through the vaginal wall into the ovary. Stick a needle in someone and you can cause bleeding, introduce infection or injure some adjacent organ. The other major issue is overstimulation of the ovaries which can vary from a nuisance to a serious medical condition. Fortunately both of these occur very infrequently. We have a 13-page informed consent that the donor has to read and sign that outlines the entire process and risks. The process involves birth control pills, fertility drug injections, ultrasounds, and blood tests and then the egg retrieval under sedation or anesthesia. The most frequent complication of egg donation is...well maybe I'll let you all guess and tell you next week. Post your guess.

Question #3: And one logistical question: I am a So. Cal. girl and was intrigued by Dr. Wisot's post about participation in a national study. Should we just call his offices in the South Bay to try and participate?

Answer: Just call our toll free number (877) 273-7763 and they can have you make a consultation appointment at your nearest Reproductive Partners office in Los Angeles and Orange Counties. We are definitely looking for subjects. You can check out this link to more information about the study.

Excerpts from the ReproductivePartners.com Infertility Bulletin Board

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 –

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.