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A Marathon of Infertility Questions

Posted Apr 28 2009 1:41pm
As this Sunday was the New York City Marathon, I figured I would have my own little marathon and answer all of the outstanding questions. Here it is.
It took me a few days to cross the finish line, but I was able to eat and sleep along the way, possibly experience some weight loss, and I seem to be injury free.

From October 4th

Niki has had a very tough time trying to have a child. She has had a number of bio-chemicals and worse (see her post). Her basic questions are 1) is a thinish lining the reason, or is it an immune problem, or some other problem we just don’t know about?
I also do not buy into the immune issues. These have been studied now for many many years and never has anyone produced a quality study showing they mean anything. However, you have few choices, so it may be reasonable to consider getting tested and treated, if something shows up. I am not recommending one way or the other. You should give equal consideration to a carrier.

Esther had open tubes on hsg and a few weeks later had both tubes blocked at laparoscopy. She is being told she needs IVF.
I am not so sure. When I have open tubes on HSG, I don’t even check at laparoscopy. Why? Because it is common for tubes to be open on hsg and closed at laparoscopy. It’s a mechanical issue. Sometimes the doctor just has trouble getting dye out the tubes at laparoscopy. Now it depends on where the blockage is. If you have proximal occlusion (blocked at the uterus), this may be a false finding. If he says you have bilateral hydrosalpinx (blocked near the ovaries) that’s different and real. If there is any question, the answer is simple, just repeat your hsg. If the tubes are open on your next hsg, there were not blocked at your laparoscopy.

Mosche and his wife need IVF with ICSI due to male factor, however even with ICSI, there was no fertilization.
I have only had one young patient make many eggs and not fertilize with icsi. So it can happen, but it is rare. It’s a little more common when there are also issues with advanced maternal age and low egg number.

Ruby asked about sperm antibodies.
I do not believe in them because no good recent scientific paper written showing me that sperm antibodies are relevant.

Angie did a clomid IUI cycle, and the sperm count was 18 million with 56% motility.
The count sounds reasonable for iui. Although you should still ask for the total motile count, and look for that to at least be over 5 million, preferably over 10.

Tabi did 4 IVF cycles, 3 with lupron, one without. The non-lupron was her worst.
We don’t know if it was the no lupron, or was it just going to be a bad cycle for you that month, independent of your stimulation protocol. It may be that in your case lupron is better. For most women who make few eggs, this is not the case, but not all women are the same. I don’t think you are declining.

Ali did IUI. The sperm count was 143 million with 48% motility. However for the iui, only 3 million were recovered.
This is strange and does not make much sense; unless the initial volume was very low (2cc is normal). I am not worried about his morphology. “Abnormal” sperm are not removed when preparing for iui.

Manny and his wife are trying to conceive. He is asking if the lining could be an issue, especially because she takes anti-migraine medication that theoretically could restrict blood flow to the uterus.
The question is interesting, but unknown. One option is to measure the lining on and off the medications. Or, try to conceive off the medication. Another option is to look elsewhere for a potential problem. Do the basic workup i.e. semen analysis, HSG, day 3, to see if there are not bigger problems with more known quantities.

Anonymous has PCO and 2 weeks of bleeding after clomid.
This is not normal. Actually, the first cycle sometimes the bleeding can be unusual, but once you get into a pattern of periods, they should not be 2 weeks long. You need a good exam and ultrasound and maybe an endometrial biopsy.

Anonymous is 42 yo with 3 failed IVF cycles. Some borderline FSH levels and 1, 1 and 3 embryos available for transfer. Should she stop?
Your odds are what they are, low. It depends on your clinic, but your chances are probably about 5-10% per try. Many women, probably most, would stop here. But some persist, and a few get pregnant. As you know there are emotional, physical and financial issues to wade through. You can’t say you didn’t try. I hope it works out.

Mark is asking if he and his wife should consider natural cycle or minimal stimulation IVF vs. the standard IVF using more drugs.
You will need to decide. My only comment on your post is that it is not true that fertility drugs for regular IVF will ruin the eggs forever. But the opposite is also true. If you do a natural cycle, you can always do a regular cycle later. Regular IVF may not be for everyone, however, for most people, it has a higher pregnancy rate, which means a better chance of having a baby. The cost is less for natural, but with its lower pregnancy rate, it is common (not in every case) to spend at least as much money because the cost of multiple cycles really adds up fast. If you get pregnant early, great, you were the lucky one.

Erika has had 9 pregnancy losses and IVF is now recommended.
I understand the theory; if you put more than one embryo in, maybe if one fails another one will stick and you can have a normal pregnancy. Certainly, your odds of loss will be higher than the average person, even with IVF. I don’t think we can tell you that your odds of loss will be lower than from a natural pregnancy. However, your options are limited, so it may be worth a try.

Dizzy has totally unexplained infertility. All tests are very normal and she is 31. She has done 6 FSH iuis and is considering IVF, but insurance does not cover.
IVF is the next step. No one will be able to tell you why you are not getting pregnant, but IVF has an excellent pregnancy rate, even if you have failed FSH iui. You odds with FSH iui are now going down, because it has not worked. Of course you could do more FSH iui, and it may work, but it may be more of the same.

Purple Mocha has a 3 mm lining on clomid.
Sounds a little too thin. You can try again, or change to FSH. You could also check you lining in a no drug cycle to see what your baseline is. Of if you want to get going, just go to the FSH.

Mtroth has some endo and failed one IVF cycle, which was complicated by hyperstimulation. She has frozens. Did an undiagnosed biochemical pregnancy lead to her hyperstimulation?
You may have had a biochemical, but probably had plain old hyperstimulation. Your estradiol was high and you needed to be coasted. I do not think the endo was an issue. You can’t prepare for the FET. The good news is you seem to have nice embryos and should do well.

Athena has 8 months of infertility, short luteal phases of about 10-11 days, and serious pelvic pain. Her doctor will not see her until she has a year of infertility.
Maybe you have insurance that will not pay your doctor until there is a year of infertility, or maybe he is not a nice person. See which it is. If you think your timing has been good, it would be better if you saw him or another doctor soon. In general I do not believe in luteal phase problems, but you may be an exception because your luteal phase is so short. But do not only get that treated; work on other things at the same time. Get the hsg and ultrasound to look for cysts and endometriosis. Get the sperm checked.

Anonymous is an over-exerciser and because of this does not get her period on her own and does not bleed after provera. Because clomid starts after the period she does not know that do about starting the clomid.
You can start the clomid without a period, providing you get a pregnancy test. I am fine with you trying the clomid, but may women like you do not ovulate on clomid because, due to the exercise, your pituitary does not have much FSH or LH, and clomid works by releasing FSH and LH from the pituitary. Most of time, injected FSH is necessary to get you to ovulate. But you can try, sometimes it works.

Milka is 37 and her doctor told her her IVF failure was age related. He also wants to repeat her sonohyst and cultrures
I do not repeat those tests unless there is a good reason. Failing IVF is not a good reason. Your failure was not age related, you are young compared to many fertility patients.

From October 15th

Niki wrote back and did her IVF cycle, froze all due to lining issues. She is considering a carrier and does not want pgd.
It all sounds reasonable to me. It will have to be your choice.

Anonymous has pco and endometriosis. She did 8 clomid cycles and is in her last FSH iui cycle. Should she do IVF?
If you have done 2-3 FSH iui cycles, IVF is the next step. I like the way your doctor is doing the FSH iui. I am very optimistic. You are 28 and have eggs, that’s all it takes (in most cases). I expect you to do well and get pregnant quickly.

Anonymous is 33 and has had 3 miscarriages.
You odds are still excellent of having a baby in your nest pregnancy. Your doctor needs to do a miscarriage workup.

Anonymous has a normal pap with some cells missing and burning and numbness in her vagina.
As long as your doctor and the report say the pap is normal, it’s normal. I do not think the burning is related to antibodies, and it’s not due to the pap.

Diana was diagnosed with a septum and that was corrected. She then had to delay fertility treatment for treatment of thyroid cancer. New she is trying again without success. She is 35.
Give it the 3th month, but start making plans if things do not work. As far as your next steps, you know the drill. Get the options, get the pregnancy rates, and then decide which treatment sounds best for you. Be sure all of the septum is gone. I see many patients who have had septum surgery, only for me to tell them their doctor left a lot of septum still in place.

Anonymous does not get her period and is starting with a SIS.
I does not matter if you see her or a RE, but you need assistance ovulating ASAP. I don’t get the SIS, unless she sees something suspicious on ultrasound. You need to ovulate and this will probably require medication. Ask the doctor about getting the HSG before you try, or trying a little while (with ovulation) and then getting the HSG.

April did an IVF cycle with some immature eggs and late icsi. The embryos did not look good.
It sounds like there were a few issues with your cycle, but they seem correctable in the next try. It’s hard to tell if there was a problem with your IVF clinic, or things just want bad on their own. If you think you are at a very good place, give them another try. If you have reason to believe there is a better clinic near you, make the switch.

Shari in Chicago has endometriosis. She was treated with lupron and is waiting a long time for her period to return.
It works like this. The lupron is given every month (unless you have the 3 month version), and that lasts about 5-6 weeks in your system. Then you need to start your cycle again, and most women ovulate 2 weeks after that, and get a period 2 weeks later. That means you get your period about 8 to 10 weeks after you last shot.

Christine asked if IVF babies were born earlier and or smaller than non-IVF babies.
The answer is maybe. Some data suggests this is the case. However not all studies break out singletons from multiples, which usually deliver early. If there is an association, it may be due to the fact that some women with infertility may have uterine abnormalities that cause premature delivery. It is also possible that infertile people are more likely to have subtle genetic issues interfering with the length of pregnancy or the size of their babies. Or it may be that there is no difference at all and the right studies have not yet been done. Or maybe the IVF process is flawed and babies are smaller and deliver early. At this point, if there is a difference it does not seem to be great.

Alesha is trying to have her second IVF baby. Her first was at age 32, she will be 35 in January; her FSH is normal. Because she is a teacher, she wants to wait till summer to try. Her doctor says try now; her ovaries may change in the next 7 months.
It will be a little harder then, but if you are very fertile now, you will be very fertile then. Although there is a small chance he is right. Don’t forget you will be 3 years older than you were at your first try. I think it’s up to you, but consider this. Many women become very sad when they get pregnant on their first try, but not on their second, because it seemed so easy the first try. This could happen, and your following cycle will need to be during school, which is what you were trying to avoid. Therefore, why not just do one during school now. The logic is a bit of a stretch but I hope you get the point.

Leila has endometriosis and a fair response to meds. Her first 2 cycles yielded few eggs, and she did much better with a day 2 start than with lupron or microdose. If this fails, should she try again?
This cycle was very encouraging. You are only 36 and make 11 eggs, not bad at all. Question for your doctor: do you really need icsi? It sounds like you are on the right track. Consider the same protocol or estrogen priming.

Anonymous asked why go to FSH iui after 6 failed clomid cycles? Why not go to natural iui?
For younger patients, natural iui has a 5% pregnancy rate and FSH iui has a 20% rate. You can do whatever treatment you are comfortable with, just know the odds.

Anonymous is 42 years of age and has a FSH of 18. She failed a response using 14 days of lupron and 750 units of FSH. Should she stop?
It really does not sound encouraging. If you really wanted another try, ask your doctor about the estrogen priming protocol. Lupron is not the best for poor responders.

Anonymous has irregular cycles and is trying with clomid. She is using cervical mucus to time things.
Use an ovulation predictor kit instead. You can get pregnant with mucus that is thicker, but, if the clomid does not work after 3-6 times, ask your doctor about FSH. You may get pregnant before you get to the FSH.

Anonymous did 2 clomids, 3 FSH iuis and one IVF. She made 9 eggs but had slow embryos.
Get yourself to the best IVF clinic available. It may be where you are, or you may need to switch. Check rates at SART.ORG. Use a different protocol. I hope it works out.

Beth was diagnosed with endometriosis and is not ready to conceive. Should she go on Lupron for 9 months?
9 months sounds like a long time to me. The pill is definitely an alternative to lupron. Ask your doctor or get a second opinion.

Amila had an iui, had intercourse that evening and then had an iui the next day. The second iui had a lower count.
Probably too much. Stick to the iui’s.

Jesse b: Wife 30 he is 34. They just started the workup and were found to have one blocked tube and a low morphology. Their doctor is already talking about IVF.
Wow, they are going fast! First of all, if the tubal blockage is “proximal occlusion” a laparoscopy is aggressive. It is an option, so is repeating the hsg. It may have been spasm. If it shows distal occlusion, maybe surgery is more indicated. The morphology is probably not an issue. I don’t why they don’t just consider clomid first. Even if one tube is blocked and one is normal, it may be worth a shot with clomid. Of course, ask your doctor or get a second opinion.

Anonymous is 37, has a bicornuate uterus and a poor response. 4 failed ivf cycles, 0-6 eggs each. Her husband had a vasectomy.
Since your last protocol seemed to work best you could try one more cycle. You could also consider stopping. If you do another, consider the same protocol you just used. The reversal is not a bad idea, because at least you can try every month. But, they don’t always work, or they work but the counts are low.

Lisa tried many natural donor sperm cycles then used low dose FSH and got only 1 egg. She is worried that if she made only one on FSH, maybe she made none on her own or on clomid.
I believe you made one on your own and one or more on clomid. Your doctor did the right thing trying to control your dose, but now it seems you need a little more. It can work with the one. If not you may need a little more drug.

Anonymous has a doctor who wants to do an endometrial biopsy the month before the IVF cycle to promote a better lining.
Most of us do not do this. If your doctor can do a study, or maybe he has seen such a study proving it works, fine with me. But I am not aware that this method is of any value.

Kate is 31 yo and she did 2 IVF cycles. Her response is fair, 5-6 eggs, and after her first cycle her embryos did not look good. They got rid of the lupron and in her second cycle she had nice embryos. A pregnancy ended in a miscarriage at 6 weeks. She was told she has bad eggs.
I do not see that you have bad eggs. Your last cycle gave you nice embryos, and it almost worked. I think your chances are still very good. You could change to a microdose, or you can stick with your last stimulation, or you can consider an estrogen prime protocol. They will all be similar, it’s hard to say which one will be the best for you. Check pregnancy rates, if their results are good stick with them.

Murgdon’s husband has very low counts and her RE and urologist feel there is nothing practical that will raise counts, leaving them with IVF as their only option.
It’s hard for me to give specific advice about your husband’s condition, but in most cases, the advice you have received is correct.

Indigirl is 40 with a couple of cancelled ivf cycles for poor response. She switched to the estrogen prime and had 10 eggs. Her FSH is 10-12 and she has a bad AMH level. Is 10 a bad count?
10 is a very nice number, definitely enough to work with. We do not know enough about AMH to know if a bad level means pregnancy is not possible. Right know it’s a guide. The technology of PGD changes for the better every day, but ask your doctor what he thinks about not doing PGD. There is an element of embryo damage that can occur. PGD may be the best thing for you, but double check.

EAS is considering IVF with PGD because she has had a biochemical, 6 week misc at 6 weeks, and now a beta that does not look promising.
As long as you are informed about the pros and cons of PGD, then the choice to use PGD is reasonable. I just get upset when patients are led to believe that PGD is a perfect science.

Anonymous is 27 and does not ovulate or get her period, even with provera and clomid. What should she do? Her doctor is suggesting metformin.
Some women go great with metformin, but they are a mininority. The down side to metformin is that you need to wait another 3-6 months to see if it works. Certainly, it’s less expensive than getting FSH injections and monitoring, and you don’t need the doctor’s visits. It is a less aggressive way to go. Weigh your options.

Kahla’s husband has a low count. They got pregnant and had a baby on their first IVF try. The next 2 cycles failed and she had a 6 week miscarriage on her 4th try. She has had it and is considering iui.
It depends on the sperm counts, and you need to know your odds with iui and IVF. Most people find it really hard to go back to iui after doing IVF. But, if the counts are at least adequate for iui, you could do iui, and IVF later if necessary.

Jennifer’s mom has the BRCA gene discovered after being diagnosed with breast cancer twice. Should Jen take clomid?
Maybe you should get another opinion. Clomid is not that different than tamoxifen, a drug used to treat breast cancer. However, breast cancer is not my area, so I will defer. You could use letrazol to stimulate ovulation. This can cause ovulation, but is also used a breast cancer drug. Make sure you are not pregnant if you take it. Make sure you are fully screened for cancers before you try.

Elize has had enough history for 5 women. Check her entry for details. Now she is left with multiple major surgeries, miscarriages, and a uterine scar.
Much depends on how much scar there is. If it’s a little area, and most of your uterus looks good, and your normal endometrium looks thick enough, you may be ok, even if the scar comes back. If scarring returns after the first surgery, the odds of a second of third operation permanently removing the scar are much lower, especially if the scar takes up a large amount of the enodmetrium. We are not sure why you had the miscarriages, so I can’t say that you are at high risk for another miscarriage. Rupture is really rare, more common if you needed to have a large uterine incision for your myomectomy. A scar will incresase your odds of miscarriage and premature labor, but again it depends on the size of the scar. Scar will increase your odds of placental problems such as increta (where the placenta grows too deeply into the uterus)

Jesus my best friend has a unicornuate uterus with an open tube, and was encouraged to try on her own.
It sounds like a good plan to me.

OK, see you next time with a topic, probably blastocyst.
And please see disclaimer 5/17/06.
Dr. Licciardi
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