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Back to School, Back to Questions

Posted Sep 23 2011 9:49pm
Hello Everyone! I hope you had a nice summer.

I’m going to start the fall off with answering some very interesting and important questions. Then I have the next few blogs already mapped out. Here we go.

PCOs. Can you have PCOS if you have regular cycles and no symptoms, just ovaries that have many follicles? No, you need to have one other symptom: irregular infrequent periods or androgen excess, the later being demonstrated by increased facial/body hair, acne, or more rare symptoms. I frequently see women who have healthy ovaries on ultrasound, meaning they look good because they have many follicles, probably enough to fit the criteria for PCOS. But without the other symptoms, these women are just lucky.

Uterine Abnormalities. If your uterus is bicornuate or dydelphic, a singleton is highly preferred over multiples. Sometimes the best way to achieve this is by having IVF and a single embryo transfer.
FSH. If you were told you have a high level, you must repeat the test. Odds are that the results will be similar; however that is not always the case. I’ve seen many women who were dismissed from other practices for having high FSH levels only to have better results on repeat: some became pregnant.

Amenorrhea. If your ovulation stopped due to weight loss, it may not return after weight gain. We don’t know why, but in some but not most cases, the changes in the brain that occur with weight loss become permanent. I am not sure about the term Ovarian Insensitivity, I would get another opinion.

Endometriosis. Most doctors today do not do a laparoscopy on women who just started trying and have no evidence of endometriosis. Evidence means very painful periods and or visible cysts of endometriosis on the ovaries seen on ultrasound. If the hysterogram is normal, i.e. the tubes are open, and the history and findings do not point to endometriosis, the odds of finding significant endometriosis on laparoscopy are very low. This does not mean you can’t have the laparoscopy if you wish, but in most cases it is recommended only as an option.

Ectopic Pregnancy. If during IVF, embryos are placed in the uterus, how is it possible to have an ectopic pregnancy in the tube? Unfortunately this does happen, probably because the embryos float into the tube sometime after the transfer. The uterus is a muscle and this muscle does undergo slight but regular contractions. It’s possible that the embryo gets squeezed up into the uterus. There are fewer ectopic after IVF these days, for a few reasons. One big one is that we put in fewer embryos these days. Fewer means there are lower odds of one ending up in the tube. Another is that many women who need IVF because of big blocked tubes (hydrosalpinx) have these tubes removed prior to IVF. A hydrosalpinx is a swollen tube damaged from infection, very severe endometriosis or previous surgery. The interior of these blocked tubes becomes damaged, making ectopics more likely.

Cervical Mucus. Most infertility doctors are not concerned with cervical mucus. We all understand that women who have no treatment or minimal treatment get pregnant on their own. Some women who get their mucus in some way adjusted get pregnant, but the rate of pregnancy may not be higher than baseline.

Thyroid. So far there is no good evidence showing a relationship between thyroid abnormlaites and embryo quality. Certainly, the thyroid should be close to normal while attempting and during pregnancy. It is very difficult to get accurate TSH level during IVF stimulation because during and IVF cycle, the estrogen levels become higher than normal, and this interferes with accurate assessment of TSH.

Embryo Quality. Are poorly growing embryos more likely to be genetically abnormal? The answer is yes, but not by much. This means that the way an embryo looks is not tightly related to chromosomal normality. A poor looking embryo is a little more likely to be genetically abnormal, but you can’t count on it. So if your best embryos are slow growing, we transfer them.

Early Pregnancy Failure. Women with pregnancy losses should have a karyotype, which is the blood test done on both partners to check for possible chromosomal abnormalities. Another necessary test is the hysterogram which will test for uterine abnormalities.
Should women with repeated loss keep trying on their own, do fertility drugs and iui, or move to IVF, possible with PGD? This one of the most difficult questions in our field. I tend to feel that if you are getting pregnant easily on your own, keep trying on your own. However, there is a place for IVF with PCG depending on your situation and age. Certainly finances come into play.

Cervical Stenosis. Usually improves after a vaginal birth because the cervix stretches so much. If the baby is born via c-section, the cervix may not have opened enough to make an improvement. Sometimes even in women without stenosis, healing post c-section can greatly increase the angle between the cervix and the uterus. This is not really stenosis, but this acute angle can make it very difficult to get a catheter, say for iui or embryo transfer, from the cervix into the uterus.

Anti-sperm antibodies.
Most fertility doctors these days do not see a relationship between anti-sperm antibodies and infertility. If these antibodies are a factor, most of the time the antibodies that are the biggest problem are those that are in the cervical mucus. The antibodies in the mucus grab the sperm trying to swim through. Therefore, avoiding the cervical mucus via iui can do the trick. You do not need to take fertility drugs if it is felt your only problem is antibodies; an iui without the drugs may suffice.

Uterine lining.
All experienced fertility doctors have many women who have become pregnant with “thin” linings. No one knows what the cutoff should be. One problem is that the studies are not done correctly. For instance, let’s say an IVF program analyzes their pregnancy rates according to the thickness of the uterine lining. What happens is the different thicknesses become grouped. They may look at pregnancy rates for women with linings greater than 10mm, 7-10 mm and less than 7 (this is just one example: some may do >9, 6-9 and <6, or any other way they wish). The problem with this is less than seven includes women with 4s and 5’s. So to say less than seven is a cutoff may not be accurate because the pregnancy rate at 7 may be just fine, but it will be lower in women with 4’s and 5’s, but they are all grouped together. The reason the studies are not set up as the pregnancy rates for 6 mm and 7 mm and 8 mm etc. is that the overall number of women in each study is small, so number of women in each group becomes too small to calculate a difference.

Why is my lining thinner today than yesterday? This is very common. The most likely reason is that the lining was measured in a different location on each day. When we scan, we quickly look for the thickest part and write it down. Most fertility doctors are not really interested in progression from day to day. If we glance at it and it looks ok without even measuring it, we quickly find a spot, any spot, and get a measurement. Another reason for differences is that you may have a different person measuring on different days. Different people may measure differently; the measurement should be close, but not exactly the same.
Another possibility is that the lining grows and shrinks a little from day to day. I’ve noticed, usually in cases where the lining is thick, that linings change from day to day. The lining does usually grow thicker as the cycle progresses. Sometimes there is a quick growth such that by day 7 it’s nice and thick and stays at about that level through the next week or so. Sometimes the lining is thin on day 10, but after 2-3 more days it has a late improvement and looks great.

AMH. How can your FSH level be normal and you AMH be very low? Because we don’t know yet what normal and abnormal levels of AMH are. The values also vary considerably from lab to lab. I have not yet started doing AMH levels for this reason. I have seen levels of 0.16 along with FSH levels of 7 in young women. In some labs, over 1 is good, I others lower levels are normal. More time is necessary to work this one out.

Ovulation Induction. You can get pregnant in an iui cycle if the follicle is 16 mm. It’s a little on the small side, but in most cases it’s big enough. One reason we wait on a 16 mm follicle is that there may be others that are even smaller. In those cases, we much prefer to wait.

IVF Failure. Are there some women who will just never get pregnant? Unfortunately the answer is yes. But we have no idea in advance who these women are, unless there is an obvious reason for their infertility. There probably a few men or women who have a hidden untestable genetic problem that prevents pregnancy. Some women just can’t catch a break. They have problems that seem correctable with surgery or IVF, but they don’t get pregnant, or they have miscarriages. It’s a terrible cast, one of many that life sets us into.

IUI Clomid at 41?
Cross my heart, we have a woman in our practice that got pregnant and had a baby at age 47 on clomid, after every other treatment under the sun. That being said, taking clomid in your 40’s may not be the best thing. Even with iui, the odds are less than 5%, and every month you are not pregnant, you are one month older.

Blastocyst Transfer. Would embryos that stop growing from day 3 to day 5 have been better off getting transferred on day 3? It depends on the experience of the IVF clinic. At NYU we are very experienced and successful with day 5 (also called blastocyst) transfer. I feel very confident that the lab is as good as the uterus from days 3-5. Very rarely I have a patient who I prefer to transfer on day 3. This is happens when the embryos look close to perfect on day 3 but terrible on day 5, a very rare occurrence. Many IVF programs are not as experienced or successful with culturing to day 5, and in these cases, a day 3 transfer may be better.

Agonist vs Antoginist. (Lupron vs Cetritide or Ganirelix). I use some but not much lupron anymore. One reason has to do with patient convenience; lupron is just one more shot people have to take. Cetritide and Ganirleix are given by injection, but only a few doses are necessary. Plus lupron can cause an ovarian cyst to grow interfering with the timing of the cycle start. In some cases, especially in older women, I believe that lupron can suppress the number of developing eggs. But the lupron protocol is still one that I go to at times.

Low estradiol on day 3? Hard to explain why the level is so low if you are having normal ovulation. If indeed you are having normal ovulation and respond with normal estrogen levels to fertility drugs, the low level on day 3 may not be a problem.

7 miscarriages. Very sorry to hear of your problem. I assume you both had karyotype testing. You may want to consider IVF with PGD. I understand that there may be financial barriers to that service and doing IVF/PGS does not guarantee pregnancy much less a successful pregnancy.

2 Miscarriages after IVF with good egg number and nice embryos.
Talk to your doctor, it sounds to me like things can happen in the positive for you.

Thanks for reading and don’t forget to read the disclaimer 5/17/06.
Dr. Licciardi
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