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Infertility Q and A

Posted Nov 29 2009 10:02pm
Hello again. Here is the latest entry.

Can a small hydrosalpinx prevent pregnancy? Yes it can and it can prevent pregnancy when trying on your own or with iui (assuming the other tube is normal) , or with IVF. Now a small one is less likely to be problematic, but the studies showing hydros are a problem do not differentiate between small and large. It is not mandatory that hydros be removed, but the pros and cons of removal should be discussed with your doctor.

Does a 44 yo a woman who makes 14 eggs have a higher pregnancy rates than most women in her age bracket? Absolutely. For women in their 40’s, egg number is strongly related to odds of conception. It may be that bigger the reserve the healthier the eggs are in general, or it may be that the more you have, the high the chances of finding at least one good one. This is less important in younger women, whose odds are good even with a lower egg number.

Should you have a second laparoscopy soon after a first in order to do more fixing and cleaning up? These are options but there are others. Back in the day before IVF worked well, this scenario was common, but today if the first laparoscopy looks that bad we recommend IVF. Now this does not mean surgery should be out of the question, it’s just that odds are if the pelvis is so bad, a second surgery will not help much. You really have to try to get a sense of what the doctor feels the improvement will be after a second surgery vs. IVF. If IVF is not an option for you, then the surgery may make sense. It’s a little strange that all of the fixing up was not performed at the first surgery, but there may have been very good reasons for stopping the first time.

Why give 5,000 units of hcg instead of 10,000, and are there any problems with this? It has to do with hyperstimulation. You cannot have significant hyperstimulation without the hcg injection. The hcg stays in your system for at least 10 days, stimulating and stimulating the ovaries to make progesterone, but the stimulation keeps the ovaries big and can push them to hyperstimulate. So it makes sense to maybe give less if we are worried about hyperstimulation. If we give half the dose we may be lowering your risks. Again, makes sense, however, I have not seen much written showing that ½ the dose is any safer. It is possible that if you try to take less you will not get enough. Now if you have a good vial that really has 10,000 units, and you are a good mixer, then ½ the dose should be enough. But it may be that some vials do not contain the full 10,000 units. Sometimes the extra mixing instructions are just too confusing and for one of a number of reasons 5,000 units do not make it into the syringe and into your body. This is why we measure the hcg level the day after the hcg injection. A few times per year someone in our practice has a blood level of the zero the day after the injection. The most common reason for this is the injection of air, which occurs by not putting the needle into the liquid before withdrawing. The second most common problem is the injuction of water only, which happens if you forget to mix in the powder. Believe me, both of these happen mopre than we would like. The water only problem can't happen when using the premixed. Sometimes the there is some hcg in the blood, but the level is really low. If we get numbers under 50, we give another shot but go with the original retrieval time. If the level is zero, we give the hcg that evening and make the retrieval one day after the original day.

Can you exercise while trying to conceive? Sure. However you cannot if your ovaries are enlarged from fertility drugs. If you are unsure when the stopping time is, ask your doctor every time you have a scan.

I am reposting this question because it’s really well written and it applies to a large number of fertility patients who are starting out. My comments are in boldSo my hubby and I have been doing infertility testing for a year. I had a miscarriage at about 7 weeks about 2.5 years ago and have been unable to get pregnant since. I did a 6 month study through the national institute of health where they gave me either a placebo or low-dose aspirin and a fertility monitor, all with no success of pregnancy. My hubby's done 3 semenalyses, (which have proved to be normal. . . he had an abnormal count of about 30% on one, but the rest were fine and the counts were fine), we both did the antisperm/antibody test most of us to not do this test, it just has not been shown to be helpful which turned out normal, he did the hamster test and got 100% penetration never done anymore, an ultrasound which proved to be normal good, as well as blood tests for both of us that have proved to be normal.
My cycle varies between 25-33 days, but always falls within that window, just varying lengths within that window no problem. I recently did an HSG test and it showed no blockages excellent.
Our next step in the process is a post coital test antiquated, a blood draw at a certain point in the cycle, and a sample of my uterine lining antiquated to see if it's thick enough at that point in the cycle to be viable for a baby.
My dr. said that at that point, if everything's normal, we can proceed with IUI. However, he did say that we should consider doing a laparoscopy to check for possible endometriosis. He said that even though my HSG test was normal that if I had endometriosis it could possibly flare up and die down. I've always experienced mild cramps for 1-2 days on my cycle but isn't that normal? He said cramps could be indicative of endometriosis. I have no problems with doing a laparoscopy if it weren't for the cost. . . $2500. I'm just wondering if with everything else positive if mild cramps being my only symptom are enough to warrant the cost of checking it out, or if it's something that won't affect my fertility too much. This is acceptable medical practice, however you need to ask about the payoff. If the hsg, exam and ultrasound are normal, the odds of having endometriosis are very very low. Actually the odds of finding a little endometriosis are about 10% because that’s the baseline rate in all women, but the odds of meaningful endometrioses that has grown to the point of interfering with you getting pregnant are very low. Now that’s not to say that the laparoscopy is not an option, but I would get a second opinion if you wish.
As far as my comments on the antiquated tests, again acceptable medical practice, but a little out of date. It does seem that your doctor is organized and at least has a plan.

If you are a little older and had a chromosomal miscarriage, should you be discouraged from trying again? I don’t think so. Yes the odds of miscarriage increase with increasing age. Most pregnancies, even in women in their early 40’s go to term. The miscarriage rate is high, but there are more babies than miscarriages.

Should you take any steps to shorten the follicular phase? If your cycles are far apart, it just makes it harder to conceive because you get fewer chances per year than most people. Another problem is that it’s hard to know when ovulation is taking place, so timing can be an issue. However, I am not aware that the egg quality is compromised in a long cycle. If you can time it well, the odds are the same as in a more normal cycle, and I have not heard that the miscarriage rate is any higher. So most do correct a long cycle to make it shorter, but it’s not because we are trying to control embryo quality.

How are polpys diagnosed? Ultrasound or HSG or sono-hysterogram (this last one is where the doctor uses a speculum and squirts a little water inside the uterus while doing the ultrasound. This really helps see small defects in the uterine lining, like polyps). I have found through the years, especially as the quality of the ultrasound machines have improved, that a careful vaginal ultrasound works quite well. HSG has been OK, but it misses small polyps. The sono-hysterogram is probably the best test because it finds the smaller ones, but if the uterus looks perfect on regular ultrasound there is only a small benefit to having the sono-hysterogram.

Day 7 blastocyst? If day 6 works why wouldn’t at least some day 7s?. I have not had any patients use day 7 embryos. It’s suboptimal. Maybe as we get more experienceday 7 will become useful. One problem may be that a good embryo will be hatched out of it’s shell by day 7, which may or may not be a problem. .

IVF during breastfeeding? It can work but I don’t know if the breastfeeding affects your chances of success. Yes most fertility drugs are the same hormones that are already circulating, but taking the drugs will increase their concentration in breast milk.

After chemo, if the sperm counts are ok, is the sperm ok? This is tough to answer. My feeling is that it is, but it’s just a feeling. You will certainly get different opinions from different doctors. I have not met any doctors who do not want the husband to use the sperm, but there could be some out there. The doctors may inform the husband that there may be unknown issues.

Translocations: is IVF the only way to have a healthy child? No. Pregnancy and delivery on your own is possible. The stats on this are tricky because most embryos that are created from a couple where one partner is a translocation carrier are abnormal. However, most abnormal embryos do not implant, so if there is implantation, odds are its normal (not 100% and the odds depend on if the translocation is maternal or paternal). You really need a genetic counselor to give you more specific numbers and more of an explanation. IVF with PGD will help, however, it’s expensive and tedious, and does not guarantee a pregnancy, or even a transfer. That being said, there are patients with translocations who are only interested in IVF with PGD.

If I am not crazy about PGD for genetic screening (for Down’s syndrome and the like) , how do I feel about PGD when you know when you have a specific disease (such as CF or hemophilia)? I feel much better. PGD works better in such cases.

Cervical stenosis: good idea for a blog, but yes it can be a cause of infertility.

If the semen analysis is abnormal, always repeat it. Sometimes the minor abnormalities just go away.

What if you go for the hsg and the cervix is closed? If you get a period, your cervix is not closed. There are different ways to do the hsg and one involves putting a tube through the cervix and into the uterus. This is at times difficult or impossible to do because the cervix may not be completely closed, but narrow. The better way is not to put the tube in and just squirt the fluid up the cervix. The cervical canal acts as the tube and brings the dye up into the uterus. In this case, there is a much lower chance of running into "stenosis" issues.

Thanks again and please read the disclaimer 5/17/06.
Dr. Licciardi
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