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

Bill and Guiliana Rancic’s third season debuted last week with a very emotional episode which walks us through their first round of IVF- in the end it was successful, but as we know sadly her pregnancy will end around 9 weeks. The second episode of this season follows the Rancic’s on the quest to find the perfect “family” house in Chicago suburbs.

It was a great episode, they are just so cute together. I have to admit after watching 2 seasons of them on their show the more and more I think Bill is John’s long lost brother. They are SO much a like- both Croatian, both love real estate and finance, and both are somewhat conservative.
They also both have the same taste in women- I relate so well to Guiliana- she is outgoing, energetic, loves celebrity gossip (she works for E! News and has my dream job, by the way!) and is a total shopaholic.

This episode also follows the Rancic’s while they are dealing with getting their estate planning in order, forming a trust and a living will. This is all stuff that John and I did about 2 years ago, and it’s hard- you have to make some tough decisions about what happens to your things, and your children in the event of your death. Bill decided this was a good time to bring up the dreaded word to Guiliana “BUDGET”. Guiliana did not take it so well, she said “budget,what’s that?” I was laughing so hard at this point, because that’s John in a financial conversation with me, I’m like “what budget, there is no budget”. Gulinana then went on to say how her new leather jacket was a necessity- I know I have said that exact sentence to John at some point. John and I were laughing so hard- and John was just shaking his head going “see I told you!”

Bill went into how it’s important to save and be financially secure for your children, but Guiliana was more worried about how she looks in her new leather jacket that she is modeling for Bill. In the end she agreed to the budget, which is where I am at with then entire thing- I just fold and will give in. I know John is right, and it’s all for our future- but come on how can you pass up a sale!?

Overall it was a great episode, it really hit home for me, not only with the infertility and the IVF and all that stuff, but the other “daily” stuff that happens in a marriage and all the hurdles that you have to overcome to be a successful couple in life and in your marriage. Don’t forgot to tune in next Monday Style Network 8pm.

The Donor Network Alliance (DNA) is the largest website that posts egg donor profiles for Intended Parents. DNA is the only website that aggregates egg donor profiles from the largest egg donor programs throughout the United Sates. To date, DNA hosts over 5000 egg donor profiles and will be adding gestational surrogates in the coming weeks. “DNA recognizes that many of those in search of an egg donor also need a gestational surrogate as well to help build their family,” said Nancy Block, CEO of The Donor Network Alliance ( http://www.donornetworkalliance.com ). DNA will utilize its current technology and platform to add a database of gestational surrogates which already has significant interest from current members and others in the fertility community. Intended Parents will greatly benefit from this service as it will simplify their search for a gestational surrogate with a streamlined process that takes out the confusion and uncertainty.

Hello Again, I hope everyone has had a mostly enjoyable summer. The weather in the Northeast has been summer-perfect.

Here are the answers to some recent questions.

IUI and IVF

At 45 should you dismiss the idea of IVF and just do iui? Most IVF programs around the country have never had an IVF success with a 45 yo woman using her own eggs. I know it sounds harsh, but it is the reality. At NYU we have had some and I am sure that there are other programs around the country that have one or more. The odds of success with iui are always lower than IVF, so that doesn’t sound so good either, but at least with iui you can try multiple times less expensively. So at any age, IVF on a per try basis is better and may be the best first choice, but iui is more attractive to some.

31 yo, severe endometriosis, 225 units of drug and 6 follicles, cancelled to iui. Was this the right choice? Can a higher drug dose increase the egg production? I do understand the “maybe you will do better next time” philosophy, but you don;t know that next cycle will bring. You may make a few more eggs on a higher dose. The left ovary only made one, which means it could do better next time, or it is damaged from the endometriosis and there is a lower number of eggs there. For someone who is 31, not more than 4 eggs are needed to still have a good chance. There may not be much of a difference in pregnancy rate between 6 and 10 or even more eggs. So for me 6 would have been fine and if you make 6 in your next cycle you should talk to your doctor about having a retrieval.

45 years of age with multiple fertility problems and multiple failed IVF cycles. Is freezing for a carrier one option? Anything is an option, but realistically, I would discourage it. If it’s a must do for you, then find a way to get it done. This really requires a sit down discussion with you and your doctors.

Embryo Donation: I 100% endorse the process. We seem to have a problem getting embryos. We get many couples who before their cycle start, say they wish to donate their embryos. But it is extremely rare for any couple to actually make the decision to donate their frozen embryos. There are obvious advantages of embryo donation and I wish there were more couples who were comfortable with the process of donating.

High percentage of immature eggs. Remember having 10-20% immature eggs is normal. High percentages of immature eggs could be a function of a few things. First, maybe you received the hCG too early, and waiting 1-2 more days may have increased the percentage of mature eggs. Most people on average do not have an excess of immature eggs when receiving hCG once their biggest follicles reach about 18 mm. Some women however, need their biggest follicles to be 20 or 22 mm before most of their eggs are mature. There is no way to know this in advance of the first cycle. But changes should be made for subsequent cycles. There are some women, who no matter how long we wait to give the hCG, still have a large percentage of immature eggs. We can’t explain this and it’s just a case of dealing with what you have. In general we don’t want to wait too long before giving hCG because eggs can get over-mature and this could show up later as poor quality embryos.

What if you make 3 follicles on 225 units of drug, will a higher dose help next time? On average the answer is yes. I think that for most people, once you get to 300-450 units per day, adding more will not help, or will not help much. There are many cases where I do use the higher doses, as much as 600 units. However, going from 225 units to 450 units usually ups the egg number. I would not expect to go from 2 to 15, but even 4-6 would be a big improvement.

Reproductive Surgery

Will a laparoscopy help find the cause of abnormal luteal phase bleeding? Most doctors would say that at least a hysteroscopy would be indicated, which would take a look inside the uterus to be sure there are no hidden polyps or fibroids. However, if the HSG and sonohysterogram are perfectly clean, odds are the hysteroscopy will be normal and maybe could be skipped. If medicated cycles fix the problem, then you are set. A laparoscopy (surgery through your navel) will probably not find anything related to abnormal bleeding of the uterus and may not be indicated.

Are there complications of uterine surgery for a septum? Yes, but the odds of having a complication are very low. Uterine perforation, bleeding and infection are possibilities, but there are very rare. Your doctor should be able to discuss the risk of miscarriage if you do not have the surgery and the rates of surgical complications. I perform my septum surgeries using ultrasound guidance to lower the odds of complications.

Ovarian Wedge/Ovarian Drilling will not help at age 44.

Failed ivf and iui with a fibroid in the cavity? It is tough for me to comment on this without doing the ultrasound myself. In general, regardless of the surgical problem, the threshold for advising surgery changes as time goes by. If there is a fibroid you may be less interested in removal initially, but as each cycle passes unsuccessfully, the option of surgery may receive more consideration. If I were to do the scan and agree that there is a fibroid of notable size in the cavity, I would be concerned that implantation could be hampered. But you really need to get a second opinion.

PCOS

If you have PCOs and are not responding to clomid, yes FSH is one of the next options.

You are 37 and have PCOS but with regular cycles? By most definitions, you can’t have PCOs unless your cycles are irregular. There are some groups who say that you can have PCOS even if you have regular cycles, however most doctors feel part of the definition of PCOS should include menstrual abnormalities.

It is not necessary to measure the LH level in women with PCOS. Irregular cycles and many follicles on ultrasound are all that’s necessary to make the diagnosis. Other tests may be necessary to rule out diabetes or other metabolic disturbances, and sometimes we check for adrenal problems, but most of us no longer measure the LH, or the ration of LH to FSH.

PCOS, 37 years old and not getting pregnant on clomid. Should you keep trying on your own? Well if you are not getting pregnant, eventually you need to change the plan. In general, clomid is used for about 3 tries, but in the case of PCO and anovulation, more tries are acceptable. This is because clomid levels the playing field. Someone who does not ovulate, but does so with clomid, has about the same pregnancy rate as a normal ovulating woman, so why panic after 3 months? Giving clomid to a normally ovulating woman is not as successful, so switching to injections or IVF after 3 months is the typical time frame.

Next steps: if you have not become pregnant after a number of cycles of clomid and then injection cycles, IVF is the next step. Of course you can continue with iui if you wish, but you need to talk to your doctor about the options and success rates of each.

Sperm

Is there a protein in sperm that kills eggs? There is not.

If you have a testicular biopsy that shows no sperm, can clomid help? It’s a discussion you need to have with your reproductive urologist. If you are unsure about the advice, get a second opinion. If clomid were an option, I am assuming it would have been an option prior to the surgery. Homogenous means that the tissue was abnormal, without the usual network of sperm making cells.

What if the sperm has 0% morphology. This may or may not be an issue. As you have read, a very low percentage of normally looking sperm does not bother me. However, occasionally, we see a sample that is unusually abnormal and this does raise a red flag. I would repeat the semen analysis to see if there is consistently 0% normal forms. Trying another lab may give you more information.

Obesity
If you are 31 and 300 lbs you need to seriously lose weight regardless of your fertility issues. Being pregnant at 300 lbs is not safe for you or your baby. If you lose weight you may start to ovulate regularly. I know this is all easier said than done, but you need to seriously look at all of your options including medical and surgical approaches.

Thanks, enjoy the holiday, and please read the disclaimer 5/17/06.

Dr. Licciardi

Go to Infertility Blog

Wow, what a relief to know that what we have been saying for years is now finally officially stated. Any sperm morphology over 3% is considered normal.

How did this change come about? The World Health Organization (WHO) determines the normal parameters for semen including volume, count, motility, forward progression and morphology. The WHO published their guidelines in 1987, with updates in 1992 and 1999. The original “normal” cutoffs were based on estimates from old data, some of it dating back to the 1950’s. There were inconsistencies in the way data was collected, ie the sperm studied was collected and analyzed in many centers, but there was little regulation of how the tests were being performed. Plus there was not clear data on the history of the men.

This time the semen tests were performed using similar protocols in all of the testing centers. Plus, some history was obtained from the men, mostly related to fertility status.

4500 men in 14 countries on 4 continents were tested. Australia, China, Denmark, Germany, Chile, Singapore, France, the UK, and the USA were some of the countries included.

Men were placed into one of 4 groups.
Fertile men. All men in this group had initiated a pregnancy sometime in the 12 months preceding testing. This was the most important group because the researchers could establish normal values based on men know to have fertile sperm.
There were 3 other groups evaluated. To save a little confusion, I’ll summarize and say 2 groups were a little more random in nature and the fertility status of the men was mostly unknown. The 4th group was also fertile, but the time since last pregnancy was unknown and may have been longer than 12 months.

The results.
The normal fertile men’s sperm had the following results.
Volume: The median (midway between the lowest and highest results) was 3.7 cc, but anything over 1.5 cc was considered normal
Concentration: the median was 73 million but anything over 15 million was considered normal
Motility: the median was 61%, anything over 40% being normal
Morphology: the median was 15%, anything over 3% was deemed normal.

Some important points.
You may have noticed that morphology is not the only parameter with a new normal value. Volume was at 2.0 cc, now it is at 1.5cc. A normal count was 20 million, this changed to 15 million. Motility was 50%, now it’s 40%. The normal morphology had the biggest change, as it went from 15% to 4%.

Keep in mind that in this group, all of these men were fertile, so even men with levels lower than the new definition of normal had working sperm. The normal values were established mathematically. If you were in the upper 95% of the fertile people you were deemed normal. The bottom 5% of the fertile people was deemed abnormal. This 95%/5% cutoff is the system used to define cut offs for other tests such as TSH, Prolactin and many others.

When comparing the different groups of men there were very slight differences in volume, count, etc, but hardly worth mentioning. Fertile men did have slightly higher volume and counts then men whose fertility status was unknown. Morphology was mostly similar in the different groups. Remember, there was no group of men who had established infertility, so in this study there is no way to compare normal fertile men to known infertile men.

And even though we have no details on the women, knowing that they became pregnant in the past year is probably all the information we need.

So now you know. Any morphology over 3% is considered normal. If your doctor tells you otherwise, ask him if he has seen the new WHO guidelines.

To take it one step farther, can there really be difference between 4% and 2%? I doubt that there is a difference between having 96% abnormally shaped sperm and 98% abnormally shaped sperm. So as I have said before, at our practice here at NYU, morphology is not considered with much respect, except in some rare cases where the sperm is unusually abnormal.

I hope this helps.

For those of you who want more details, here is the link.

www.who.int/reproductivehealth/topics/infertility/cooper_et_al_hru.pdf

Dr. Licciardi

Go to Infertility Blog

By Dr. Joe Massey, Reproductive Endocrinologist, Batzofin Fertility Services, New York, NY

The treatments available for treatment of cancer in young men are highly successful. Leukemias, lymphomas, and malignant tumors often are treated with chemotherapy which is toxic to the testicle and sperm production. One of the most devastating consequences of anticancer therapy is the loss of fertility. Semen cryopreservation prior to therapy has been a strategy utilized for over 20 years in these situations.  After early attempts at IUI had low success rates, the advent of IVF, especially with ICSI, raised the level of successful outcomes.

In the Netherlands a large series of patients over 600 collected semen since 1983. Among the subjects, 14% of the population died, most of them very early. In 9% of the men there were no motile sperm at the time of collection of the sample. In follow-up, some of the men regained sperm function and achieved pregnacies. Many still have sperm waiting for usage.

Of those who did not recover, and wished to conceive at the reporting center, there were only 37 men.

In the cases in which  IVF was performed with ICSI usually, success rates for achieving parenthood, including multiple attempts, was 54% (Van Casteren,  2008). The age of the females was an adverse factor in some of the cases in this study.

Another report involved over 100 cases of men who had sperm thawed and their wives underwent IVF treatment. The average age of the women was 35 suggesting again that the circumstances did not induce these men to push initiation of their family forward aggressively. Pregnancy rates were in the30% range per cycle and enough patients repeated therapy to reach cumulative results of nearly two thirds of couples  succeeding (Hourvitz 2008). Other research has found success rates from 33-73%.

It must be remembered that, though offering hope, there are limits to the success of this method. Sperm quality from men who are ill may be poor. Preserving multiple samples prior to therapy is a good concept to keep in mind.  There is always some urgency to begin chemotherapy and the referral for semen cryopreservation should not be a last minute recommendation. This study points out the need for awareness of the option among all men facing cancer treatment who may wish to preserve their reproductive options.

Increasingly, the same availability of the option to preserve fertility is being offered to young women thanks to the advent of successful egg cryopreservation.

References:

Hourvitz A et al. ICSI with cryopreserved sperm from men with malignant neoplasm.  Fertil Steril 2008; 90:  557-563.

Van Casternen NJ et al.  Use rate and assisted reproduction technologies; outcome of cryopreserved semen from 629 cancer patients. Fertil Steril 2008;90:2245-50.

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

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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

Go to Infertility Blog