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The Answers to Infertility Questions

Posted Mar 09 2012 6:42am

Hello everyone and welcome to the latest Infertility Blog. Today I have answered your questions on a variety of infertility topics.

IUI

What if your estrogen is lower than expected after you take fertility drugs? Estrogen alone is not the most important factor in your fertility drug treatment and is not the best predictor of pregnancy. The ultrasound is more helpful. If say you have 3 eggs growing, we may expect you estrogen to be 240-500, but levels in the 100’s could work out just fine.

IUI vs. timed intercourse. With normal sperm, logic says intercourse should be just as good, but the studies show that there is a slight improvement in pregnancy rates with iui. 1% of the sperm makes it from the vagina to the uterus during intercourse and 1% of that make it to the tubes. For women easily conceiving, the numbers mean nothing. When someone is having trouble conceiving, every little bit helps.

Ovulation after the hCG injection take place approximately 36 hours later. The time will only be shorter if you have started to ovulate on your own before the shot.

Sperm

Treatment for low morphology. If you suspect a problem with the sperm it is best to consult with a top fertility urologist. Overall, we do not believe that morphology means much. Many cases of low morphology are really normal morphology. What I mean here is that we may not know what a normal sperm looks like, and the shape we see may mean nothing. Of course there are exceptions.

Luteal Support

Progesterone support for clomid or femara? Some doctors always prescribe progesterone and some never do. Most studies show no benefit, unless in an IVF cycle. If your period comes much earlier than expected, you may be more of a candidate for progesterone. However, just because you get your period early does not mean that you were unable to get pregnant. It is most likely that if you had a good pregnancy going, the period would not come at all.

Clomid

Vision problems with clomid. Almost always temporary and some doctors don’t take patients off clomid who have such issues. I have women switch.

Stress and Clomid. Fifteen percent of women have side effects from clomid which are mostly mental. Depression is a top contender. If you are taking clomid and now you feel way more stressed than before, talk to your doctor about an alternative medication.

40 years old doing Clomid. It’s fine as long as you are informed of the actual pregnancy rate per try, and you are told about the pregnancy rates of injections and IVF. I do not like to use Clomid in women in their 40s because the pregnancy rate is low and time is slipping away. But if you are informed and you are ok with your choice, than that’s the best treatment for you. I do not use estradiol with Clomid.

In cases of no response to clomid, we have used the extended clomid protocol. This just means if ovulation does not start, you can start the clomid within a few days again instead of waiting for another provera period.

IVF

Not starting IVf due to a high progesterone. Few of us measure progesterone on day 2 or day 3. Currently we do not think it is important. Very low levels are hard to measure accurately. For example, a lab may report a level of 2.1, which some consider ovulation, but your levels may really be 0.9, no ovulation.

What is the theory behind estrogen prime? Most women who are recommended for E2m (estrogen) prime are poor responders, many of whom have elevated FSH levels. The theory is this. FSH is the same compound that is in the fertility injections, so f there is extra FSH floating around (high FSH levels) before the fertility drugs are given, the injected FSH may not make much of a difference. Estrogen lowers the amount of natural FSH floating around. If we can lower the natural FSH, the injected FSH will be more of a shock to the ovaries and get them to jump into action. Just a theory.

IVF works just as well if your ovaries are retriperitoneal. The ovaries are usually in a similar place as a normal ovary, but they are just covered with a layer if internal skin that has formed as a result of all of the chronic inflammation caused by the endometriosis.

Nice embryos on day 3, very bad on day 5. I whole-heartedly believe in day 5 transfers, but the individual patient cannot be ignored. If the embryos look super on day 3 and terrible on day 5, I sometimes go back to the day 3. In my practice I see this in about once every 200 patients.

Can you biopsy a frozen blastocyst? Yes. Sometimes the embryo needs to be refrozen while waiting for the results, and sometimes refreezing is not necessary.

Day 5 morulas can result in a normal pregnancy. However the odds are lower than of the embryos have reached a more advanced stage.

Frozens

Can a frozen cycle be better than a fresh cycle. Some say yes for a couple of reasons. First, the estrogen level is usually higher in a fresh cycle and there are some theories, mostly unproven, that higher estrogens are better for implantation. The other reason has to do with these small rises in progesterone that occur before the hcg injection in a fresh cycle. This is also unproven, however the field in general is starting to pay more attention to this issue. More research is coming. Right now, almost every clinic prefers a fresh cycle.

Natural cycle Frozen Embryo Transfers (FET). I d not usually perform the natural FET. The reason is that the cycle is more likely to be cancelled for uncertainty of the surge timing, or known premature ovulation. Otherwise it’s an ok option.

Uterine Adhesions: Ashmermans

The unstuck type of Ashermans. I have never heard this term before, but completely understand what you are saying as I have seen some cases of this. I am assuming the term means the uterine cavity is open and the HSG shows a normal shaped cavity with no scar. However, for some reason, probably due to scarring that takes place just under the lining, the lining is very thin. Something has damaged the part of the uterus that makes the gland cells. Some gland cells are made, but not enough to let the lining grow to the expected levels. This is a tough situation because not much can be done to make the lining thicker. However, many women do get pregnant with very thin linings.

Septums

If you had a septum and you are still not pregnant, you may need to have another hsg to be sure the septum was fully removed. This is a common issue. Once that is done, certainly there may be other issues for your infertility, sometimes discovered and sometimes not. If you are not pregnant post septum correction, you may need to follow the regular infertility treatment paths.

FSH Levels

Day 21 measurements of FSH are not helpful unless that are very high. Very high anytime is bad, very low anytime is not helpful. When low it has to be days 2-4 and an estrogen must be measures with the FSH. If the Estrogen is high, the FSH is not valid and both need to be repeated.

An FSH of 17 on day 2 is not good. It may be a mistake, it may need a repeat, but it needs to be investigated further.

PCO

Alternatives to clomid with PCO or anovulation. Certainly all of the complimentary treatments can be tried. If weight is a possible problem, tackle that and good results should follow. Don’t forget about the nutritionist as there may be many subtle non-calorie issues that need adjusting.

PCO with a spike in FSH from 5 to 9? There is some variation in FSH levels form month to month. If you really have PCO I would not worry about the level of 9, it may just be a blip. If your resting follicle count is not in the PCO range, the level may indeed be accurate.

First treatment for those who have PCO and do not ovulate. There are options. The quickest way to get a chance at pregnancy is to make an attempt with clomid. There are other very good options. Weight loss, or at least diet adjustment, is a great start but ovulation may not return right away, if ever. This is a discussion you need to have with your doctor. If you would rather start with Injections or IVF, that’s ok too.

Endometriosis

Can fertility drugs exacerbate endometriosis? Yes, however usually not to a large degree. Overall fertility drugs will increase pregnancy rates in women with endometriosis, not lower rates. I do not believe in “freshening up the ovary” by removing an endometriosis cyst pre IVF, but every case is different and you need discuss this with your doctor. One problem is that removing cysts, no matter how careful your doctor is, will result in removing some eggs. Many women with endometriosis have damaged ovaries with reduced egg numbers, therefore losing even more eggs with the cyst may not be good.

Should everyone get checked for endometriosis? Yes, but the details may differ. Everyone should have an ultrasound. If the ultrasound shows endometriosis, there is your answerer. If the ultrasound is normal and the exam is normal and there is no history of pain, and the hsg is normal, the odds of endometriosis being a factor are really low. Is a laparoscopy to double check indicated? It may be, depending on the history and the motivations of the patient, In general, laparoscopies are not performed in such cases.

Polyps and Fibroids

Small polyps probably do not cause miscarriage. In many cases polpys can be seen during your ultrasounds for fertility monitoring. It’s easier to see them as the follicle size and estrogen levels increase. It’s harder to see them post-ovulation.

Fibriods and infertility. I tend to be conservative with fibroids and in many cases I do not recommend surgery. However, two 6 centimeter fibroids could be a problem, you need a second opinion. Letrazol will probably not increase the size of a fibroid by much.

Thyroid

Hypothyroidism and thyroid antibodies. The general feeling across the country is that the TSH needs to be lower than 2-3.5 to improve fertility and prevent miscarriage. NYU preformed a large studying showing this is not the case and that there is no relationship, providing the hypothyroidism is treated. Many doctors are over treating basically normal women with thyroid hormone. Of course discuss the problem with your doctor.

Letrazol

I am not aware of any large studies showing letrazol reduces miscarriages.

I am unaware oflegs cramps with letrazol

Miscellaneous

RH antibodies can be measured, so your doctor can easily test you for this.

Exercise can weaken or remove ovulation, but the amount of exercise needs to be extreme, i.e running 25+ miles per week. There may be some variation there, but 5 hours in a gym per week is probably not enough to make a difference.

28 years old and no pregnancy despite 8years of unprotected intercourse? Testing is required. Not necessarily a lot of testing, just start with the hsg, semen analysis and day 3 FSH testing.

Thanks for reading.

Nice to be reaching out to everyone again. Don’t forget to read the disclaimer 5.17.06.

Dr. Licciardi

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