Egg donor agencies, egg donor services, fertility clinics at Donor Network Alliance!

By Robin von Halle

Surrogates are unusual women who selflessly carry a child to term for someone who cannot otherwise do so. They endure psychological counseling, fertility treatments, pregnancy cravings, swollen feet and more, all with a smile on their face. The end prize: happy families that they help create.

What these surrogates don’t have much of is a network just for them.  A place to go when the hormones are raging, to question other surrogates about the legal process or just to express how they’re feeling after the baby is born.

Alternative Reproductive Resources has created and is sponsoring an option for this community. “The Surrogacy Spotlight” is a Facebook community for current surrogates, women thinking of becoming surrogates, and surrogacy experts. To join, go to: http://www.facebook.com/pages/The-Surrogacy-Spotlight/133621049988224.

We know there are plenty of great surrogacy forums online already, but many of them seem to be a location where intended parents go to solicit them. The Surrogacy Spotlight is just the opposite.

It’s a place to meet other surrogates going through the same experience. It also gives women thinking about becoming a surrogate a chance to ask questions to see if it’s right for them. It’s a place to express their, joys, fears, frustrations, pregnancies, births and more.

If you are, have been or are thinking about becoming a surrogate, please join The Surrogacy Spotlight as a fan, and we hope you’ll recommend it to others in your network who might be interested. (http://www.facebook.com/pages/The-Surrogacy-Spotlight/133621049988224).

In addition to welcoming your comments and observations, we’ll have two special features. Each month, we’ll have a Surrogate of the Month and a different surrogacy expert.

Starting Tuesday, July 6, our Surrogate of the Month will be Jodi, who recently gave birth to twins for two wonderful intended fathers. She will share her surrogacy journey and take questions from you throughout the month.

Our expert will be Mary Ellen McLaughlin, an ARR partner and former nurse who works with surrogates. She’ll discuss the psychological and medical aspects of the experience. Future experts will include attorneys, psychologists, physicians and more.

We have been working in the fertility field for more than 15 years, and understand that having an outlet to help get you though the process is therapeutic. We trust The Surrogacy Spotlight will do just that, and welcome your involvement to ensure it happens.

So you’ve been trying to get pregnant and it’s taking longer than you think it should. Now what? Sounds simple, you probably have a local gynecologist who you have been seeing for your checkups. Why not start there?

This may not be a bad idea at all. A general gynecologist could quite possibly be a very good fertility start. She has your history and may be conveniently located. But how can you tell she is good?

It boils down to 2 things: diagnosis and treatment.

Let’s start with diagnosis. If you have been trying 6-12 months, and you doctor says relax and try for 6-12 more months, relax your relationship with him. Of course he will occasionally be right and some people will be successful by just hanging in there, but most following his advice will still not be pregnant, and will be that much older.

Even if you want to wait, you should strongly consider at least having some basic simple testing. You can keep trying on your own as the testing proceeds, but at least you will acquire some important information. Once you get some answers, you will have the power to decide how to proceed.

Now what tests are we talking about? The gold standards are the HSG (hysterosalpingogram), semen analysis, and day 2 or 3 blood testing for FSH and estradiol (estrogen). All of these tests can be finished within a few weeks, and within that time you will have your bundle of information. Now some of this is a little simplistic because many of you have very complicated problems, but most people just starting out do not. And if the testing is systematic and is done quickly, you will all be on the right track.

You do need someone good to read your HSG. Many doctors will not look at your films; they will just read the report. This becomes less material when the report is normal, but much more significant when the report is abnormal. If you are told its normal, odds are it is. However, if you are told it’s abnormal, then you may need to take things one step further, usually by getting a second opinion, preferably with an RE. If you are told it’s normal and you continue without conceiving, you should have someone else have a look at it.

That’s the basic testing, sounds simple and it is.

What about the treatment side? For example, let’s say the HSG really is abnormal and you are told you need surgery on your uterus or tubes? Who should do your surgery? Your GYN or an RE? Many generalists are excellent surgeons, and some REs are terrible.

How do you know where to go for quality surgery? And let’s extend the question to “How do you find any good doctor?” Whether it’s a generalist or Reproductive Endocrinologist, how do you know who is good?

This is one of the most difficult questions in medicine. I would start by doing some of your own investigation.

What about those best doctors lists? This could be a good place to start because many doctors on those lists are good. However if you show a list to a good doctor who is very familiar with the people listed he will really wonder how some of them made it on. And I don’t know too many fertility doctors that are not on the “Best Doctors in America” list. That’s not a list of the super-best doctors in America, it’s a complication of all if the doctors who are on the best local doctors lists. So there is no cut to make the America list. Most of those lists give a high priority to chairmen and division directors, again most of whom are good, but holding one of those positions is not an automatic for quality. Some lists are assembled through other doctors voting, and some of that could be politically biased.

You may have local infertility organizations that could make suggestions. This is tough because although I think these groups do an excellent job, I have been involved with at least one group who referred to their biggest supporters. But it might be good to at least find out which doctors are on their list.

What if the doctor is in all the medical societies? Medical societies are very important organizations that provide education and networking, but unless you have a criminal record, almost all societies allow members in. So you will see most doctors with impressive lists of their fancily named societies, but membership is usually about paying your dues and getting your certificate. There are usually no entrance criteria that represent quality control.

What about board certification? There is no excuse not to be boarded in OBGYN. Most of us are. What if you are going to a specialist, does he need to be boarded in Reproductive Endocrinology? This is usually important but there are some excellent physicians who have good reasons for not being boarded in RE. Maybe they are young and are waiting to become eligible. Maybe they are a little older and trained before getting certified was the thing to do. I would say that if your doctor is not, you need to carefully evaluate other criteria.

Does it matter where she did her training? Again hard to say, but better programs are more likely to turn out better physicians. Some of this may have to do with recruitment. The places with the best training reputations can more easily recruit the smartest and most caring people. So just by getting the best, they will turn out the best. The problem for you is knowing which training programs are the best. There are many renowned institutions that just have bad programs. It’s not uncommon to have a hospital with a great program in one specialty and a very bad program in another. And sometimes things change quickly within a program, so the training can become worse before the reputation changes. Magazines do publish the lists of top hospitals, and I don’t think there are many bad places that make those lists. However, there are many excellent places that don’t get the nod.

Nurses can be a good referral source because they see the doctors work every day. But a referral from a nurse may not be a slam dunk. I have seen nurses refer to their better friends, or to the doctor who is popular because he frequently brings in pizza.
Nurses know who operates the most, but not about their daily functioning and this brings us to the next point.

Is a doctor who operates at high volume the best surgeon for you? Maybe. A doctor who operates frequently may be really wonderful and have a massive referral base that keeps him in the OR frequently. They can be more experienced and confident and have fewer complications. However, some busy surgeons are busy because, for whatever reason, they over-operate. And some of these doctors have not gained from their experiences and maintain a higher complication rate. They may feel their procedures are indicated, but others may not. Getting back to the nurse, he sees what’s happening in the OR but he does not know about how the patients have been worked up and how they are followed after surgery.

There is one good trick that only works in a teaching hospital: ask a resident. No one knows the skills and limitations of your doctor better than a resident. The resident is in the hospital all day long and is involved with the workups, surgeries and recoveries. They are constantly communicating with your doctor. And believe me the residents have very strong opinions about each of the doctors they work with. Now it is hard to get hold of a resident, but ask around, may be a friend of a friend knows one. Plus, many hospitals have departmental web sites that list the residents, and some may list contact information. Because they are young, tired and stressed, sometimes the residents are a little too opinionated, and they may know about some of the doctor’s personal issues that don’t affect you. If you have a doctor and want their opinion, you don’t need to hear the doctor is the best of the best. You do want to hear that she is solid, not that she is below average or worse.

What if your only source is your friend who became pregnant after seeing the doctor she recommends to you? This is not enough at all. Many questionable doctors get some of their patients pregnant. It doesn’t mean that they are good. Just like there are some of the best doctors who just can’t be successful with everyone. This is probably one of the most common ways couples find fertility doctors, but it is the least reliable. So if you are told about a doctor, use other sources to validate the person.

Check the available medical misconduct sources in your state. Your doctor should not be listed there. There is also the National Practitioner Database, but information about specific doctors is not available to the public. The database is viewed by hospitals and insurance companies. In addition to misconduct, it lists the cases where a doctor was sued. Even the most excellent doctor can have a few things listed; it’s the nature of the beast, the way of the world. Most doctors are non-malicious hard workers who can run into a bad outcome, but this should happen only very occasionally, and if they have any cases listed the list should be very short. Some of the doctors who take care of the most complicated cases are more likely to be sued. That being said your hospital or insurance company should evaulate each case and avoid the frequent fliers.

And then there’s the internet. Have you ever stayed at a nice hotel and enjoyed the experience? Go to the internet and check the reviews, you would be surprised by all the negative comments. But, the average of the reviews would at least be close. So yes, the internet chats are some of the best places to find doctors, especially if you repeatedly read similar concrete reasons why a doctor is good or bad. I have heard of administrators going undercover on the sites to steer business to their doctor, so watch for that.

More on the best doctor for you next time,

Dr. Licciardi

Go to Infertility Blog

PCOS (Polycystic Ovaries) and Ovarian Drilling.

Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Androgens, by the way, are the hormones that get changed into estrogens, so androgens are absolutely necessary for normal repoduction, but in PCO the androgens are in excess. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because they do not always work, can cause scar tissue, and there are other alternatives.

There are other ways to stimulate ovulation, including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option.

Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling.

So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin.

What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.

Other PCO Topics

Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.

When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.

Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.

Egg quality clomid vs FSH? Probably similar.

Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.

Sperm Topics:

Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.

Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.

Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.

Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.

Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.

Miscarriage

What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.

Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.

Frozen Embryos

Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.

What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.

General Topics

Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.

Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.

Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.

What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.

How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.

Thanks for reading and don’t forget the discalimer posted 5/17/06.

Dr. Licciardi

Go to Infertility Blog

What if you are on drugs for an IVF cycle and there is a low number of follicles? Should you do cancel and have an iui (provided there is sperm and at least one tube is open) or should you have the retrieval?

The number of eggs is less important the younger you are. So at age 31, 4 eggs still results in an excellent pregnancy rate. At age 41, 3 eggs is much worse than having 10. So is there a “cutoff” number? Not really, and if there is it will vary from program to program. There are no strict guidelines for who should be retrieved and who should not. In most cases, when there are 1-4 eggs developing, the doctor will say that the odds with IVF become so low that it’s not worth the cost and effort of the IVF, so the better thing to do is the iui.

There was a very interesting paper presented at the last meeting of the American Society of Reproductive Medicine. One IVF center compared the pregnancy rates for women who decided to cancel to iui vs. those who decided to have the retrieval, when 1-2 eggs were present. Those women who continued on and had their retrieval had a higher pregnancy rate than those who had the iui. Now the rates for IVF were still in the single digits, but the rates were better than the iui numbers. So IVF is better than cancelling to IVF, but the odds of getting pregnant from that retrieval is quite low. Would you have a retrieval if your odds were 2% with iui but 5% with IVF? Some patients would, some would not.

I have mentioned before that we all know or suspect that there are IVF programs who cancel the 3 eggers because they are worried about lowering their statistics. I think there is less of that going on. I see patients being informed of their odds and then be allowed to make the decision. And the threshold may be different depending on your perceived potential. If it’s your first try and the doctor really thinks that a different protocol will do you better, cancelling makes more sense. If you have been cancelled for 3 follicles, and after protocol changes you make 3 again, well you make 3 and that’s it, so retrieve away.

What about multiple egg issues at the same time?
For example there are some women who make a large percentage if immature eggs, have low fertilization rates and have low embryo quality. Others have different mixes such as high rates of polyspermy, low rates of normal fertilization and poor embryo development. Others have mature eggs that do not fertilize without ICSI despite normal sperm, and then poor embryo quality. Is there one basic problem with the eggs that is leading to a completely bad scenario? This may be, but we don’t know what it is. The reality is that most women with a large percentage of immature eggs do pretty well with the ones that are mature. And women who have polyspermy, do pretty well with the eggs that fertilized normally. But for some of you, everything seems to be wrong despite protocol changes and changes with icsi, in hcg timing and day of transfer. Yes there may be a missing link resulting in multiple problems at once. It’s a matter of trying a few times and keeping all of your options open.

Persistently elevated prolactin levels need a full workup, which usually means an MRI of the pituitary.

What if your FSH is a little high and your AMH is a little low, but you have a good number of resting follicles and make a good number of eggs for IVF?
Those hormone tests are more about predicting egg number than quality. I believe the numbers have less of an effect on egg quality. Others may disagree, ask your doctor.

What if you suffer from autoimmune disorders and are having trouble conceiving? Is there a relationship?
Overall women with autoimmune disorders seem to be as fertile as anyone else. High risk OB practices are busy dealing with pregnancy complications of Lupus, RA and others. However, there are so many unknown factors related to fertility and the immune system, it does make one think that there may be a relationship when pregnancy is not occurring. I have seen a few cases of relatively young women with autoimmune disease who are very poor responders. I think there is a relationship between their disease and antibodies to their ovaries. Unfortunately there is still no good test to measure ovarian antibodies. There are good tests for thyroid antibodies, adrenal gland antibodies, but not yet for the ovary.

Here are a couple sperm questions.
Sperm counts that go from 100 million to zero then up again? He needs to be evaluated for intermittent obstruction: a blockage somewhere that occurs some of the time. Also could be intermittent retrograde ejaculation. Send him to a reproductive endocrinologist.

What if the urologist finds low counts and motility and does a thorough workup and tells you the numbers are what they are, can’t be increased and recommends IVF. You are always welcome to get another opinion, but it sounds like this guy is honest and he is telling you what most men are told. I believe in seeing a urologist because sometimes surprises are identified, but in most cases of very low counts and or motility, nothing is found and the only answer is IVF.

Yes ovarian hyperstimulation and ovarian torsion are related.
Torsion becomes more likely as the ovaries enlarge and become heavier. This increases the chances of the ovary rolling over and twisting on its stalk. Torsion with clomid can happen, but it’s much rarer because the ovaries have fewer follies and are smaller and stay lighter.

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

Go to Infertility Blog

Good day to all of you. As you have seen, the last few entries were on egg freezing. If you are not interested in egg freezing, but want to know more about IVF, I think you will learn a fair amount about regular IVF from the egg freezing entries.
I am in the “catch up” phase, so you will see a few more FAQs answered. I’ll start with a little case from my recent day in the office.

The question leading to the topic was, “Can you be a poor responder and get pregnant on your own? “ So al little story about a couple I saw this week. She was a poor responder with borderline FSH levels, normal tubes and a favorable age. He had low sperm counts. They had been through IVF. I suggested that he see a urologist because there maybe something that can be done to improve his counts. She still ovulates every month, so by upping the odds on the sperm side, maybe they could get lucky and get pregnant on their own. My statements were very surprising to them. They were told that because of her “fertility status”, meaning her FSH was a little high, pregnancy could not occur naturally, so why bother with the sperm. This may be close to accurate but it is not completely true. Unfortunately, many couples with significant fertility problems never get pregnant, but for some the pregnancy rate per month is not zero. Even if its ½ percent per month, after a year, a few women with normal tubes, borderline FSH levels and good sperm will get pregnant (age helps). Can you count on it? No, but if there is something fixable, you might as well explore the options. I do hope they do take the advice. This is also the reason that some doctors suggest a laparoscopy after many failed IVF cycles. Even if the odds of tubal disease are low, correcting a small problem may improve the odds of a spontaneous pregnancy down the road.

Here are some surgery questions.
If you have severe endometriosis and pain with a history of multiple laparoscopies, and you are at the end of your rope, is a hysterectomy the answer? This is too complicated for me to give any hard advice here. The options are to get another opinion from a doctor is an established endometriosis laparoscopy doctor, who can maybe improve your pain without a hystersctomy. Maybe even someone who is not in your area. On the other hand, there are some women who say the hysterectomy was the best decision they ever made, and some who are neutral and some who are not happy with the results.

Is a laparoscopy through 3 incisions better than a laparoscopy where the doctor only used 2 incisions? Impossible to say. Some surgeons are really crafty using only 2, some need 4. Sometimes a doctor who usually uses 2, will need to use 3-4 in the really tough cases. But redoing a laparoscopy just because only 2 incisions were used does not make sense.

What if there is a hydro on hsg and at laparoscopy the tube does not fill with dye? Should the doctor assume the tube developed proximal occlusion and just leave it? I think not. For some reason, sometime tubes just to not fill with dye at the laparoscopy. Even normal tubes sometimes do not fill, but a post op hsg shows normal tubes. So if they are hydros at hsg, but closed at laparoscopy, your doctor should consider removal.

Is it normal to have a myomectomy and have some fibroids left behind at surgery? This does happen, but I do not leave any behind. I could see rare cases of fibroids left behind for a couple of reasons. Fibroids on the cervix are more dangerous to remove because the cervix is where the uterine arteries bring blood to the uterus, so around the cervix there is more blood flow and more chance for heavy bleeding during the operation. Also, if there are very thick intestinal adhesions attached to a fibroid, separating the intestine from the fibroid may cause excessive bleeding or damage to the intestines. That being said, leaving fibroids behind should be reserved for the most extreme cases. I have not left a fibroid in 15 years. The doctors I work with do not leave in fibroids. However I am aware of doctors who routinely leave in some of the smaller or difficult to reach fibroids, and I do not know if this is the best thing. A myomectomy is not minor surgery. In many cases, smaller fibroids get bigger. So if your problems are bad enough that you need the myomectomy, getting them all is the best thing. It is also true that the doctor may do a great job getting them all out, and sure enough, 3 months later a scan shows another fibroid. This is harder to explain, but probably there was a very small one that could not be seen, and it that grew after the initial surgery.

Clomid, IUI and PCO
Do you need to get a period before starting clomid? If you have either post pill amenorrhea or hypothalamic amenorrhea, it will be hard for you to get a period anyway. You probably will not bleed after provera. So in my patients, I do not require that they bleed. Also, you may not respond to clomid. Clomid causes the pituitary to release its stores of FSH and LH. Women with hypothalamic amenorrhea, because their brain makes no GnRH, do not have FSH stored in the pituitary. That being said, it may be worth trying because sometimes it does work and it’s much easier and less expensive than the injections. I have been pleasantly surprised by some nice responses and pregnancies in women who should not have responded.

Can you have polycystic ovaries and have low ovarian reserve? No they are the opposite. Women with PCO have many many eggs and are not close to menopause. Now women with PCO eventually lose their eggs to and get to menopause, but if you are told now that your ovaries are PCO on ultrasound, you do not have low ovarian reserve.

If IVF is not in your future, does it matter if you do iui with Menporur or FSH? It probably does not matter.

Are progesterone levels important to measure in the luteal phase during a natural cycle. Very few infertility doctors feel this is important. It has not been shown well that levels matter, plus they change throughout the day.

What if your follicle size looks good, but it’s Friday and your doctor wants to try to get you to Monday for the iui? Not so good. In some cases it may be fine, but in others it’s not the right thing to do. The fertility doctor you work with really needs to provide services 7 days a week. Many say they will, frequently resort to doing things a little late or early because they are not as staffed as they say. It’s probably true that a little late or early here and there actually may not make a difference, but more than a little is a problem.

Miscarriage
Does having a miscarriage after iui mean IVF should be your next step? As hard as it is to lose the pregnancy, the delay is sometimes the worst part. It took you a while to get pregnant, then you may have waited a few weeks to confirm the status of the pregnancy, then there is waiting 1-2 months after the miscarriage. There are tons of factors that will go into your decision of how to proceed, but the frustration of the miscarriage process does push many people into IVF.

If you are in the process of an early miscarriage, should you have a D and C? There are pros and cons of the d and c vs. waiting for a natural bleed. A d and c should not be automatic. Go over your questions with your doctor and you will both come up with the best course of action.

4 biochemicals in a row with a normal uterus? Your age is important, along with any miscarriage tests your doctor feels is necessary, especially the karyotype. This is a tough one. It is true that implantation is at least starting, and this is a positive. But finding cause may not be possible. I hope it works out.

IVF and Stimulation Questions
Should you avoid pregnancy if you are starting an IVF cycle with day 21 Lupron or Synarel or Buserelin? The stock answer is yes. However there are many women who have become pregnant while on those meds. If you do become pregnant, make sure you get luteal support with progesterone and maybe estrogen. Ask your doctor.

Does it help to take estrogen for luteal support in an IVF cycle? Probably not. There have been studies showing no improvement. There is even scientific evidence that estrogen may be unnecessary in the luteal phase. Some clinics routinely prescribe the estrogen; I tried it for a while in select cases with no improvement. I have had a little success using estrogen in women who have luteal bleeding despite progesterone. It’s used in medicated frozen cycles and DE cycles because the ovaries in those cases make no hormones (no estrogen or progesterone) so we add both hormones during their cycles.

Should you try IVF again if you are 29, have an FSH of 12 and make 8 eggs with 2 fertilized? Yes. I have been getting many comments from young women, some with high FSH levels, who are failing first cycles. Get to the best clinic possible and have your doctors come up with possible improvements for your cycle. Age is key. A high FSH in a 27 year old woman, or even a 36 year old, is not as telling as it may be with a woman in her 40’s.

What can I suggest to up your odds for the FET? Most FETs are pretty routine. Sometimes we suggest thawing more than you need and picking the best for transfer. Not everyone wants to do this. Some would rather thaw few so they can get more cycles out of what they have frozen. Either way is ok; see what your doctor says.

Hopeless after failed iuis, 2 fresh IVFs and one FET cycle? You do have to take into consideration age and FSH levels and embryo quality. It’s rarely hopeless. Maybe less hope, but not none. Know your stats, get another opinion and take it from there.

Can a para-ovarian cyst interfere with IVF or implantation? Probably not.

What if you are an established young poor responder who has had multiple failed IVFs. In addition there is a question about your uterus, meaning the was a scar but hysteroscopies and hsgs are now normal? This depends somewhat on the thickness of your lining on ultrasound. I have said before, and still believe, the lining thickness may be less important than we once thought, but of course everyone’s story and uterus are a little different. If you want to carry and our uterus is “acceptable” then donor egg without carrier is what most women would do, and probably with a very acceptable pregnancy rate. If you feel strongly that carrying is not important, just getting that baby asap, consider a carrier. However, donor egg, carrier is not guaranteed either.

I am hearing from women who have premature surges during antagonist cycles. I have not had this so I don’t know why people are having this problem. Antagonist should start at a follicle size of 13 mm (some clinics use 12 mm). Sometimes the estrogen levels do fall a little when the antagonist is started, but this fall does not mean there has been premature ovulation. So if the estrogen falls (but not by too much), but the follicles still grow, and the estrogen level goes up the next day, that’s all ok. There has not been a surge.

How long after the last depot lupron shot do you need to wait for IVF? The depot shot is supposed to stay in your body 4 weeks, but may be in a little more. Ask your doctor about this one but probably if you start 4 weeks after your last shot, but the time you are retrieved it will be 6 weeks after the shot.

What’s the doctor doing at my transfer, and why is there a delay? You can’t see what’s going on at the transfer, but any of your questions at the time should be answered. Doctors have certain catheters they like to start with. If they have trouble getting the catheter through the cervix, they may ask for another type. They should keep you informed.

Breastfeeding during IVF. FSH levels in breast milk will be higher than during a natural cycle. I really can’t comment more than that. There are some women who do IVF while breastfeeding.

Can a varicocele repair correct azospermia? I am not a urologist, but I have not had an azospermic patient develop sperm in is ejaculate after a varicocele. I’m not saying it can’t happen. It is also possible that the counts could go up without surgery.

What about a period that lasts for months with a completely negative workup? Make sure you do not have a bleeding disorder. Some women have vascular abnormalities if the uterus that cause constant bleeding. Maybe an MRI will help.

Thanks for reading, read disclaimer 5/17/06, and talk to you soon.
Dr. Licciardi

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Once again, some of this also applies to regular IVF.

Just as not every follicle gives up an egg, not every egg we get is usable. This mostly has to do with egg maturity. We can’t use an immature egg, it will not fertilize later. For those of you familiar with in vitro egg maturation (IVM), I don’t want to get into that whole thing here. Suffice it to say, IVM had a very limited role with very limited success.

Basically, getting an egg to mature after we retrieve it is of little value, we count on the eggs to mature in the ovary before we get them. We need tree-ripened fruit.

Most retrieved eggs are mature but 10-20% may not be. So if say you get 15 eggs, having 3/15 immature is typical. Like anything else we talk about, variations exist. Some women, no matter how we change their drugs or increase the number of days on drugs, end up with ½ or more of their eggs immature. This is an exception, as is the case when every egg is mature.

Less often we have another small problem: atretic eggs. Atretic eggs are basically just dead eggs. This is much rarer than immature eggs. Another rare problem is a cracked zona (cracked shell). These also are not very viable.

So the point here is that if your doctor sees 15 follicles it does not mean there are 15 eggs to use. By the time you account for eggs that don’t get retrieved, immature and atretic eggs and eggs with cracked shells, you should still be left with about10 that are usable. But it could be more or less depending how the chips fall.

And away they go, into the deep freeze, for months or years (decades?. You work, you live and then one day you decide the time has come to attempt pregnancy; you go to the bank and make your withdrawal. This is another spot for potential attrition.

Not every egg survives the thaw, but most do. One of the many really nice papers on egg freezing recently published by NYU’s own Drs. Grifo and Noyes ( Fertility and Sterility Volume 93, Issue 2, 15 January 2010, Pages 391-396) shows that about 92% of eggs survive the thaw. If they survive we can attempt fertilization.

There are 2 ways to fertilize eggs, one is to mix the eggs and sperm together and let the sperm swim in: this is used when the sperm counts and motility are close to normal. The other is, under the microscope, to pick up a sperm and inject it into the center of the egg: this is used when the sperm counts and/or motility is low. This is called ICSI (inter cytoplasmic sperm injection). For some reason, eggs that have been frozen require ICSI to develop into good embryos. The requirement for ICSI is not a big deal; it seems to work quite well, although it does add to the cost of the procedure. But to continue with a familiar theme, not every egg that has ICSI fertilizes. The same study above shows that 79% of eggs that get ICSI normally fertilize, which is very similar to the rate for fresh eggs.

So the 10 that were frozen are now fewer. You could have 10, but the number may be more like 9, 8, 7, 6, or even 5. And we’re not done yet.

Fertilized eggs need to grow in the lab for another 2-4 days before the transfer. I have a number of blogs that describe embryo and blastocyst development, starting on December 14, 2008. There you will see the changes that take place as things progress from egg to embryos as the the days in culture. You can see the difference between good and bad embryos. Naturally you would like to have nice good looking embryos. And as the story goes, not every fertilized egg makes it to a nice embryo.

Reading this one would think that it’s impossible to have a good outcome from egg freezing, but in reality most women have an average egg yield and enough nice embryos to have an average chance for pregnancy. But again, there is variation. The luckiest women have high egg number high fertilization rates and many really nice embryos, and even some extra embryos for freezing. In other scenarios, there are many eggs and embryos, but they do not develop well.

There is a bit of a waiting game to get your results. In fresh IVF, you know within a few days where you stand. With egg freezing, you will not know how many good embryos you have until you thaw the eggs maybe years later.

We do not yet know how many eggs we will need to thaw later. We may feel comfortable enough to thaw 4-6 and try with those. However, as we accumulate more data, we may find that you need to thaw more to have a good chance. This is important because if you have 8 eggs frozen, thawing 4 at a time can give you 2 chances, but thawing all 8 will give you only one. And then there will be a question about how many embryos to put in your uterus, the recommended number may change with time so this is just something to keep in the back of your mind.

Here’s another question. Should you do any “fertility” or “preconception” workup prior to freezing your eggs? The question here is should you have any tests that may effect you ability or decision to get your eggs/embryos back later. For example, should you have a hysterogram to look for abnormalities in your tubes or uterus before egg freezing? Should you have any genetic tests, cystic fibrosis for example, before freezing your eggs? This you should you discuss with your doctor. In actuality, there are very few things that would keep you from getting your eggs back later. If you are a carrier for cystic fibrosis, you probably will still want to become pregnant with your eggs, providing you screen your partner or donor. If you doctor is minimally good at ultrasound, she should be able to tell you if you have a major abnormality of your uterus without a hysterogram. Most women are still candidates for pregnancy even with an abnormal uterus. However, this is very important to review your history and the potential tests with your doctor. I have had women who wanted to have all the tests done before egg freezing, but not everyone does.

Costs. There are a number of cost centers associated with an egg freeze cycle. There is the cost of the egg freeze cycle. This is the fee that the IVF center charges for the ultrasounds and blood tests associated with your cycle. It includes the retrieval procedure and the egg freezing.

What does in not include? You first need to see the doctor and he usually performs an ultrasound. This is separate. There are the optional tests described above, but there are mandatory blood tests that check your thyroid, prolactin, hepatitis status and others. Your insurance may be more likely to pay for theses but you need to check.

You will most likely need anesthesia for your retrieval procedure; in many cases this this is an extra fee of $1000 or more.

There are also yearly charges to store your eggs, which usually kick in after the first year.

Plus there are real costs, in the thousands, associated with getting your eggs back. This requires the thaw, lab handling, ICSI, ultrasounds, blood tests and the embryo transfer. If you have extra nice looking embryos, you may be allowed to freeze some of them, but again there is an extra cost, and a thaw transfer cost again.

OK, I think that’s almost everything you need to know about egg freezing. I hope it helps.

Thanks for reading, and read the disclaimer 5/17/06. Looks like spring may finally arrive.

Dr. Licciardi

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Hello Everyone,

I have been asked by a researcher to help recruit people to participate in her infertility study. I have spoken to her and she seems dedicated to a very good and important project. Please consider taking her survey. The information is below. This study was approved by the University of Texas internal review board.

Have you and your partner been undergoing treatment for primary infertility?
If so, please consider participating in an online study of the impact of an infertility diagnosis on marriage.
1. You are eligible to participate if you are a married heterosexual couple
2. You do not have any biological or adopted children living in your home
3. Either you, your spouse, or both has received an infertility diagnosis (unexplained infertility qualifies as a diagnosis)
4. You are currently receiving medical treatment for infertility, have done so in the past six months, or plan to do so in the next 6 months
5. Both you and your partner are willing to participate and have access to the internet.

Participation in the study will involve completing an online survey focused on your experience of infertility, your self-perceptions, and your feelings about your marital relationship. This is expected to take no more than 15-20 minutes per spouse.

Participants will receive a voucher good for a pair of free movie tickets upon the completion of the surveys by both partners.

To participate, please send an e mail to: morray@mail.utexas.edu
Elizabeth B. Morray, MA
Doctorial Candidate
Counseling Psychology
The University of Texas at Austin.

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Thanks to all of you who voted for the Infertility Blog. It was recognized as the Best Infertility Blog by you, and the people at Wellsphere. Their Logo is now on the side of this blog.
Thanks again and more to come.
Dr. Licciardi

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Ovulation Timing Questions
If your cycles are 55 days, are you ovulating? Most likely, probably around day 41. However, it is possible that you are not, so you must confirm through your doctor.

What if your cycles are 28-31 days but a progesterone test proves ovulation day 11? Very unusual, but it does not mean you are infertile. Check for ovulation a little earlier using the LH kit to see when it starts and to see if this is a consitant issue.

Is there a problem with 70 day cycles? Yes. You can try to track ovulation but when do you start to do so? If your cycles are always 70, check a progesterone day 60. If it shows ovulation at least you have that. It’s just harder to time things with such a long cycle, and you really don’t have many ovulations per year. If you want to get pregnant, get some help.

Miscarriage Questions
If you are having miscarriages on clomid, will IVF up your odds of going to term? Different doctors will give you different opinions. The IVF option will sit differently with different patients. We aren’t sure if IVF will reduce your miscarriage risk. So the answer is probably no, your odds will be the same with or without clomid. However there may me a play to try IVF with PGD. This option you really need to talk about with your doctor.

Does having an early miscarriage predict further pregnancy loss? Usually not. The odds are still excellent for having a baby in the next pregnancy if you had had only 1 miscarriage, or even 2-3 for that matter.

Will you ever conceive again after trying 3 iuis that resulted in one ectopic and 2 miscarriages? And suppose one of the tubes was removed? If the remaining tube is open, your odds would be excellent of conceiving again. But don’t wait too long before getting help.

Is there a relationship between a long follicular phase and miscarriages? Most likely no.

IVF Questions
Is it better to transfer a fair quality embryo on day 2 or let it grow to day 3 or day 5? Does the uterus provide an advantage over the Petri dish? Unless the lab is really bad (these days there are few really bad labs), then it does not matter. Now that’s’ if there are only 1-2 embryos. If there are more, going to day 3 will help you select the better embryos for transfer. Lab differences are more of a factor when going from day 3 to day 5.

What if the sperm is normal and you are not fertilizing? Should you try donor egg? If you wish, but the problem is more likely related to the sperm. Of course, unless you try donor sperm or donor egg you would not know, but if you look at a 100 patients who are having your problem, almost always the sperm is the issue.

If you are a poor responder, will adding clomid to an IVF cycle give you more eggs? It is one of the options. I make it may last, I put Estrogen prime of microdose first, then maybe clomid. Clomid sometimes makes the uterine lining thinner.

Is there a weight limit for IVF? It depends on the program. The fact is, people are getting bigger and doctors are getting more used to dealing with the big problem. However, it may be important to meet with the anesthesiologist who would be taking care of you during your retrieval. More important than your weight is the configuration of your neck and throat. They want to be sure that if you have trouble breathing, they can get a tube down without a problem. And let’s not forget that your doctor may be less worried about the retrieval and more worried about you and your baby during and after the pregnancy. It has been clearly shown that obesity is bad for pregnant women and bad for babies to be in the short and long term.

If you’re a poor responder, will dexamethasone produce more eggs? This has not been shown to be the case.

Do frozen embryos make healthier babies than fresh? There was one article that somehow came to this conclusion. We do not think there is a difference.

What if a “dominant follicle” seems to be the problem? Dominant follicles come in a variety of forms. Some women are very poor responders and only make one follicle. I have heard this referred to as a dominant follicle. More commonly, a dominant follicle means that you have the potential to make many follicles, but for some reason, only one is big and the others remain small. There are strategies to try to reduce this phenomenon but they may or may not work. We believe that in a natural cycle, the dominant follicle may be selected before the period even comes, so by day 2 the body has already laid out its plan for that month, and stimulating the ovary with drugs may not be able to alter that plan, leaving you with a low number, or just one dominant follicle. So by using oral contraceptives or lupron to turn off the ovary system for a little while, we may be able to stop the dominant follicle pre-selection and give more than one follicle a chance at becoming dominant. However, most of the time, the difference is not extreme

25 years old and not pregnant after an IVF cycle with nice embryos? In the end you will probably be fine. As I have said many times, get to the best program possible. Even at the best programs, these things happen.

What if you have a low AMH level (a sign of poor ovarian reserve) but have many resting antral follicles as seen by ultrasound and make many eggs during stimulation. In your case, the AMH is just dead wrong. As far as we know the AMH is not predictive poor egg/embryo quality, just egg numbers. AMH is promising as a way to measure reserve, but there are a few problems, most of us are not comfortable yet using if for a definitive diagnostic tool. In many cases it does give us correct information, but we need to fine tune the testing and result interpretation.

Interesting question. If a clinic is more aggressive in bring patients to IVF early without much other treatment, will their IVF success rates be higher than clinics that get some people pregnant first with clomid or FSH? Will doing IVF on fertile people make a clinic look better? I would say in a few case yes, this makes sense. In fact overall, since IVF seems to work well enough for most people, more people are doing IVF after shorter intervals of clomid or FSH. However it depends on the IVF success rate differences between the 2 clinics. If there is a small difference, I would point to the selection. If there is a big difference, IVF quality is a big part of the discrepancy.

How do you know if the clinic does a good job with blastocyst culture? Try asking what percentage of transfers are blastocyst for your age group, then ask the delivery rates for blast vs. day 3. Of course check their SART statistics. If they have very good pregnancy rates but do much blast, that may be fine. However also check on the number of embryos they put back. If they have good rates with a higher number of embryos returned and a higher number of triplets, that’s not so good. One of the goals of blastocyst culture is to take advantage of the natural selection process so that by day 5 the best embryos will stand out. If we can see which ones are better, we can put fewer in and reduce the odds of multiples, while maintaining higher pregnancy rates.

IUI Questions
When should you do the iui after the trigger shot? Ovulation will take place 36-38 hours after the shot. There is not a specific time that has been shown to be better. The sperm may be available to fertilize for at least 2 days. The egg is good for about 1 day. So it is reasonable to have the iui performed 24 hours after the trigger.

What if it seems on FSH you are ready too early? Even though you may be ready on the early side, the egg or eggs are probably not affected. However, if it is early there is less harm in waiting an extra day or 2 to give the hcg. I have not heard this to be more effective than just giving the hcg at the usual follicle size, independent of the cycle day.

Should you see an RE or should you let your general OBGYN handle the clomid? It depends on your threshold. If it’s really that more convenient and less expensive, and you are not in a super rush, a few months with your generalist is fine. Otherwise, get to the RE.

Donor Egg Questions
One of my most difficult questions. What if you are doing donor egg with a proven donor and your embryo quality is not great, even when splitting the eggs ½ donor sperm, ½ partner sperm? Clearly all avenues have been explored. If you have not already, and wish to continue, consider another opinion. Now I have seen proven donors give disappointing results in subsequent cycles. It is true that a young donor is more likely to make a baby with embryos that don’t look as good, so maybe the proven donor made fair embryos last time and made a baby. We have been surprised when there are pregnancies from poorly looking donor embryos, but thankfully we see it now and then.

Tubal/Uterine Questions

What about a second surgery for a septum, may it be necessary? Occasionally, more likely with a larger septum. Sometimes at surgery the cavity looks fully repaired but an HSG 2 months later shows there is still a good piece remaining. In this case maybe the upper septum scars together making it appear it was never cut. Or maybe it was never cut, which could be for 2 reasons. Maybe the doctor cut and cut and cut and was really pleased and observed there was a little piece left but felt almost it was gone, and that it was ok to leave a little. He may have wanted to avoid cutting too much, which would increase his chances of perforation. And many women do just fine with a small piece left, as long as it is not too big. But leaving a small percentage may still be leaving a substantial amount. To cut more and reduce the odds of perforation, the doctor can use an ultrasound during the surgery to watch the uterus and the septum, to help cut most of the septum but not perforate.
Another reason for finding some septum after the surgery is that there may be times when the pressure of the fluid used to distend the uterus during hysteroscopy pushes the and remaining septum up towards the muscle layer, making the inside of the cavity look smooth and normal. Yet, once the pressure is relieved by removing the fluid, a bit of the septum bulges back down into the cavity of the uterus. This is theoretical on my part, but I am guessing it does happen this way.

If you have proximal occlusion and your tube is opened, will it stay open? If it was really blocked and you have a procedure to have it opened the odds are about 70% that it will stay open.

Thanks for reading and please read the disclaimer from 5/17/06.

Dr. Licciardi

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Again, this entry has many elements that apply to standard fresh IVF cycles.

Here we’re trying to close in on the real question, “If you do egg freezing, will it help you have a baby?”

Well, it will really does help if you can make some eggs. Sorry if that sounds too obvious, but the more you make the better your odds of this whole thing working years down the line. Just as with any IV F cycle, egg production is based on the number of eggs that are still in your ovaries, and how they respond to the medications.

Much of this is loosely related to a woman’s age but there are a number of other factors involved. The dose of drug can have an effect on the number of eggs produced; the more drug the more eggs, but only to a point. In other words, if your ovaries are full of eggs, a dose of 450 units per day may be way too high and lead to danger, but a dose of 225 might get you 15-20 without much of a risk. However, if your egg reserve is marginal, 225 may make 6 eggs, 450 may make 8, but going over 450-600 probably will not get you any more.

There are papers and book chapters written about how to stimulate ovaries to get the maximum response in women with limited ovarian reserve. For today let’s just say that one of the hardest things we do is try to get the ovaries to produce more eggs than they want to. There are numerous stimulation protocols that we try, and sometimes we get more eggs than expected, but sometimes we get fewer. In very many cases, it may be that it wasn’t the doctor’s choice of medications; it was just the woman’s body being more or less cooperative during that cycle.

Testing for ovarian reserve is one way to get a general guess about your response, but it’s not always helpful. A bad ovarian reserve test is not good news; a favorable result does not guarantee results. There are many of you reading this who despise ovarian reserve testing and some of you who have proved doctors wrong, having babies after being rejected for bad day 3 blood tests. I understand this. I think the testing is should at least be performed to give you a general idea about your prognosis so that the expectations can be based on all available information. Included in this is an ultrasound examining the antral follicle count. Again, not a perfect test, but it will help you get closer to answering the question, “Will this help me?”

You will not know about your egg production until after you start your cycle. Let’s say you have had your consultation and testing and things look reasonably positive, so you decide to give it a go. Fine, but you need to know a few more things. Especially if you have never been on the fertility injections before, the number of follicles that you develop will be a mystery until you are on the drugs for 5-8 days. By then your follicles will have begun to grow and your doctor can count them up and let you know how you are doing. Unfortunately, some women will be producing a low number of eggs.

Follicle number does not equal egg number. We see follicles on ultrasound; we get eggs from the follicles. We never really know how many eggs you will get until we try to take them out on the day of retrieval, but we have certain expectations. If we see 10 good sized follicles, we expect to get 8-10 eggs. There are endless examples of variations. For instance, let’s say you are ½ way through the stimulation and it looks like there are 5 follicles. But there may be others that look very small, maybe too small, but over next few days the small ones may catch up, giving you say 9-10 decent follicles on the day of retrieval. Another possibility is that you have 5 good ones and 4 tiny ones at retrieval, and even the tiny ones that never caught up in size, still give up good eggs (this is not typical).

The opposite could also happen. Your doctor may see 10 follicles and only retrieve 5 eggs. How is this possible? It’s not uncommon to have fewer eggs than follicles. Some doctors feel that there are some follicles that do not have eggs in them. I think this is possible but not very common. It may also be that the egg is in the follicle but it just does not come out through the needle. This I think is more common. Generally the egg is very loosely attached to the inside of the follicle, but if it’s stuck to the inside, it may evade the needle.

So how many eggs do you need to have a successful egg freeze (or fresh ivf cycle for that matter)? Again the too obvious answer is the more the better. However 10-15 is a good yield. More than that is a bonus. It is true 30 may be better than 15, but most women do not make 30 so that should not be your goal. Estimates in the 10-15 range usually do not prompt much patient/doctor discussion, however when the estimate is lower, the talks become more frequent and important.

Usually your doctor is close enough with the pre-retrieval estimate, so assume it will be close. If a low number is estimated you will need to make a decision, with the help of your doctor, about having the retrieval or not. Yellow flags should rise if you are told there are less than 10 follicles, and red flags should rise if you are told there are 5 or less.

Overall there is just no absolute egg number cut-off for cancellation. Some programs may have strict guidelines, but most do not. We all understand the dilemma. If there are few, your odds of success are lower, however if there are few, it means your fertility may be passing. Getting, say, 4 eggs now may be better than nothing, because as months pass, you may make fewer in the future. Stopping without the retrieval, and restarting in a short amount of time, using a different protocol, would probably be the best choice. However, even with making changes you may have the same or even fewer next time. Now I picked 4 follicles as just one example, but the discussion needs to be tailored for 3,5,6,7 etc. Your age, previous response and your desires all need to be taken into account each time.

Your doctor needs to take the information above and formulate your chances of not just getting eggs, but of getting a baby from your egg freeze cycle. This applies to all cases, good egg production or not.

You will get the most accurate information if you are using an egg freezing practice that has results, not just freezing experience. Experience and results with the thaw and transfer is very important; you need a program with a track record. You need to know their experience in going from eggs to babies. Many busy egg freezing programs have no results because they have not thawed any of their eggs yet. Others have done less than a handful of cases.

I do want to refer you to the NYU Fertility Center web site section on egg freezing.
http://www.nyufertilitycenter.org/egg_freezing.
Spend some time going through all of the pages, the information is very helpful.

Thanks to the fantastic research and efforts of the doctors listed there, NYU is known for its egg freezing practices and results. I could summarize the site here, but in the interest of accuracy, go directly there to get it from the horse’s mouth. The results are frequently updated.
The breakthrough, as mentioned on the site, is that we believe that our egg freezing success rates will remain similar to our fresh IVF success rates. Therefore, it will help if you have your eggs frozen at a program with excellent fresh IVF pregnancy rates. If their fresh IVF rates are low, their egg freezing rates will probably be low too.

Not all egg freezing programs can show good data to support good results (2 out of 4 pregnant is not enough.) There are a few who can, so if you are interested in egg freezing, you need to seek out the good ones. Details are sparse, so I really only know about NYU. Odds are there is not a quality program near where you live, so if you can swing it, it may be worth traveling.

Even the NYU rates need to be clarified. Most of the studies at NYU and elsewhere on egg freezing have been performed with good prognosis, younger women. We are not positive that older women’s eggs will freeze and thaw well. They probably will, but there is no data yet to prove the case. We don’t know how long eggs will last in the freezer. We do know there have been children born from sperm and embryos frozen for over a decade, so eggs should be able to last at least as long, but again there is no proof yet. Egg freezing is very new and still considered experimental you do need to freeze your eggs at the right place.

We and other doctors can not completely predict the landscape 5-10 years down the road. We are optimistic that our pregnancy rate estimates are correct. However there is a chance that due to unforeseen circumstances, the rates will be lower. You just need to know this going in. It may also be possible that the outcomes will be better than we had hoped.

Next time we will cover what you should know about what happens after the eggs are retrieved and how the cost structure works.

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

Dr. Licciardi

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