Wisdom from Wisot Wednesdays, Round 19!

Reprint from Redbook’s Fertility Diaries

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

Question #1: Dr. Wisot, I have hypothalmic annovulation and my doctor has started me on high doses of Repronex on my last two cycles (both which ended in negative pregnancy test). I responded great, but my doses were like 250units for the first 5-6 days, then 150units for the last 3 days. Followed by IUI. Do you think too high of doses can cause poor egg quality? Should we start at a lower dose?

Answer: The dose needed is dependent on the exact cause of the lack of ovulation. If it's really hypothalamic (the hormones from the hypothalamus are dysfunctional), lower doses of pure FSH will usually work. Pure FSH drugs have no LH; the body manufactures it itself so you don't need extra LH. Repronex has both FSH and LH and the higher doses of LH can affect egg quality. If the problem is hypogondotropic (the body does not produce FSH or LH) then both are needed and in fairly high doses. But based on two cycles you can not assume that this is an egg quality issue. Even at a young age, all this can do is restore you to normal fertility for your age and that would give you a monthly fecundity rate (the rate at which women conceive per cycle at a given age) that would probably give you less than a 50% chance of conceiving in two cycles. It may need more time.

Question #2: Hi, Dr. Wisot. I am writing in reference to this week's #2 question about a husband taking Clomid that increased his sperm count "from 1.5 to 3 million in 12 weeks." Is Clomid often used to increase sperm count? I had asked you a question via this site a few months ago. I am 32, DH 38 diagnosed with male factor: low count. Of 3 sperm analyses his counts were: 2.92, 4.7, 7.1. We are currently in the middle of our 2WW with IVF/ICSI #1 (I'm a nervous wreck!), but in the meantime...would this be an option for us? For him to try the Clomid thing to increase his count? This would be so much more affordable for us. Again, thank you so much...for all that you do! Your shared knowledge and expertise is so greatly appreciated!

Answer: I am not an expert in male fertility so I turned to Dr. Jacob Rajfer, Professor of Urology at the UCLA School of Medicine, who is a male fertility expert extraordinaire. He says that Clomid may be used primarily in men who have both low counts and low testosterone levels. "Clomid is used to increase the testosterone levels within the testicle. This supposedly is "beneficial" for speramatogenesis (making sperm). Since each sperm takes about 70 days to form and then it takes about 12 or so days for it to transit from the testicle to the outside, Clomid should be used for a minimum of 3 months and preferably for 6 months, which includes two full spermatogenic cycles." But let's hope the IVF worked so you will not be confronted with this issue. If it doesn't, ask your doctor if this would be an appropriate course of treatment for your husband.

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.