Fertility: General Questions and Answers Part 2
Estrogen Level and Egg Development
Q: I am undergoing medicated IUI cycles and have 3 mature eggs ranging from 18-22mm. I've heard that the estrogen level should be around 200 for each mature follicle, but my estrogen level is only 337. Does this mean that some of the eggs are not mature? Thank you.
Low estrogen levels could reflect 2 things happening: 1. If the medication you are taking includes a GnRH antagonist, approximately 8% of individuals taking this medication have estrogen levels that do not reflect functioning follicles or 2. If not taking this medication, the estrogen concentrations would suggest not all follicles are functioning.
Q: I am taking clomid 100 mg on days 5-9 of my cycle. I have heard that some women take it on days 3-7. Is there any difference in the response based on what days the clomid is taken?
There should be no difference in response of ovulation. The only difference might be the day of ovulation. The earlier you take the clomid, the earlier ovulation would be expected.
Trying After Miscarriage
Q: How soon after a spontaneous miscarriage at 6 weeks is it safe to try to conceive again?
We usually recommend waiting one full menstrual cycle to make sure that the lining of the uterus has regenerated after a miscarriage.
Poor Egg Quality
Q: I have undergone four unsuccessful IVF cycles, all showed poor egg and embryo quality. I am only 29 years old, yet my doctor is recommending donor eggs, as my husband's sperm appears healthy. All of the labs my doctor has tested to explain the poor egg quality have come back as "normal." The tests included the immunologic reasons for poor egg quality. I am having a hard time with this as I am only 29 years old and we have no answers as to why this has happened. Are there any other tests that can be done to help explain this?
Before recommending additional testing, it would be important to know which tests have been done and were "normal". These would include drawing blood on day 3 of your cycle for not only FSH and estradiol, but also inhibin B as well as antiovarian antibodies, We would also need to know how many eggs were retrieved and the presence or absence of insulin resistance.
Vitamins and Sperm Quality
Q: I have heard of men taking high doses of vitamin C and Zinc to help improve sperm quality. Does this really work, and can it help a couple avoid more invasive treatments like IVF with ICSI when the problem is purely male factor infertility?
Every little bit helps, but the treatment of choice for male factor infertility is IVF with ICSI.
Q: I am 35 yrs. old and have been trying to conceive for 3 yrs. I was told that I have elevated FSH between 11 and 16, and it's been tested more than once. I ovulate, have regular cycles, and have tried all fertility assistance except IVF. Is there anything I can do for this?
The elevated FSH level indicates that you have low number of eggs left in your ovaries. There is nothing we can do to make more eggs. What we can do is to try to maximize the chances of conception each cycle by generating more embryos with IVF. If that doesn't work, the next step would be to consider donor eggs.
MEDICATIONS FOR PCOS
Q: I have polycystic ovarian syndrome (PCOS) and am trying to get pregnant. I've heard about some medications that are available to help women with PCOS become pregnant. Can you explain them?
There are several types of pills that one can take to induce ovulation in PCOS. One is an estrogen antagonist such as clomiphene or tamoxifen. Another is an aromatase inhibitor. Lastly, some women with PCOS respond to oral hypoglycemic drugs such as metformin.
Q: I have two children from a previous marriage. My husband has a low sperm count and they are "slow." Is there anything we can do to improve or give us any chance of having our own children? My husband and I are both 30 years old.
Your best option for treatment of infertility associated with a male factor is IVF with ICSI.
Q: I recently underwent my second IVF cycle. Of the 8 eggs that were retrieved, only one of them fertilized. All had ICSI performed on them. Sadly, the one that did fertilize never progressed and the transfer was cancelled. My first IVF cycle had the same results. According to the embryologist, both the egg quality and sperm quality looked normal. Do you have any suggestions on where to go from here?
We need to know whether the problem is in the sperm or the egg. Further studies on the sperm with the Sperm DNA Integrity assay will help to answer the question. Also day 3 blood drawn for inhibin B concentrations will give us better insight as to egg reserve. Once we know which gamete is the problem we can better recommend treatment.
BORDERLINE FSH LEVEL
Q: My FSH was borderline this cycle at 9.5 and I seem to be a somewhat slow responder (9 eggs with 13 days of stims). I'm only 32 and not really ready to consider donor eggs at this point. What would my options be aside from donor eggs?
A number of different protocols are available for low responders to try to maximize response to stimulation. These include using estrogen priming protocols and GnRH antagonists as well as phosdiesterase inhibitors. You could talk with your doctor about these alternatives.
LATE OVULATION AND MISCARRIAGE
Q: I ovulate spontaneously each month, however usually not until between days 18-24. I have been pregnant twice but miscarried both times within a week of the positive pregnancy test. My OB does not recommend any testing at this time, and mentioned that three miscarriages is the "cutoff" to begin testing. I am concerned about repeat miscarriage if I do become pregnant on my own again. Does ovulating so late in the cycle pre-dispose me to miscarriage? Is the egg quality poorer than if I ovulated earlier in the cycle? What would you suggest I do?
With your history of recurrent pregnancy losses (even after 2 losses), we would need to evaluate you for causes of the losses including both immunologic and thrombophilic risk factors as well as sperm contributions to the losses with the Sperm DNA Integrity assay. In addition, you should ask your doctor about diagnosis and treatment of polycystic ovaries with your history or irregular periods.
SHORT LUTEAL PHASE
Q: I have been diagnosed with a luteal phase defect. I ovulate spontaneously on day 13 or 14, and my period arrives on day 21. I've tried progesterone supplementation to lengthen the luteal phase, but it doesn't change anything. I've been pregnant several times with beta numbers within the "normal" range for a healthy pregnancy, but they've all ended in miscarriage. Do you have any advice on what to do?
With your history of short luteal phases which do not respond to progesterone treatment, you should talk with your doctor about being tested for genetic mutations in you progesterone receptor.
Q: What is the difference between hysterosalpingogram (HSG) test and the hysterosonogram test? Is one more diagnostic or routinely used than the other?
A HSG evaluates both the uterus and tubes. The hysterosonogram evaluates only the uterine cavity.
CLOMID USE FOR MEN
Q: Is there any merit to the use of clomid for men with low sperm counts?
It depends on the cause of the low sperm count. Most low counts have a genetic cause and are not responsive to clomid.
Q: Is taking an Ultrasound the only way to tell if someone has Polycystic Ovarian Syndrome (PCOS)?
Ultrasound will demonstrate the presence of polycystic appearing ovaries. For a diagnosis of PCOS 2 out of 3 of the following will be demonstrated: 1. chronic anovulation (or irregular periods with normal gonadotropins or elevated LH/FSH ratio), 2. excess male hormone and 3. polycystic ovaries seen on ultrasound examination.
ENDOMETRIOSIS AND IVF
Q: I have been diagnosed with stage 3 endometriosis and had surgery to remove several lesions. I wend through 4 IUI cycles without success, and am now considering IVF treatment. I have read that there are issues with implantation of embryos in women with endometriosis. If this is the case, even if we have good embryos, are my chances for success lower than the average woman without endometriosis going through IVF?
Women with endometriosis can have a higher risk of implantation failure than those who do not have endometriosis. To look for risk factors before IVF so that these can be treated at the same time as the IVF, you may talk with your doctor about looking for both immunologic and thrombophilic risk factors contributing to implantation failure.
Q: I was told by my last RE that my best option for pregnancy is to use donor eggs. I am 28 years old and had 2 IVF cycles which yielded 5-6 eggs each cycle. In each cycle, I had 3 and 4 eggs which were reportedly of good quality however the embryos we produced were of poor quality and didn't result in pregnancy. I am having a hard time accepting that my eggs are "bad" and that I'll never have a genetic child of my own. Would a third IVF cycle be worth it to see if the results are any different, or should we accept the advice of our RE and move forward? To date, there has been no explanation for why I didn't respond very well, or why my egg quality is considered to be poor. Thank you for your response.
Poor quality embryos can be the results from a contribution from the egg or the sperm. To look for a contribution from the sperm, you husband could have a Sperm DNA Integrity assay performed. To look for a contribution from the egg, estimates of ovarian reserve can be obtained by drawing blood on day 3 of a cycle (counting the first day of bleeding as day 1) for FSH, estradiol, and inhibin B.
Q: I have a T shaped uterus, will I be able to have children? What are the risks associated with this? Does this mean that my eggs might be abnormal as well?
The greatest risk with a T shaped uterus is preterm labor and preterm birth. It usually does not necessarily imply anything about egg quality.
OVULATION PREDICTOR KITS
Q: How reliable are OPK's in predicting ovulation? If I got a + OPK, is it possible that I didn't ovulate that cycle, even when I got my period about 2 weeks later? These tests are pretty accurate. If you got a positive result and a period 2 weeks later, you most likely have ovulated.
Q: I have been diagnosed with PCOS and have irregular periods. I have had several rounds of clomid, however nothing has happened. I then had a post coital test done and found that the cervical mucus is killing the sperm and my doctor recommended intrauterine insemination (IUI). My doctor also wants me to start taking metformin. Would the metformin do anything to improve the cervical mucus?
Metformin helps to induce ovulation in around 80% of women with PCOS. The hormones produced in response to ovulation could help to improve your cervical mucus. Intrauterine insemination will bypass your hostile cervical mucus. If these methods don't produce a pregnancy, you may talk with your doctor about IVF.
Q: I have been diagnosed with hydrosalpinx of one tube. Can I still have an IUI with only one tube open? What are my options?
With one tube open there is always the possibility of pregnancy occurring. However, with even one hydrosalpinx the probability that the open tube does not function properly is high. Your best option for pregnancy is IVF.
AGE AND FERTILITY
Q: I have read so much about fertility sharply declining after the age of 35 in women, however I still see sources saying that it starts declining after the age of 27. When does fertility REALLY start to decrease?
Fertility starts decreasing ever so slowly in the late twenties but doesn't become clinically apparent until after age 35 years. It falls precipitously after 40 years.
QUESTIONABLE RESPONSE WITH IVF
Q: I am on my first round of IVF and will be having the egg retrieval in the next few days. Up to this point, there has been no obvious reason for our infertility. I currently have 4 follicles that I have been told are nearly mature, ranging from 15mm to 17mm. I also have 6 or 7 others that are smaller (around 10-14mm). Is it likely that any of the smaller ones will catch up in the next couple of days prior to the retrieval? I am under the impression that I have not responded as my RE expected me to respond. Assuming this cycle fails, what would be the next step?
It would depend on the number and quality of eggs retrieved. If your response to gonadotropin is low the 2 options for further treatment are, changing stimulatory medication to increase the dose of medication or donor egg.
THE NEXT STEP
Q: My husband and I have been though three unsuccessful IVF attempts (all three with poor embryos), and I feel that we should start to consider alternative routes to parenthood. My husband would like to try another IVF, but I strongly feel it's time to move in a different direction. At what point do you tell your patients to consider adoption or donor material in order to start/complete their families?
We would recommend proceeding with donor gametes or adoption in individuals who could not generate good embryos for transfer.
Q: What percent of infertility patients undergo IVF treatment?
It depends of the individual practice but overall around 30% of infertile patients undergo IVF procedures.
PREMATURE OVARIAN FAILURE (POF)
Q: I am 29 years old and have been diagnosed with POF by several Doctors. I constantly search the internet for new developments in this area of infertility and have found that TCM is the best option for me at this point.
Can I continue with my Chinese herbs for now without taking HRT? Is this advisable or not?
My last FSH level was of 58 and my LH of 25. I do not have many hot flashes.
Herbs are fine as long as you have periods and have not symptoms such as hot flashes. If pregnancy is desired, the in vitro fertilization with donor egg is the best treatment option.
Q: I am aware of the most common causes of infertility, but I realize there are a small percentage of people with unexplained infertility. What exactly is unexplained infertility, and have there been any unique finds within "unexplained" that are now explained and being observed? Unexplained infertility is infertility that is not associated with obvious caused such as low sperm count, lack of ovulation or blockage of the tubes. It is estimated that about 40% of infertility can be attributed to male factor with problems with the sperm, and 40% attributed to by a female factor such as difficulties with ovulation or tubal problems, leaving 20% of infertility unexplained.
Q: My husband I recently went through the infertility workup and all the tests come back that everything looks good as far as my husband goes, but she said that I my have slight adhesions on either side of my uterus. I have never had any gynecological surgeries. She said she would schedule me for a laparoscopy to remove them, since I am ovulating, and she can find nothing else wrong. We've had unprotected sex for the length of our marriage (11 years) so my question is, what's the success rate of this type of procedure, and how common is it.
After 11 years of infertility, surgery for lysis of adhesions does not have a high success rate. You should talk with your doctor about in vitro fertilization.
Questions have been answered by Dr. Carolyn Coulam, a Reproductive Endocrinologist practicing in Chicago, Illinois.
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